5 ways to support value-based care when writing prescriptions

Medications are nothing short of remarkable. In the 1980s, I watched two of my med school professors work from patient bedside to lab bench and back to win the Nobel Prize in Medicine for refining our understanding of cholesterol metabolism. Brown and Goldstein’s research laid the groundwork for the development of statins, which top the charts of drugs prescribed today.

A daily dose of a pill that costs pennies can prevent cardiac conditions that could devastate patients and their families. A curative course of a hepatitis C drug may cost tens of thousands of dollars, but that’s a fraction of the cost of a liver transplant. By averting consequences of disease, drugs can meaningfully reduce long-term costs for the entire healthcare system.

Rising prescription prices are a concern for those looking to manage healthcare costs. Prescription drugs are estimated to cost around 9% of total healthcare expenditure. A Kaiser Family Foundation poll revealed that a fourth of patients have trouble paying for their prescription medications. Drug affordability can become a real barrier to adherence, resulting in patients losing out on the benefits drug can provide. According to one estimate, the morbidity and mortality resulting from suboptimal adherence costs $528.4 billion annually.

Underprescribing, overprescribing, and misprescribing can also have costly consequences for patients and for healthcare spending. Here are five ways that clinicians can factor value considerations when prescribing:

Look beyond generics for savings

Prescribing a 90-day supply of generics covered by a patient’s insurance formulary isn’t always the most cost-effective option. Generics aren’t always available, some require time-consuming prior authorization by health plans, and some paradoxically require patient co-pays that can actually exceed the retail cost of the drug. A 2013 study showed that for nearly a fourth of filled prescriptions, patient copays exceeded the reimbursements that pharmacies received from insurers. Average retail price information is available in epocrates. When insurance co-pays exceed out-of-pocket drug costs, or when patients are uninsured, providers can help patients realize savings by:  

• Encouraging patients to take advantage of retail pharmacy discounts  
• Prescribing individual drugs instead of combination medications  
• Opting for prescription drugs sold over the counter in lower doses

Leverage manufacturer patient assistance programs

Many drug manufacturers offer patient assistance programs, including discounts or co-pay coupon support for low-income patients. Search engines for such programs are available from Medicare, Pharmaceutical Research and Manufacturers of America, and Needymeds.

Prevent adverse drug events

While many side effects are unpredictable, reviewing drug allergy cross-reactivity, contraindications, and cautions before prescribing supports risk-benefit considerations. A colleague of mine was asked to consult on a patient who developed inexplicably low sodium levels. He was in the ICU for days to correct severe hyponatremia. Before even seeing the patient, my colleague glanced at the patient’s record and ran his medication list through the epocrates drug interaction check. Within seconds, he had the answer: A recently prescribed medication was interacting with a drug the patient was already taking, resulting in dangerously low sodium levels. The new medication was stopped, and the patient was soon discharged. Adverse drug events are even more heartbreaking when a drug should not have been prescribed in the first place, such as antibacterial agents for typical viral infections.

Deprescribe when possible

Regularly review medication lists for opportunities to reduce prescriptions. Use shared decision-making to weigh the balance of risks and harms of continuing medications, especially in patients with limited life expectancy. Consider the Beers List in patients 65 years and older. Transitions — including discharge from hospital to outpatient care — are a vulnerable time for extending drugs unnecessarily. I witnessed this in a family member who was taking an antiarrhythmic drug (which was prescribed only for perioperative use) for two full years after surgery because their primary care physician assumed that continuation was intended by their cardiac surgeon.

Consider cost-effectiveness analyses

Prescribers have little influence over the drug pricing set by pharmaceutical manufacturers or the negotiations between drugmakers, pharmacy benefit managers, and insurers. Data to support value-based prescribing isn’t often available, and clinical practice guidelines often fall short of factoring cost considerations into their recommendations. Organizations like Center for Evaluation of Value and Risk in Health, Drug Pricing Lab, and the Institute for Clinical and Economic Review (ICER) weigh in on quality-adjusted life-years (QALYs) and life-years gained (LYG) for drug treatments. One recent ICER analysis explored the effectiveness and value of weight-loss drugs; another concluded that the world’s most expensive drug, Zolgensma, was cost-effective at $2.1 million per patient for spinal muscular atrophy. When cost-effectiveness evaluations are available, they can support confident value-based prescribing decisions.

Despite all the available data surrounding adherence and affordability, there are challenges to implementation. Physicians may need to be proactive in discussing affordability, as patients may not be comfortable initiating a discussion about costs. In addition, exploring affordable drug options and connecting patients to assistance programs can be time consuming: For a comprehensive landscape of options, prescribers would need to individually compare the patient’s health plan drug coverage information to discount retail pricing opportunities, as well as pharmaceutical manufacturer assistance programs. Yet, the effort spent on drug affordability can return dividends in terms of increased adherence and decreased healthcare spending.