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    Value-based Rx: How physicians can manage affordability, adherence

    For doctors, the price of prescription drugs used to be largely a medical concern: Patients wouldn’t get better if they couldn’t afford to fill their prescriptions. But with Medicare’s growing emphasis on value-based care, many physicians now also have a financial stake in ensuring that patients can pay for the medications they need.


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    The specific catalyst for this development is the Merit-based Incentive Payment System (MIPS), Medicare’s payment program covering most small and solo medical practices that took effect at the start of 2017. MIPS—which was created as part of the Medicare Access and CHIP Renewal Act of 2015—links Medicare reimbursements to physicians’ performances on metrics in four broad categories, the most important of which is quality. And many of the MIPS quality metrics include outcomes for diseases and conditions routinely treated with prescription medications.

    Hence medication affordability—or its lack—could spell the difference between a bump or drop of as much as 9% in a doctor’s Medicare reimbursements by 2022. 

    There are no data on the number of patients whose outcomes are affected by the cost of drugs. However, a 2013 study by the Centers for Disease Control and Prevention found that 8.5% of Americans between the ages of 18 and 64 did not take their medications as prescribed due to cost concerns.

    Fortunately, despite the ever-rising cost of prescription drugs, physicians have numerous tools at their disposal to help patients fill the prescriptions they write. Moreover, experts say, a value-based payment system—which includes tying Medicare reimbursements to the thorny issue of drug affordability—has the potential to improve care.

    “Until now there hasn’t been much incentive for physicians to learn that there are things they can do to help their patients [afford medications] because their payment wasn’t affected either way,” says Emmy Ganos, Ph.D., a program officer with the Robert Wood Johnson Foundation. “Now with this shift hopefully there will be more emphasis on patients getting what they need out of the [doctor-patient] interaction, because ultimately that’s everyone’s end goal.”

    Communication is key

    So what can doctors do to help patients afford prescription medications? Like so much else in medicine, the solution begins with good doctor-patient communication, experts say. 

    “That conversation [about prescription affordability] doesn’t come up as frequently as it should,” notes Eric Schneider, MD, FACP, senior vice president for policy and research at The Commonwealth Fund.

    Schneider, who closed his internal medicine practice at Boston’s Brigham and Women’s Hospital in 2015, notes that the affordability issue had been coming up
    increasingly over the years, with patients voluntarily acknowledging that they’re unable to pay for a prescription he has written. 

    “I think this performance payment system [MIPS] is probably going to drive these conversations to happen more frequently,” he adds. “In fact, if adherence is detected to be a problem for a patient, one of the questions that’s often asked now is ‘Are you having trouble affording your medication?’” 


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    Concerns about prescription drug affordability are not limited to patients who are poor, notes Damon Raskin, MD, an internist and addiction specialist in Pacific Palisades, California. Raskin treats patients with widely varying incomes, “but all my patients care about the cost of prescriptions, even those who are wealthy,” he says. “Especially for older patients on multiple medications, it’s a big chunk of their incomes each month.”


    Focus on generics

    Probably the most important step doctors can take to minimize affordability problems, say those who have studied the issue, is to prescribe lower-priced generics whenever possible. While that may seem obvious, not all physicians make it a priority, says John Rother, president and chief executive officer of the National Coalition on Health Care.

    Next: “You’d be surprised by how many doctors are still writing brand-name prescriptions"


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