Introduction

Approximately 670,000 Canadians live with heart failure (HF), and the incidence and prevalence of HF are rising [1]. Daily use of evidence-based HF medications by patients living with HF with reduced ejection fraction not only impacts survival but also leads to improved quality of life [2]. In Canada’s single-payer healthcare system, physician and hospital-based services are covered. However, prescription medication coverage is not universal and some patients have to pay to access medications. In fact, Canada is one of the few countries with socialized medicine that does not provide universal pharmacare [3]. One in five Canadians does not have prescription drug insurance or is underinsured [3]. Approximately 1 in 12 Canadians over 55 years of age has not filled a prescription or missed doses because they could not afford out-of-pocket costs [4]. Out-of-pocket drug expenses contribute to non-adherence, but may also lead to an increase risk of hospitalizations, morbidity, and mortality [5]. Prescribing healthcare providers are generally not knowledgeable of costs and how they can impact access to medications [6, 7]. They may also overlook potential strategies that could minimize out-of-pocket prescription drug costs.

The objective of the present study was to identify potential methods patients and prescribers can employ to reduce prescription costs for individuals with HF who pay for medications out of pocket.

Methods

We collected data from outpatient pharmacies in Hamilton, Ontario. We aimed to collect data from two locations for each of the major chain pharmacies in the area and from a selection of independent pharmacies. Between March and June 2019, study personnel administered a standardized questionnaire to pharmacists or their designate in-person, over the telephone, or through the online REDCap electronic data capture tools hosted at McMaster University (Appendix 1) [8, 9]. Questions focused on pricing information for all pharmacological therapies at evidence-based dosages included in the Canadian Cardiovascular Society’s 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of HF (Appendix Table 5) [2]. Our questionnaire also gathered information on supplementary charges for delivery, pill-splitting, and blister packaging. We determined the dispensing fee, drug price, and total price of a (1) 30-day generic prescription, (2) 30-day brand-name prescription, and (3) 90-day generic prescription of the drugs/dosages indicated in Table 1 at each pharmacy. In cases where more than one generic or brand-name version of a drug was stocked at a pharmacy, we obtained the price of the least expensive option. We then calculated the minimum total price, maximum total price, range, and mean for each prescription option.

Table 1 Description of participating pharmacies
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To explore the generalizability of our results, we administered our questionnaires to a smaller number of pharmacies in the Greater Toronto Area (Ontario) and in Winnipeg (Manitoba).

We confirmed with the Hamilton Integrated Research Ethics Board that ethics approval was not required to conduct the present study.

Results

We collected data from 24 different pharmacies. This included 4 hospital-based pharmacies, 17 pharmacies that were part of chains, and 3 pharmacies that were identified as independent (Table 1, Appendix Table 6). The average annual household income in the postal codes where the responding pharmacies were located ranged from $41,396 to $190,813, according to Canadian Census data [10].

Drug Costs

Table 2 presents the cost ranges—the difference between the most and least expensive option—for each drug class. Table 3 lists the cost ranges for each drug, separately for generic and brand-name drugs. The differences in costs for the same agent manufactured by two different companies and/or sold at two different pharmacies ranged from $13.05 to $131.76 per 90 days for generic drugs and from $36.24 to $650.07.00 per 90 days for brand-name drugs. Table 4 details the lowest and highest cost regimen (including dispensing fees) for a 90-day supply of guideline-directed medical therapy. Prescribing the least expensive generic as compared with the most expensive brand-name drug for a single class of agent could save a patient as much as $1486.68 every 90 days.

Table 2 Cost range for 90 days for all options in each guideline-recommended drug classa
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Table 3 90-Day drug cost ranges not including dispensing feesa
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Table 4 Lowest and highest cost regimen (including dispensing fees) for a 90-day supply of guideline-directed medical therapy for heart failure with reduced ejection fraction
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Accessory Costs

Dispensing fees ranged from $3.89 to $12.99 per prescription. Twenty of 24 pharmacies offered a delivery service; 16 pharmacies offered free delivery (80%). When available at a cost, delivery fees varied from $5 to courier rates at costs; one pharmacy waved the cost of delivery for three or more prescriptions. All but one pharmacy provided blister packing and pill-splitting; this service was always free. The proportion of pharmacies that set their own prices was 46%, while the remainder were set by a central office. In Canada, manufacturer-sponsored access programs exist for some brand-name only medications [11]. However, representatives confirmed that neither of the guideline-recommended brand-name only agents had such a program.

Generalizability

Results from pharmacies in Toronto (Ontario) and Winnipeg (Manitoba) were similar (Appendix Table 7).

Overall Cost Difference

In the most extreme scenario (i.e., by choosing a 90-day prescription instead of a 30-day prescription and the least expensive generic drug instead of the most expensive brand-name drug), prescribers could save patients $495.56 per month or $1486.68 every 3 months (Table 4).

