The Price Is…Complicated


Patients want transparency about prescription costs and are turning to pharmacists as a trusted source to help them navigate.

By Jane E. Rooney

Prescription drug spending reached almost $370 billion in the United States in 2019, according to National Health Expenditure data from the Centers for Medicare & Medicaid Services. A Mayo Clinic study in 2013 revealed that almost 70 percent of Americans take at least one prescription medication—a number that has certainly risen in the past several years. In his April address to Congress, President Biden noted that the United States pays the highest prescription drug prices of any country in the world. The national conversation about healthcare spending includes discussions about how to control those costs.

Where do pharmacists fit into that conversation? Evidence suggests that during the pandemic, more patients relied on pharmacists for information about payment options and cheaper alternatives to their prescribed medications. According to a March 9 Forbes article, more than two thirds of pharmacists surveyed reported taking on new job responsibilities over the past year, including helping patients find ways to save money on prescriptions. ASHP’s recently released National Trends in Prescription Drug Expenditures and Projections for 2021 indicates that the pandemic had a significant influence on U.S. spending for prescription drugs last year.

“Pharmacists play a critical role in helping patients navigate drug pricing,” said Dr. Annesha White, associate dean for assessment and associate professor, the University of North Texas Health Science Center College of Pharmacy. “We are at the forefront of healthcare, especially community pharmacists. There’s a community pharmacy every five miles. That exposure is there, that interaction is there. Patients are coming in asking questions about pricing. Because of the access—there was a recent study in JAMA showing that pharmacists are even more accessible than primary care physicians—it’s the pharmacist interacting with patients on a day-to-day basis.” White predicted that the trend toward pharmacists taking on increased responsibility in this area will continue.

“I think that pharmacists are equipped to take on that role because they have the training, not just the medication knowledge but also an understanding of formularies, managed care and drug pricing,” she explained. “Bringing those skillsets together lets pharmacists take a lead role in explaining to patients and helping them understand and become more adherent. That’s a critical outcome we’d like to achieve. It’s definitely an opportunity to step up and take those lead roles in many pharmacy settings.”

Drug pricing is set by manufacturers and is based on several factors, including R&D costs, competition, market forces and proprietary information. While pharmacists have no direct influence on pricing, they can help patients navigate the system and can influence policy as well as formulary decisions. Price is only one element of pharmacoeconomics—the study of costs and consequences of a drug to society and the healthcare system—and although it does not address why drug prices are so high, pharmacoeconomics provides a foundation for understanding issues such as cost per successful outcome or adverse event and costs of direct and indirect medical care. Pharmacy school faculty discuss how pharmacoeconomics fits into the curriculum, what the drug pricing landscape will look like going forward and the ways that the pharmacy community is stepping up and preparing student pharmacists to get involved in advocacy at the state level.

Pharmacists are in a unique position. They have the knowledge about the drugs and how the insurance is covering things, PBMs, Medicaid, but they are also at the cash register. MTM services are mostly focused on the clinical side. That role is going to expand. This is where pharmacists can make their mark. They can advise patients on the clinical and also the cost-effective side.

Dr. Varun Vaidya

Kickstart the Cost Conversation

White has seen an increase in the number of topics taught related to pharmacoeconomics, which is emphasized in the curriculum at the University of North Texas Health Science Center College of Pharmacy. “I tell my students that when I was in school, there were very few hours in the curriculum dedicated to pharmacoeconomics topics and now many of these topics are included in Chapter 1 of major textbooks. It continues to be needed,” she said. “We’ve heard it from faculty and students and also from patients. Why are drug prices so high? Why aren’t health outcomes improving given the high cost of healthcare? The majority of schools do cover pharmacoeconomics topics but there is room for improvement. A lot of schools are teaching it later in the program years, the P3 year as opposed to P2 or even the first year. It’s never too early to introduce these topics. Customers are coming into retail settings and asking why isn’t a drug covered or why are prices so high?”

