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GoodRx CEO: The Rise of the 'Pay-tient' Means We Must Reimagine Health Care Plans

It's time for us to rethink what health insurance looks like in the U.S. I remember a time when having a commercial health plan meant my basic health care needs were covered. I would go to the pharmacy counter, pay the $10 copay, and walk away with my prescription. Now, it's rarely that easy. The Declining State of Health Insurance Coverage It's no secret that health insurance is covering less while simultaneously becoming more complex to navigate. In fact, a new report from GoodRx Research—Coverage With a Catch: The Uneven Landscape of Prescription Coverage and Restrictions Across U.S. Insurance—shows that prescription insurance coverage has become less comprehensive and more restrictive across all insurance types—commercial, Medicare, and Medicaid. A pharmacist is seen taking a drug from a drawer cabinet. A pharmacist is seen taking a drug from a drawer cabinet. Getty Images For the average commercial insurance plan, our research shows 21 percent of medications lack coverage and 35 percent of covered medications have restrictions, meaning these drugs are subject to additional requirements before insurance agrees to pay. For patients on Medicare, coverage is even worse—the average Medicare plan doesn't cover 44 percent of medications and imposes restrictions on nearly half of the medications that are covered. And while the average Medicaid plan covers 97 percent of medications, 63 percent of those medications have restrictions. Across the board, getting through the red tape is often lengthy and complex, potentially leading to delays in treatment and added stress for patients. Understandably, these insurance challenges leave millions of Americans frustrated when trying to fill prescriptions. The bureaucratic obstacles not only exacerbate delays, but often translate to more of the cost burden shifting to the consumer. And consumers don't want to pay more than they feel is fair for their medications, especially when they're already seeing monthly health insurance premiums increase, taking more from their paychecks. Beyond the price factor, they also don't want to spend their free time jumping through hurdles to access medications. What used to be a quick trip to the pharmacy now requires cost-conscious consumers to price shop and find affordability options ahead of time due to the complex nature of navigating health plans. Faced with these challenges, an increasing number of Americans are turning to cash pay, meaning they are paying for their medications out-of-pocket, to bypass the often time-consuming insurance processes. The Rise of the "Pay-tient" Ten years ago, consumers didn't even know what "cash pay" meant—there was no need for it. Now, millions of Americans are reliant upon it. We must find ways to make cash prices more accessible and we can start by reimagining what health plans look like. The next-generation of health insurance needs to be fully integrated—cash prices and funded prices should be ubiquitous. Let's look at what that means in practice. When a consumer goes to the pharmacy counter, they shouldn't have to worry about whether a drug is covered under their insurance plan. Drugs not covered by insurance should automatically have a low cash price attached to them, and drugs that are covered but still have high price tags or restrictions should show the consumer the cash price if it's lower than the copay. Under this model, it makes no difference to a consumer whether they're using their insurance benefit or not, as the charge hitting their credit card will be the lowest possible. GoodRx has already started doing this with covered generics through its Integrated Savings Programs, automatically giving consumers the lowest available price at the pharmacy counter and applying it toward their deductible. We are working to integrate off-benefit and brand-name medications as well. Reengineering Health Plans One of the driving forces behind shrinking coverage is that employers simply can't afford to cover everything. Add on inflation, the threat of tariffs, and rising health care costs, and it's very unlikely that this trend will reverse in the foreseeable future. But there's more employers can do if they think outside the traditional bounds of health insurance plans to ensure their employees have an easy pathway to accessing medications that aren't covered. This is where reengineering health plans comes in. Implementing an integrated system would drive better value for consumers and employers, while also supporting the interests of health care professionals, retail pharmacies, pharmaceutical manufacturers, and many other stakeholders in the prescription ecosystem. Beyond giving consumers the best price, regardless of insurance coverage, this shift will free up health care professionals who are bogged down with prior authorizations and paperwork, giving them more time and energy to focus on the right treatment plan for each patient. It also supports the profitability of retail pharmacies, helping overcome the epidemic of abandoned prescriptions when patients walk away due to cost. And pharmaceutical manufacturers can get more patients to start and stay on brand-name therapies, rather than lose these consumers to alternative treatments when their insurance plans won't cover the medication. The U.S. health care system is notoriously complex, and changes won't happen overnight. But to address high health care costs and keep people adherent to their prescribed treatment plans, it's critical that we evolve our current system to bring fair prices to all Americans—without the extra legwork. Wendy Barnes is president and CEO of GoodRx. The views expressed in this article are the writer's own.