Discussion

Key Findings

We found significant variations in the costs of evidence-based HF drugs within drug classes and across pharmacies. In the most extreme scenario (i.e., by choosing a 90-day prescription instead of a 30-day prescription and the least expensive generic drug instead of the most expensive brand-name drug), total medication costs can differ by up to $495.56 per month. Costs were affected by choice of agent within a drug class, choice of a generic versus brand-name drug, quantity dispensed, dispensing fee, and delivery cost.

We have identified six potential strategies to reduce costs for patients with HF who pay out of pocket for guideline-indicated medical therapy (Fig. 1). In collaboration, prescribers, patients, and pharmacists can minimize drug costs. Prescribers can choose generic drugs and inquire about the cost of different agents within a drug class. They can also prescribe a 90-day supply to minimize dispensing fees and work with patients to apply to manufacturer-sponsored programs, when they exist, for cost subsidies for drugs without a generic alternative. Patients should be cognizant that their choice of pharmacy can impact their out-of-pocket costs. Patients should be informed that pharmacies can differ with respect to dispensing fees and services provided and consider a pharmacy with free delivery if not in walking distance. Finally, patients should also understand that the price of generic drugs could vary between pharmacies. There are several websites that patients can use to compare costs from multiple medication providers simultaneously (e.g., pharmacychecker.com (international); goodrx.com, blinkhealth.com, and wrx.org (USA); and pharmacycompass.ca (British Columbia, Canada)).

Fig. 1
figure 1

Strategies to minimize out-of-pocket medication costs for patients with heart failure

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Pharmacists play an essential role in minimizing medication costs for patients who pay out of pocket. In contrast to many private and government plans, there are no specific supply dispensing guidelines (e.g., 1 vs. 3 months) for out-of-pocket payers. Pharmacists in most jurisdictions are required to dispense the lowest cost product listed in a category of drugs (there are some exceptions to this policy). In Ontario, this is guided by the Drug Interchangeability and Dispensing Fee Act [12].

Results in Context

Our study is the first to comprehensively explore the potential cost variation for a standard evidence-based drug regimen for HF with reduced ejection fraction in Canada.

Medication costs clearly impact patient adherence. A survey of 5784 Medicare beneficiaries in the USA identified strategies used by patients to reduce medication costs and measured their association with medication adherence from claims data [13]. These strategies included obtaining free samples from physicians, splitting higher-dose pills, and purchasing medications from other countries or through the Veterans Administration. In that survey, factors associated with non-adherence included use of more medications, pill-splitting, acquisition of free samples, and male sex. In a multicenter, open-label, randomized clinical trial conducted at nine primary care clinics in Ontario, provision of essential medicines at no charge increased adherence to treatment over 1 year of follow up [14].

Studies conducted in different healthcare systems have identified approaches that may be effective at a system level. A nationwide study of medication claims in Austria (universal drug program; population approximately 9 million) estimated that using the least-expensive agent among frequently used cardiovascular drugs could have reduced overall costs for these drugs by as much as 18% [15].

Interpretation of Results

Minimizing cost matters to patients. Decreased costs may increase adherence, improve outcomes, and reduce the financial burden of the disease on the patient. Minimizing costs also matters to society. Canadians pay among the highest prescription drug prices in the world [16, 17]. The per-capita expenditures on prescription drugs in Canada were second only to that of Switzerland [17]. Higher medication prices in Canada combined with healthcare providers prescribing costlier drugs accounted for an excess expenditure of $2.3 bn in 2015. This estimate is derived from the estimated cost if the average medication cost per day in Canada had been similar to nine other high-income countries with universal healthcare coverage (Australia, France, Germany, The Netherlands, New Zealand, Norway, Sweden, The UK, and Switzerland) [17]. Some of the strategies we have proposed could be implemented not only in the prescription of evidence-based HF therapy but universally to decrease drug costs and to promote adherence, which is likely to result in significant cost savings to public systems [18].

Strengths and Limitations

This is the first study examining strategies to reduce out-of-pocket HF medication costs for Canadian patients. We assumed all drugs within a class to be equivalent, provided they were listed in the Canadian Guidelines [2]. Cost variations may differ in communities other than Hamilton and over time; healthcare providers may need to assess costs in their own community.

Conclusion

Prescription content and pharmacy choice impact out-of-pocket costs for HF medications. Prescribers can reduce costs by writing 90-day prescriptions and choosing the lowest-cost generic drugs in each therapeutic class. Patients should know that pharmacies can differ with respect to dispensing fees and services provided, access free delivery services where needed, and request inexpensive generic drugs. Pharmacists can help facilitate cost minimization without compromising therapeutic efficacy.