Given that coverage of pharmacoeconomics varies from school to school, White sees a need to develop a standardized approach to teaching this in the curriculum. “We definitely need to increase the number of hours spent on these topics. Don’t wait until the third year because it’s too late,” she added. “I’m an advocate for introducing these topics early on in the curriculum. Some schools may not have faculty that have this as a specialty area and they don’t have the students who are as interested in it. That is a concern, because if you have no pharmacoeconomics in your curriculum, that really is an issue in terms of preparing a student for the future.”

Student organizations are one way to get those conversations going. White suggested that pharmacoeconomics can be integrated into an introductory pharmacy course. If schools don’t have faculty who have a pharmacoeconomics background, guest speakers can be brought in to keep students up to date.

At the University of Toledo College of Pharmacy and Pharmaceutical Sciences, this content is addressed in a P3 course that covers pharmacoeconomics principles, pricing, cost and quality issues, said Dr. Varun Vaidya, professor, Division of Pharmaceutical and Policy Sciences. “Every college in some shape or form is delivering [this content to meet accreditation standards] but most Pharm.D. students don’t think of this as core material. They are more focused on the clinical side,” he noted. “The board [exam] is heavily focused on therapeutics. The exam isn’t testing them extensively on pharmacoeconomics. It’s part of ACPE’s accreditation requirements but I don’t know how much importance student pharmacists see in this. The pharmacy Academy can work on improving that.”

Vaidya offered an example of how he explains to students the ways in which pharmacists can help patients consider cost and improve their health outcomes. “In my class I discuss a new generation of anti-coagulants. The price difference is $400-$500 a month. From an efficacy standpoint all of these drugs are almost equal,” he explained. “The only benefit is convenience. If this is being laid out and patients are educated on the options, they can choose to pay the extra cost. But if it’s someone who cannot afford it, they should be given the alternative. That’s just one example. We can make these recommendations at the patient level that would not only save money for the patient but also the PBM. It is in the PBM’s interest to have pharmacists trained and be compensated for that.”

He believes pharmacists should be trained to understand how we value the cost effectiveness of drugs and make that investment to learn to provide these services and get compensated. “These recommendations will save money and that’s a great value that pharmacists can add,” he continued. “Pharmacists are so accessible. When it comes to reimbursement for MTM services, the insurance companies’ perception is it’s overlapping with what they get from the physician’s office. Pharmacoeconomics in practice settings is a niche area that pharmacists can take advantage of.”

Vaidya supports pharmacists being more involved in discussions with patients about pricing and cost effectiveness. “Pharmacists are in a unique position,” he pointed out. “They have the knowledge about the drugs and how the insurance is covering things, PBMs, Medicaid, but they are also at the cash register. MTM services are mostly focused on the clinical side. That role is going to expand. This is where pharmacists can make their mark. They can advise patients on the clinical and also the cost-effective side. The clinical often gets covered at the physician’s office or with nurse practitioners or with other healthcare providers. For certain medications, such as diabetes and for some chronic conditions, prices have gone up significantly. More patients are turning to pharmacists and I hope they are asking these questions—why are these drugs costing so much, what can be done, what are the alternatives?”

White agreed that the focus will continue to be on decreasing costs without reducing quality of care. “Pharmacists have such an opportunity right now to take a lead role in this area. We have to step up to the plate and really share with different stakeholders in terms of the best ways to navigate this changing landscape of healthcare,” she said. “When you look at AI increasing, big data…at the core of it is still going to be the fact that transparency is lacking in terms of pricing. Patients are telling their stories about outrageous drug costs but pharmacists need to be able to communicate why those prices are high and be more transparent in sharing data across settings. We know that people want transparency and want to understand why prices are so high, so we need to be proactive to answer these questions.”

Advocacy Around Affordability

Efforts to address drug pricing issues are gaining momentum at the state level and some pharmacy faculty are getting involved. In Maryland, a first-of-its-kind Prescription Drug Affordability Board was created in 2019 to take action to make drugs more affordable for state residents; board members were selected in 2019 (four members) and 2020 (one member) based on their expertise in the space as well as strong research and policy backgrounds. Dr. Eberechukwu Onukwugha, associate professor, executive director, Pharmaceutical Research Computing, Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, was chosen as one of the five board members for her expertise in data analysis, health economics and outcomes research.

