Marsha K. Millonig
Marsha K. Millonig B.Pharm., M.B.A.

My last two columns have been about digital health trends and interoperability, with a focus on patient opinions. So it was with great interest that I read about Surescripts’ recent survey of patients, pharmacists, and prescribers about their interactions and how the COVID-19 pandemic has changed this dynamic. The survey was conducted in mid-July by phone among 300 patients, 200 prescribers, and over 500 pharmacists. Key takeaways are that the pandemic is driving the need for greater interoperability, especially because of increased technology use during the past 18 months and increasing desire for price transparency to serve patients who were more anxious and price conscious than ever.

Both prescribers and pharmacists reported an increase in questions from patients about medications (58% and 30%, respectively) and general health (68% and 45%, respectively) during the last 18 months. Pharmacists said they often did not have all the patient information they needed to address these questions or provide medication therapy. They often turn to prescribers and report that they contact the prescriber regarding 22% of all prescriptions they process. Top reasons for contacting prescribers are not surprising and include:

  • Seeking refill renewals (27%).
  • Asking for prior authorization to be done (25%).
  • Clarifying prescription orders (24%).
  • Asking for lower-cost alternatives to be prescribed (10%).
  • Resolving drug interaction issues (10%).
  • Seeking more-effective alternative medications (3%).

Unfortunately, the majority of these interactions still occur via phone (36% for prescribers, 38% for pharmacists) and fax (14% for prescribers, 20% for pharmacists) rather than using the electronic health record system (42% of prescribers) or the pharmacy management system (35% of pharmacists). This survey data is reflective of my experience working at various pharmacy locations across the Minneapolis and St. Paul area during the pandemic. The advent of using electronic prior authorization has been helpful in addressing some of the workload. And integrated electronic prior authorization is the top tool pharmacists surveyed say would make prescription processing easier, and it is among the top three tools mentioned by prescribers. Pharmacists also would like to see drug alternatives in the pharmacy system, and prescribers would like to see medication adherence support tools. Both groups, however, ranked medication pricing information as their second top-desired tool.

Both prescribers and pharmacists said they believe prescription costs are among the top issues in healthcare today. Among the patients surveyed, 19% report it has become more difficult to afford medications during the pandemic. Not surprisingly, a quarter of the prescribers said patients asked them to prescribe a less-expensive medication, and pharmacists reported 10% of patients not filling a prescription because of cost. Prescribers and pharmacists alike say they have difficulty accessing a patient’s out-of-pocket prescriptions costs. Part of this difficulty may be the growth in nonplan payment for prescriptions. Several years ago, Walmart started offering $4 generic drugs, and other pharmacies soon matched the offer. These payments were not applied to patients’ insurance deductibles, and because they were not processed through a patient’s insurance, some drug utilization review functions could not be done.

Today, it is common for more than half the patients I see to ask me about a discount plan of some kind. Many have been spurred to ask after viewing television commercials, often starring celebrities, for specific products or discount cards. Others bring in cards they received in the mail or from their healthcare clinic. RxSaver and GoodRx are two of the plans that patients most frequently ask me about. At some pharmacies, the pharmacy system can easily make comparisons between GoodRx prices and company-specific discount plans in order to provide patients with the best price, including better pricing than their insurance at times. Other pharmacies that do not have agreements with GoodRx or RxSaver may provide their own discount plan to help patients. Many independent pharmacies do not have agreements with prescription discount programs at all, and in fact are voicing concerns about these programs.

A good example is the concern expressed to a recently
announced initiative between GoodRx and Surescripts. The partnership between the companies would integrate GoodRx’s discount pricing information into Surescripts’ platform. Prescribers would then have access to this information at the time of prescribing. The GoodRx pricing would only show for uninsured patients or those whose price information is not available from their PBM (pharmacy benefit manager) or insurer. The initiative is supposed to address price transparency and certainly addresses the top tools mentioned in the Surescripts’ survey. However, a group of pharmacists wrote to Surescripts’ board with their concerns that this would hurt independent pharmacies and further obscure pricing. In my experience, I have already seen numerous messaging in e-prescriptions from the prescriber stating the patient would be using a discount card and providing the card’s BIN, PCN, group, and ID number. Sometimes this is for common off-formulary “lifestyle” medications (e.g., drugs for erectile dysfunction or weight loss), and at other times it is for ongoing therapy for chronic disease.

I often wonder, as do colleagues I query, whether GoodRx presents a conflict of interest. After all, it is partnered with Express Scripts (ESI), one of the major PBMs that along with United Healthcare and CVS Caremark control the vast majority of the prescription benefit management marketplace. This dominance is what has driven major PBM reform legislation across the country in the past several years, which has only become more feverish as federal DIR (direct and indirect remuneration) fee reform remains elusive. Isn’t ESI — through its partnership with GoodRx — directly competing with any employer or insurer for whom the company creates and manages a prescription benefit? In this case, rebates and discounts go to ESI/GoodRx instead of returning any portion to ESI’s clients or employers. Patients who use these discount card programs don’t have their prescription costs counting toward their deductibles, which may mean they are paying out-of-pocket far longer than they may have without the discount cards, in spite of paying less for each prescription than they would running it through their insurance. In some cases, use of the cards is illegal — for example, in government-sponsored health plans. But in my experience their use is growing, and I am getting more-frequent emails directly from such programs touting their savings.

Writer Emily Olsen notes in her MobiHealth article that after becoming publicly traded, GoodRx announced its first earnings, bringing in $550.7 million in revenue in 2020, a 42% increase from the year before. For 2021, GoodRx reported first-quarter revenue growth of 20% year-over-year to $160.4 million. Industry expert Adam Fein noted in his Aug. 11, 2020, Drug Channels blog, that this means “…GoodRx earned about 15% of the $2.5 billion that consumers spent at pharmacies with its programs.” In that blog, Fein goes on to say, “Pharmacies lose in two ways. One, they lose the potential revenue from a cash-paying customer, who would have paid more than what the pharmacy received from a PBM. Two, the pharmacies must pay a fee for the privilege of dispensing to a patient who may have used their pharmacy anyway. However, pharmacies are effectively prevented from offering low cash prices, because they risk undercutting their third-party margins.”

This observation has led Fein to say in a recent blog that GoodRx, not Amazon, might be the true PBM pharmacy disrupter (subscription may be required). He notes GoodRx and its discount card competitors profit by incentivizing people to bypass their own insurance plans. He writes, “…our crazy pharmacy pricing system deters pharmacies from pursuing consumer-driven pricing and PBMs from undercutting their own clients.” He then posits, “…discount cards could become the force that upends PBMs’ pharmacy benefit economics, plan sponsors’ decisions, and the entire generic market. Should PBMs continue to profit from discount cards’ rapid growth…while ignoring the risk that this growth could undermine the value of their benefit management services?”

That’s a good question. I have written in ComputerTalk and spoken at ASAP meetings about Amazon’s potential channel disruption. The company has since exited its healthcare initiative with JPMorgan and Berkshire Hathaway. Is Adam Fein right that GoodRx and the proliferation of discount cards may finally be the disrupter to our complex, and often untransparent, pharmacy pricing system, not Amazon? Stay tuned. CT

Marsha K. Millonig, B.Pharm., M.B.A., is president and CEO of Catalyst Enterprises, LLC, and an associate fellow at the University of Minnesota College of Pharmacy Center for Leading Healthcare Change. The author can be reached at mmillonig@catalystenterprises.net.

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