Getting sick can be expensive. Once you consider the cost of medical care and medications, plus the impact of lost wages from missing work, an unexpected illness or injury can quickly do serious damage to a family’s monthly budget.

Even with medical insurance, the out-of-pocket costs of a medical event can swiftly add up. And, unlike going to the grocery store or shopping for a new car, you rarely have a chance to shop for the best deal, or even to understand what your costs will be until you pull out your credit card to pay. Healthcare has traditionally been unique in that regard—much to the frustration of many consumers who have fallen ill and racked up unexpected and significant medical bills.

Patients are paying more for medical

Today, patients are shouldering more and more of the cost of their own medical care. The average family premiums in the U.S. increased 20% from 2011 to 2016, per the Kaiser Family Foundation. Consumers are also responsible for larger deductibles and co-pays, as well as higher out-of-pocket maximums. Adding salt to already wounded pocketbooks is the fact that out-of-pocket prescription drug costs continue to rise:  up 20% from 2013 to 2015. Most of those price hikes fly under the radar and don’t get the same kind of press as the EpiPen, which increased some 400% in price over the last 10 years. Epinephrine autoinjector (EpiPen) is a medical device for injecting a measured dose or doses of adrenaline by means of autoinjector technology.

Traditionally, consumers have had minimal insight into the costs associated with their medical care. However, with the rise of consumer-driven health plans, patients are demanding greater transparency into care costs, including out-of-pocket costs for prescription drugs—which now represent about one-fifth of all healthcare spending.

Medication adherence/price transparency connection

Patients aren’t the only ones worried about prescription drug costs. Physicians and payers realize that the inability to pay for drug therapies is one of the primary reasons that 20% to 30% of patients never fill new prescriptions. Failure to adhere to prescribed medication therapies increases the likelihood of disease progression and leads to avoidable doctor visits, trips to the emergency room and hospitalizations.

For payers, these types of complications can negatively impact bottom lines. When patients fail to follow prescribed therapies, they often end up utilizing even more healthcare resources. Providers can also suffer financial hits, especially under newer value-based compensation plans that link provider incentives and penalties to quality outcomes and cost-effective care delivery.

To bend the cost curve, physicians and patients need more up-front transparency into the cost of prescribed medications. Unfortunately, providers rarely have access to the cost of prescribed therapies, leading them to occasionally prescribe high-priced therapies when similar effective lower-priced alternatives are available.

With expanded insights into how much particular medications will cost a patient, physicians are more likely to select cost-effective alternatives that increase the likelihood of medication adherence.  However, until relatively recently, physicians—and their patients—have had little access to cost details for different drug therapies, especially at the time of prescribing.

Historical roadblocks

For many years, physicians have had access to payer-supplied medication formularies, often from within their electronic health records (EHRs), but the available details have been limited and very imprecise. For example, providers might be able to see if a medication is covered under a given patient’s health plan as a tier two drug, but they wouldn’t have sufficient details to calculate the patient’s exact out-of-pocket cost based upon factors such as drug co-payment amounts and current deductible levels. Furthermore, prescribers rarely have access to pricing information to help patients determine which pharmacies offer the lowest out-of-pocket cost or if there is a less expensive alternative medication that could be prescribed and what the exact cost difference would be.

Historically, the complexities of drug benefit plans and issues of access between EHRs and pharmacy benefit manager (PBM) systems have made it difficult to deliver to physicians more precise details on out-of-pocket medication costs, especially at the point of encounter, during the patient visit. In fact, at the time of prescribing, providers often lack complete and current information on a patient’s insurance coverage, coverage restrictions, therapeutic class guidelines, deductibles and other essential details that impact medication selection and adherence. In addition, formularies can be complex, change frequently and may apply differently to specific groups or individuals.

Standards and innovation

The National Council for Prescription Drug Programs (NCPDP), along with payers, PBMs, pharmacies, providers and health information technology vendors, has spent years trying to eliminate the roadblocks to prescription drug pricing transparency. One NCPDP initiative has been establishing industry standards for benefit checking technology at the point of provider-patient encounter. One of the industry’s earliest participants in the initiative was Humana, based on its desire to help patients maximize their benefits and avoid health complications.

In 2015, Humana announced the availability of the first real-time prescription drug benefit program that delivers patient-specific prescription price information to providers at the time the prescription is being written. For the first time, physicians could select a medication and, in real-time, be notified whether the prescribed medication was covered under the patient’s formulary benefit design. The service also offers up to three alternative drug therapies that may be less expensive and advises on the availability of alternate pharmacy options, including mail order and retail. Most importantly, the technology allows the physician to see the patient’s out-of-pocket cost for each drug therapy option.

 And your cost is…

Programs like Humana’s finally give providers the ability to tell patients exactly how much their medications will cost—before they even walk out of the doctor’s office. Consider some of the ways that real-time benefit checks can impact the care process:

Identify the most cost-effective therapy. The prescriber and the patient can see the out-of-pocket cost for the selected medication, as well as alternative therapies. The out-of-pocket cost at specific pharmacies is also displayed, which can be a big plus for patients with high-deductible plans who want to minimize these costs. The doctor and patient can review options together and have an intelligent and informed discussion about therapy costs and their therapeutic value, plus review viable alternatives if the preferred therapies are too expensive.

Drive medication adherence. By selecting a more affordable therapy, physicians can minimize the risk of non-adherence and increase the likelihood of positive patient outcomes. Enhanced clinical outcomes result in better patient health overall and minimize the patient’s need to utilize additional healthcare resources due to complications, which ultimately benefits both payers and providers.

Improve the patient experience. When patients aren’t aware of the cost for prescribed therapies at the time of prescribing, they can be unpleasantly surprised when picking up medications at the pharmacy. If the out-of-pocket cost is very high, it’s up to the pharmacist to share the bad news. Even if the pharmacist is aware of possible alternative therapies, no changes to the original prescription can be made without physician approval. In the end, a patient may go home with an affordable solution, but not without having to wait—for what could be several hours or the next day—for the pharmacist to hold a discussion with the doctor and then fill the new prescription. Alternatively, the patient may simply opt to disregard the physician’s medical advice and not fill the prescription.

What’s next?

Politicians are hotly debating the future of the country’s healthcare, but don’t expect a big change when it comes to this one healthcare reality: the cost of being sick is more than the cost of being well. Fortunately, more and more payers are following Humana’s lead and offering technologies that deliver real-time benefit information at the time of prescribing, giving physicians the transparency they need to select the most cost-effective therapies. In turn, more patients now can minimize their out-of-pocket costs, maximize their health benefits, adhere to prescribed medication therapies and experience improved health outcomes.

By the end of 2017, we anticipate that real-time benefit technology will be available for as many as 30% or 40% of the country’s covered lives. As more physicians take advantage of these services, prescribers will be better equipped to drive medication adherence—and provide the answer to every patient’s question, “What’s this going to cost me?”

Cameron Deemer, is president of DrFirst, which develops software and services for accessing patient data in real-time, and improving communication and collaboration.