Research looks at out-of-pocket prescription costs

One study evaluated the effect of real-time pop-up recommendations for lower-priced prescription alternatives, while a second study modeled capping monthly expenses and shifting the patients' savings back to the insurance plan.

Notifying physicians of lower-priced prescription alternatives reduced patients' out-of-pocket costs by 11%, with the largest savings of 40% for high-cost medications, a cluster randomized clinical trial found.

To investigate whether real-time prescription benefit (RTPB) recommendations reduced patients' out-of-pocket costs, researchers randomized medical practices at NYU Langone Health, a large, urban academic health system, to receive or to not receive RTPB recommendations for the first half of 2021. They limited the analysis to prescriptions for which RTPBs could recommend an available alternative.

The RTPB system used pop-up alerts to recommend available lower-cost, clinically appropriate alternatives for a different medication, length of prescription, and/or choice of pharmacy. The prescriber could select either the original order or one of the recommended alternatives. The researchers analyzed the effect using data from electronic health records. The primary outcome was patient out-of-pocket cost for a prescription, and secondary outcomes were whether the prescriber ordered a mail-order prescription and a 90-day supply. Results of the study were published Sept. 12 by JAMA Internal Medicine.

Of 867,757 outpatient prescriptions, 36,419 (4.2%) had an available alternative. Out-of-pocket costs were $39.90 for a 30-day supply in the intervention group and $67.80 for a 30-day supply in the control group. The intervention led to an adjusted 11.2% reduction (95% CI, −15.7% to −6.4%) in out-of-pocket costs. Mail-order pharmacy use was 9.6% and 7.6% in the intervention and control groups, respectively, and rates of 90-day supply did not differ between groups. In high-cost drug classes, the intervention reduced out-of-pocket costs by 38.9% (95% CI, −47.6% to −28.7%).

The authors noted that RTPBs made recommendations for only a small percentage of prescriptions. They concluded that medication price transparency solutions can generate savings for patients if they target patient-specific, real-time out-of-pocket cost information to the prescriber and recommend clinically appropriate alternatives.

An accompanying editorial noted that the observed savings may be overestimated because they are based on the price of the ordered versus filled medication, that pharmacists may still have substituted lower-cost options in absence of RTPBs, that the authors did not report the fraction of orders prescribers changed due to the alert, and that it was unclear whether the tools facilitated other cost-saving strategies such as steering patients to lower-priced pharmacies preferred by their insurance plans.

“Like much good research, this study motivates as many questions as it answers,” the editorial stated. “Because [real-time benefit tools] are fundamentally prescriber-facing tools, they naturally raise the question of the patients' role in decision-making, especially when there are trade-offs involved in the selection of a less-expensive alternative.”

A second, unrelated study found that capping monthly out-of-pocket expenses would save commercial insurance plan enrollees from 45% to 56% while likely raising premiums by more than 5%. The findings were published Sept. 15 in a research letter by JAMA Network Open.

Researchers used national commercial health insurance claims data to assess changes in patient cost-sharing and plan spending under hypothetical monthly limits among a sample of patients younger than age 65 years who were enrolled for a full calendar year. Those enrolled in a health maintenance organization or capitated plan were not included. The researchers recalculated patient and plan costs under a $250 and $500 monthly limit for in-network out-of-pocket costs across all claims, then calculated the percentage of enrollees benefiting under each monthly limit and the share of total costs shifted back to plans as a proxy for how much premiums would have to increase.

They estimated that a $500 monthly limit for in-network out-of-pocket costs would affect nearly one-quarter (24.1%) of the commercially insured. Median annual in-network out-of-pocket costs decreased from $2,024.66 (interquartile range [IQR], $1,267.82 to $3,233.34) to $1,102.61 (IQR, $720.73 to $1,628.05) among those with costs exceeding the cap, a 45.5% decrease. Enrollees in high-deductible health plans saved more than those with lower deductibles (49.9% vs. 44.1%). The median highest monthly out-of-pocket costs for in-network care decreased from $1,139.80 (IQR, $710.61 to $2,038.11) to $500.00 (by definition) among those affected, a 56.1% decrease. Shifting avoided costs back to the plan led to an estimated increase of 5.6% in annual mean plan costs per enrollee, a proxy for how much premiums could be expected to increase, the authors said. Out-of-pocket costs were further reduced with a $250 monthly limit for in-network care.

The researchers concluded that capping monthly out-of-pocket costs could meaningfully reduce the cost-sharing burden for many commercially insured patients in the U.S. without regulating health care prices. “However, the preponderance of evidence suggests that underconsumption of health care because of cost is a substantially more pressing problem,” they wrote. “Offering plans with smaller deductibles that reset over shorter time periods could help ease affordability while creating another dimension of patient choice.”