“We have several tools available to consider—there are multiple options from a policy standpoint to lower costs,” Onukwugha said. “The initial work we are tasked to do in the first year is to get a better understanding of the drug supply chain before getting to the stage of considering appropriate measures to reduce the cost burden. That work is ongoing and is key to gaining more clarity. What’s important is making sure we are evidence based and we are getting a sense of the stakeholders throughout our review of the supply chain. What we think about is the burden—both clinical and economic—families are feeling related to affordability concerns. We are approaching it holistically to think about medical care, not just prescription drugs. We attend public forums and listen to the public at these forums. Individuals and families are making tradeoffs in some cases and forgoing taking their medications. Price is one component but there are other dimensions to it. We want to understand that more fully before thinking about recommendations.”

The board’s executive director, Dr. Andrew York, who is a pharmacist, said the aim is to take a comprehensive look at what affordability means for residents in Maryland. “We are looking at reducing costs, but just as importantly, we are looking at improving access. We are trying not to get tied up on things like ‘price,’ which is a loaded term,” York explained. “There are so many metrics that can be said to be the ‘price,’ but they seldom reflect what anyone in the supply chain actually pays. Instead, we hope to develop a report that is a comprehensive study of the pharmaceutical payment and distribution system. We have decided to take a broad view, and we hope to look at every aspect of the supply chain and look at every opportunity to make drugs more affordable. We are working on understanding the issues by the end of this year. Then, we plan to make recommendations and take action that will materially improve patients’ lives by making their prescription drugs more affordable. We are thinking about the interventions that would make the most impact.”

York added that pharmacists are in a great position to help patients navigate affordability issues at the point of patient/caregiver interaction. “The prescribers may not even know these are issues for the patients. It’s a huge opportunity for pharmacists to help patients by providing the necessary information to the healthcare team and to let them know that they need to take cost into consideration when prescribing,” he said.

Drug affordability is an issue for all states, and York and Onukwugha hope the board’s approach can be translated outside of Maryland. “There’s been a lot of research already conducted to describe and document barriers to healthcare utilization and the impact of the cost burden,” Onukwugha noted. “We aren’t always fully aware of what’s already been studied and documented. It’s important to understand the literature. Something for those who are looking to do more in this space is data-oriented work—study your own populations with surveys or patient interviews.”

Dr. Marta Brooks, chair and associate professor, Department of Pharmacy Practice, Regis University School of Pharmacy, sees an opportunity for pharmacy faculty to play an advocacy role. The school has representation within the Colorado Pharmacists Society to provide perspective from the educators’ side of the equation on policy issues. The Colorado legislature is considering forming a prescription drug affordability review board, which would have the authority to cap the price of certain high-cost drugs.

Financial health is often a corollary of general health. Those conversations aren’t traditional in the delivery of care but we are creating space for those conversations because patients want to talk about their options and their concerns. With pharmacists being on the front lines and seeing patients more often, there’s a unique opportunity to engage patients around this topic and at least be a resource.

Dr. Eberechukwu Onukwugha

“The impact on the pharmacy community—there is a lack of understanding of what it could do to individual providers,” Brooks said, explaining opposition to the bill. “We’re more concerned with the lack of availability of certain prescription drugs to Coloradans. Right now it’s not a feasible bill so we’re strongly opposing it.” Strategies that the pharmacy community supports, she continued, include redesigning drug rebate practices, advocating for easier substitutions of biologics and making biosimilars more available to patients. “We’re looking for greater transparency on drug prices from PBMs and pricing information being shared with consumers when drug manufacturers market their medications directly to the public. Pharmacists are continuing to do what they do, which is identify less costly options. We are actively working to address prescription affordability. We don’t want pharmacists to be caught in the middle.”

Dr. Karen Smith, a professor at Regis in the Department of Pharmacy Practice, noted that pharmacists want the best health outcomes for patients, so it is a concern when drug pricing and insurance availability and coverage impact access and adherence. “I think pharmacists will always try to maximize adherence and affordability of drugs. We can try to navigate the system for patients and try to find the drug and improve outcomes, but pharmacists do get caught in the middle of pricing and while they want to be an advocate for patients, it is difficult to be in that position.”

