The Exam Room Is a Sacred Space: How One Doctor Broaches Prescription Costs

As a physician and as Surescripts Chief Medical Information Officer, I often find myself talking with other clinicians about how they’re using technology to improve patient care. I recently had the pleasure to chat with Dr. Michelle Forbes, a partner and practicing pediatrician at MD Pediatric Associates in north Texas. She shared how she’s using technology to open up cost conversations with her patients. An added benefit? These conversations are not only improving her patients’ medication adherence, they’re fostering trust between her and her young patients, as well as the families that care for them.

• Q: What do you like about your work?

  A:

  I love being with families, especially taking care of children. That's why I became a pediatrician. 

  Q: Why is medication cost so important to your practice?

  A:

  Adherence is the number one reason. I can formulate the best plan of care, but if the family can't afford what I'm prescribing, my patient won't improve.

  Q: In medical school, we’re taught to focus on the clinical efficacy of a treatment, to the exclusion of other factors. But given the cost of healthcare, that’s no longer enough. Can you talk a little bit about how it’s important that we look to clinical efficacy but also affordability?

  A:

  Yes, I used to think the cost of a medication was between the patient and the insurance company. I really didn’t think I had a role in that conversation. Over the last few years, though, with needing prior authorizations and having pharmacies call and say, "Your patient can't afford the medicine, what do you want to prescribe?" it became clear that I—actually, we physicians—need to take on that role and have these cost conversations.

  Q: Have you had an awkward cost conversation in the past?

  A:

  Yes, as I recounted in the webinar we did, I’d prescribed a medication to a patient who suffers from Attention Deficit/Hyperactivity Disorder (ADHD). It became clear during a follow-up appointment that my patient was not improving. In fact, both the parents and teacher reported the patient had become worse. So, during the follow up, I began talking about increasing the dose and the parents stopped me and said: "We never started the medicine because we couldn't afford it." I had to pause and think, do I want to be the kind of physician who essentially says, “That’s not my problem,” or the kind who finds a solution?

  Q: How are you using prescription price transparency tools in the exam room?

  A:

  The Real-Time Prescription Benefit tool allows me to turn my computer screen to my patient and family members and say, "I have this medication in mind, but let's look at it together and see what your costs will be." Within seconds I have the cost of the treatment, an indicator of whether it needs a prior authorization, the cost for a 30-day and for a 90-day supply, and I have their preferred pharmacy plus a few other area pharmacies they can choose from. I don't have to search for the information; it's right there embedded into the workflow.

  Q: What was the patient care journey like before you had access to this information?

  A:

  Painful. Before my EHR made this tool available, I would get calls from the parent or the pharmacy about the cost of the medication. I would manually prepare a list of 10 to 20 options and say, "Here, you call your insurance company. Find out how much it costs and call me back and let me know what you want me to prescribe." Having patients call up insurance companies was also problematic—for a myriad of reasons. They'd be told, "Well, this medication is tier one, this is tier two." Patients shouldn’t have to master the intricacies of formularies to get on affordable and effective medications. Price transparency at the point of care is better for the patient, for the pharmacist, for the prescriber.  

  Q: Do you have any tips on how to have the cost conversation?

  A:

  When it gets to the part of the visit where the patient and family and I discuss a treatment plan, I say something like, "There's a medication I'd like to prescribe, but before I do, I'd like you to look at something with me. I can show you your specific cost for the medication. If that doesn't work with your budget, we can look at alternatives." My approach is that we’re allies, we’re making a decision together. Taking the mystery of cost out of the equation also eliminates any potential embarrassment. Doing so lets the family know you're on their side.

  Q: How does technology support this conversation?

  A:

  The technology brings the decision making back into the exam room, which is a very sacred space. Real-Time Prescription Benefit allows us to decide together, myself and my patient and their parents, the best course of action. Technology brings the decision back where it belongs.

  Q: Anything else you’d like to share?

  A:

  I’d say let’s point your readers to the webinar we had around just this very topic: Well, That Was Awkward: The Rx Cost Conversation. We had fun, and it was informative, too!