BANGOR, Maine — When doctors prescribe a medication, they typically know the drug’s intended uses, side effects and proper dosage. But few realize how much those prescriptions cost, even though price is a major reason why patients in the U.S. fail to fill up to 30 percent of all prescriptions, according to recent research.
The founders of a Bangor startup hope to change that with a new online tool that allows health providers to learn whether a patient can afford a drug before leaving the exam room. Mick Delargy, an entrepreneur and data cruncher, and his business partner, Nick Mamula, a former drug sales representative, created Rx-Option, an application that compiles and searches the voluminous prescription drug lists published by health insurers.
The lists, known as formularies, detail coverage restrictions that can make the difference between a $10 co-pay and a staggering drug bill. Drug formularies vary widely from insurer to insurer, imposing limits such as caps on the number of pills patients can take home. Rx-Option amasses the information through a single, easily searchable online application, allowing physicians to learn in three clicks whether a patient’s insurance will cover the drug they want to prescribe, Delargy said.
Many doctors remain unaware of how much medications cost, he said.
“The cost of a generic prescription drug across Bangor can vary by 1,000 percent,” he said. “It’s pretty radical.”
While prescribers can already look up each insurer’s drug formulary, the documents prove hard to find and challenging to navigate, Delargy said. All too often, patients learn at the pharmacy counter that their insurance plan won’t pay for needed drugs or imposes restrictions, he said. Then the patient or the pharmacist must call the doctor to tweak the prescription or find an alternative medication, which not only wastes time but delays treatment, he said.
Health insurers limit coverage for prescription drugs for a host of reasons. Paying only for generic versions, for example, cuts their costs, and insurers say declining to cover unproven therapies protects their policyholders.
Doctors treating numerous patients with varying insurance plans have no hope of keeping track of coverage restrictions without some help, Delargy said. Insurance plans may require an extra step of review before covering a medication, called prior authorization, or refuse to pay unless a patient tries another less costly or better-proven drug first, among other criteria.
“It’s just way too much information for any one doctor to have all in their head,” he said. “It would be the equivalent of having several volumes of Encyclopedia Britannica memorized, including every comma, period and exclamation mark, like 14 or 15 times over. It’s literally millions of bits of data.”
Rx-Option’s database includes more than 13,000 drugs and 19 insurance plans offered in Maine, including MaineCare, Delargy said. Add in the five coverage criteria typically associated with each drug — plus the array of health conditions those medications treat — and Maine prescribers face tens of millions of possible combinations, he said. Insurers also regularly adjust their formularies throughout the year, which Rx-Option will account for, he said.
Take Lisinopril, a common drug for high blood pressure, Delargy explained. One insurance plan might categorize it as a hypertension drug, while another classifies it as an ACE inhibitor. Both are correct, but doctors searching for the drug in a typical formulary might be hard-pressed to locate the medication, he said.
The formulary for MaineCare, the state’s Medicaid program, lists another hypertension drug called Diltiazem nine times, Delargy said. Depending on the strength and form of the drug, prior authorization may or may not apply, he said.
Prescribers can select the patient’s insurance plan, then search Rx-Option by drug name or medical condition, such as asthma or diabetes. The program displays the price category medications fall under — from common drugs with small co-pays to much costlier therapies — and searches discount drug programs offered by retailers such as Hannaford and Wal-Mart. Prescribers also can check those retailer discounts on generics for patients with no health insurance, Delargy said.
He and Mamula have funded the startup themselves, with no money from pharmaceutical companies, ensuring doctors get unbiased information, Delargy said.
“The whole idea was to put all the formulary information at the doctor’s fingertips, not to influence the doctor in any way on what to prescribe,” he said.
Rx-Option rolled out a test version of the online tool in May, and 70 prescribers across the state now use the service, he said.
Billie Jo Cole, a mental health nurse practitioner at Penobscot Community Health Care in Bangor, said Rx-Option is useful and easy to navigate. If a medication isn’t covered or proves too expensive, she can easily research other drugs, she said.
Confusion at the pharmacy counter over drug coverage can dangerously delay patients’ access to medication, and many of hers already struggle to find transportation to pick up their prescriptions, Cole said.
“I’m not dealing with frustrated patients who can’t get their medications and don’t know what they’re going to do,” she said.
When Rx-Option formally launches, prescribers will pay a flat monthly subscription of about $1 per day, Delargy said. Users will receive two concurrent login options, so two providers in the same office can query the program at once, or allow a doctor to check the program from more than one device, such as a computer and a smartphone.
Delargy and Mamula must not only convince doctors to pay for the program but also to add the step of checking Rx-Option to their already hectic workdays.
At first glance, Rx-Option appears well-researched and potentially useful, Gordon Smith, a spokesman for the Maine Medical Association, said after perusing the program’s website.
“It looks like a service that would be valuable to busy physicians, who don’t want their staff checking all the formularies, and very helpful for patients,” he said.
While prescribers may invest a few minutes upfront to check the program, they’ll save time in the end by avoiding callbacks from pharmacies, Delargy said.
Prescription obstacles amount to much more than just wasted time and paperwork, however. The failure to take prescriptions causes about 125,000 deaths per year and contributes to up to 10 percent of all hospitalizations, according to a December 2012 study published in the Annals of Internal Medicine. Researchers found that Americans’ failure to follow doctors’ medication orders costs the U.S. between $100 billion and $289 billion per year. In up to 30 percent of cases, patients never fill their prescriptions, and up to half of all medications aren’t taken as prescribed, they found.
Cost was cited as a major factor.
“There’s sort of a level of opaqueness with prescription drugs,” Delargy said. “Medicine’s one of the few things you actually buy where the decision to buy it is disconnected from what the price of the thing is. There’s huge variance in the price of the same prescription medicine from pharmacy A to pharmacy B.”
Rx-Option includes all major health plans in Maine, including those offered by employers, and the startup is working to add TRICARE, the health program for military personnel, Delargy said.
The idea for the program first seeded about four years ago, growing out of Mamula’s observations as a drug sales representative, he said. In the future, pharmacists also could potentially subscribe to Rx-Option, he said.
Delargy managed to reduce his own medication costs from over $100 per month to $12 per month, he said.
“I’m basically getting the same drugs but getting them at a different place,” he said.