Smith said Regis offers a survey course in the first year called Pharmacy and the U.S. Healthcare System that addresses pricing and what’s involved in developing a new drug. “We look at how the pharmaceutical industry prices their drugs and we also address the patient cost side by looking at those who would be non-insured, different levels of insurance, HMO government insurance and what is the patient responsibility from that perspective,” she explained. “In the second year, we have a pharmacoeconomics course. That looks at the value of drugs in terms of population benefits—how drugs are valued in society and different methods used to value them. We look at examples of cost-benefit analysis and cost-utility analysis.”

Smith and Brooks emphasized that the best use of pharmacists’ time and expertise is direct patient care rather than talking about pricing, but Smith said pharmacy schools need to be realistic about the kinds of cost issues that will arise in practice settings. “It’s important to introduce student pharmacists to how legislation works and how they can advocate for the profession and for patients,” she said. Brooks added, “As a university we believe in producing a well-rounded pharmacist who is principled and taking care of the whole patient. As we try to foster some non-traditional career paths, I hope that those pharmacists that go into industry will bring that whole-person approach to population management and help change the tide.”

A Foundation for Future Pharmacists

Frequent interactions with patients put pharmacists in a position to understand cost burdens and know what questions to ask patients. “Financial health is often a corollary of general health. Those conversations aren’t traditional in the delivery of care but we are creating space for those conversations because patients want to talk about their options and their concerns,” said Maryland’s Onukwugha. “With pharmacists being on the front lines and seeing patients more often, there’s a unique opportunity to engage patients around this topic and at least be a resource.”

York added, “One thing I wish I’d learned in pharmacy school is more directly how the payment system works, considering how much time pharmacists spend on this. They have to work through wholesalers and insurance reimbursement. That’s a major part of what pharmacists do. It is critical to understand how the payment system works and how to advocate for yourself and your patients.”

Onukwugha has observed expansion in recent years around population health and healthcare system courses but believes there are creative ways to more formally integrate pharmacoeconomics into the curriculum such as rotation opportunities in different settings. Maryland has seen more interest from faculty and students in interprofessional education. “The [goal is having] the pharmacist interact as part of a team, provide an important perspective to those discussions and hear from others about whether they see cost considerations coming through. I see opportunity for teams to talk more about cost considerations,” she said. “More students are seeing opportunities to bring that knowledge to the counter. They will ask more questions about a patient’s ability to pay or whether they have any concerns related to their ability to pay.”

Smith emphasized, “I think that introduction to PBMs, how formularies are created, how pricing comes to be and how legislative decisions come to practice…those are very important to pharmacists. Including those in education helps us get to that well-rounded, involved pharmacist who can take care of patients no matter what specialty they go into. They have a foundation to benefit patients in the pharmacy world.”

Brooks agreed, adding, “As we develop pharmacists who are leaders, that is how we will be able to evolve the narrative on prescription drugs and hopefully the [drug review] board won’t lead to healthcare professionals being caught in the middle.”

Toledo’s Vaidya said pharmacy faculty should embrace the idea that this is an area where pharmacists can make a difference. “For student pharmacists, their heroes are often their clinical professors. For years the emphasis has been on the clinical side,” he pointed out. “The belief has been that as long as you know therapeutics, that’s what you need to know. That messaging has to change a little bit. Yes, the clinical side is important—that’s the foundation—but where we’re heading it’s important that students are not only taught to think about cost issues but how this is going to add value to the profession. That should be covered in the curriculum through an independent course. Academia needs to take it seriously.”

He said faculty must convey that pricing is a key topic. For example, pharmacy faculty at Toledo educated students about a gag order in Ohio that prohibited pharmacists from advising patients on drug options that would cost less. “If we take a three-pronged approach where faculty give students the right tools, we promote the message that we can make a difference in this area and then from an accreditation standpoint we give it a push [through the board exams], it would create a much larger impact. The other thing I’m strongly in favor of is having fellowship programs,” he continued. “I would like to see student pharmacists specifically looking into the cost-effectiveness side of drugs. They should be given specialty training through pharmacoeconomics fellowships. Then they can be trained in this specialization so they can make a larger impact. That should be a sustainable model.”

Jane E. Rooney is managing editor of Academic Pharmacy Now.