High-cost medications: Barrier to care for many

At MultiCare, we are committed to working toward health equity — ensuring all people have access to quality health care regardless of age, race, ethnicity, gender identity, religion, sexual orientation, ability, socioeconomic status or location. But we also recognize the reality that longstanding biases and barriers embedded in the health care system, and our society, can prevent people from accessing the care they need.

In this series — inspired in part by society’s growing awareness that not everyone has the same chance to be healthy — we take a deeper look at the disparities that impact our patients and how we as health care providers and community members can reduce those disparities and improve the health and well-being of all.

A life-changing diagnosis often comes with high medication costs

After a life-changing diagnosis, it may feel as though everything has been flipped upside down. There are important decisions to make about treatment and how to balance it with family and work.

Your recovery will likely come down to finding the right medication.

The last thing you want to hear is that the medication you need could cost you thousands of dollars a month. For many people, that is the harsh reality.

“When it’s a life-threatening diagnosis, patients don’t need to add financial and insurance worries on top of it,” explains Melissa Gallegos, MultiCare specialty pharmacy manager. “Many patients probably don’t know how expensive medications can be unless they’ve seen it firsthand. It can be extremely frustrating if you don’t have the right support and services.”

At MultiCare, our social workers, patient financial navigators and providers help connect patients to various financial assistance programs available to cover costs, Gallegos says. But even for them, it’s a complicated and ever-changing environment.

Why are some medications so expensive?

You’ve likely bought more affordable over-the-counter medications, especially if you don’t have a chronic condition that requires regular prescription medications. Depending on your insurance and prescription coverage, many medications can still be relatively affordable.

In the past decade, though, these prices have been increasing. Humira, for example — which is commonly prescribed to treat moderate to severe rheumatoid arthritis, plaque psoriasis and Crohn’s disease — previously cost about $2,000 a month, Gallegos says. Now, it’s about $6,000.

Many health conditions also require more than one medication.

“Most people in heart failure have a general cardiologist, a primary care provider and a provider who monitors their pacemaker, and each of these providers may prescribe medications with a high copay. These add up,” explains Jennifer Bayne, MSW, LICSW, medical social worker at MultiCare’s Pulse Heart Institute Heart Failure Services. “So, you’ll have five to six medications that are $80-$100 copays each.”

Or, if you have multiple conditions that each require a prescription, those costs quickly add up, too.

As patients move into the specialty pharmacy realm, which provides access to medications for more complex conditions like multiple sclerosis or cancer, the costs skyrocket in part because of the work that goes into creating these treatments.

“What happens when people have to go off their medications for whatever reason, like losing insurance? We’re working against the clock a lot of the time.”

“These medications often treat very small patient populations, and because of that, the cost of research and development is spread out over a much smaller population,” she says. “That’s partly how high prices are justified.”

This research and development is crucial, though, Gallegos adds. There are new, more effective therapies available, and sometimes even cures for conditions we didn’t previously have.

Strensiq, for example, is the first and only treatment for people with perinatal/infantile — and juvenile — onset hypophosphatasia (HPP), which is a rare, inherited disease that can lead to soft, weak and deformed bones and have long-term impacts on development and mobility. The cost of this treatment can reach $100,000 a month, Gallegos says.

Who is most impacted by high medication costs? 

Unfortunately, anyone could face a diagnosis that requires expensive care at any point in life. At the Heart Failure Clinic, you may expect patients to be older, but Bayne says it’s getting more common to see people in their 20s and 30s.

“We have a lot of young moms who had complications during pregnancy and develop heart failure,” Bayne says. “We have other people whose bodies may have tolerated their heart condition for years because of their healthy lifestyle and it suddenly shows up later.”

Heart failure is a lifelong, progressive disease, and many of the procedures patients undergo require long-term medications afterward, she explains.

“What happens when people have to go off their medications for whatever reason, like losing insurance?” says Bayne. “We’re working against the clock a lot of the time.”

Your out-of-pocket costs largely depend on your insurance status, she explains. Someone could be uninsured for several reasons, including not qualifying for state or federal programs, not having employer-offered insurance, or not being eligible for coverage due to immigration status — although that is slowly improving.

Those enrolled in commercial insurance, whether through an employer or elsewhere, may still face high copays. Medicaid can be a helpful resource to cover costs if you qualify (in Washington state, a single adult with income less than $1,732 a month qualifies for Medicaid).

Medicare — for those ages 65 and older, or younger individuals with certain disabilities — can help alleviate some of the burden, says Bayne. But depending on how robust your Medicare plan is, you may still have very high copays, which can be challenging for people living on very tight budgets.

The Heart Failure Clinic averages about 100 new patients per month, she says. Of those, at least one a day is struggling to pay for medication. 

What support is available?

Patients have several options for financial assistance, including drug manufacturer copay cards, grants/foundations or patient assistance programs that can help cover costs, Gallegos explains.

Eligibility for assistance may depend on your current plan or income, or which state you live in, adds Michael Lee, MultiCare managed care pharmacist.

“We have to train every staff person to know how to get people help,” Bayne says.

The sooner patients get the process started, the better the outcome and assurance that there’s no lapse in treatment, she adds.

Financial resources for
the medications you need

MultiCare medication assistance

Social workers, registered nurses and financial assistance navigators, often embedded within clinics like Bayne is, can help patients collect all the necessary forms (such as prior authorizations), meet application deadlines and stay current when dosages change.

There’s also foundations and patient advocacy groups for more specific populations, such as those with rare diseases, Lee says.

“It’s crucial to raise awareness about these resources,” he says. “If we can reduce the cost burden now, hopefully we might prevent disease progression. Think about what could happen if you don’t receive treatment now — untreated conditions often lead to complications that are far more costly in the long run.”

It also worth exploring cost options on your own, Lee adds. Sometimes your insurance may not be the most affordable route. As of 2018, pharmacists can share the cash price of your medication when requested under the Know the Lowest Price Act and the Patients’ Right to Know Drug Prices Act. With the improved transparency under these changes, patients can compare prices and make more informed decisions about how to save on medication.

Additionally, many health care systems, including MultiCare, have staff who can help you choose the best plan during open enrollment.

On the federal level, changes are underway to help reduce out-of-pocket costs for some patients. In August 2023, the U.S. Department of Health and Human Services announced the first 10 drugs covered by Medicare that would be eligible for price negotiations with manufacturers, although these changes won’t be seen until 2026.

“This cannot come too soon … people are struggling now,” Bayne says. “And people are desperate because, at least in terms of heart failure, we finally have drugs that are effective, but not everyone can access them. This is massively inadequate and demonstrative of health inequity across the board.”

MultiCare is leading the way for employees

At MultiCare, we’re always looking for ways to ease the financial burden that our employees face when they need care.

“With our employee health plans, we carefully consider these factors when designing our own benefits,” Lee says. “Since it’s our program, we have the flexibility to make these decisions ourselves.”

For example, the MultiCare employee plan includes an extensive list of preventive medications that employees can receive for free when prescriptions are filled at a MultiCare pharmacy, he adds. This list includes a range of insulin and epinephrine products, which have seen rising prices elsewhere.

Additionally, MultiCare provides a financial assistance program that employees can apply for, if needed.