Why does your prescription cost so much? A Mass General Brigham expert explains

You’ve probably had the experience of going to the pharmacy to pick up a medication and being surprised by how much it costs.

If prescription drugs in the United States (U.S.) seem expensive, you're not alone. Understanding why medications cost so much can be complicated, involving everything from drug development and patents to insurance coverage and government policies.

That’s where the expertise of physician scientists such as Benjamin Rome, MD, MPH, of Mass General Brigham, come in.

Dr. Rome studies is a primary care physician and health policy researcher studying how federal and state policies shape the regulation, use, cost and affordability of prescription drugs, how those decisions affect patients' access to care and health outcomes.

We spoke with Dr. Rome to better understand why prescription drugs cost what they do and how his research is working to make them more affordable.

What does your research focus on?

Rome: I am part of the Program on Regulation, Therapeutics and Law, or PORTAL, an interdisciplinary research group within the Division of Pharmacoepidemiology and Pharmacoeconomics at Mass General Brigham.

Our group focuses on the development, regulation, evidence-based use, and cost of prescription drugs. 
My research focuses on the cost of prescription drugs, how policies affect those costs, and how affordability influences whether patients can access the medications they need.
 

Why do prescription drugs cost so much in the United States?

Rome: When a new brand-name drug comes to market, it is typically protected by patents that prevent other companies from selling competing (generic) versions.

Without direct competition, the company that makes the drug has significant flexibility in setting its price based on what insurers and patients may be willing to pay.

Once the protection ends – typically after about 15 years – competition can help bring prices down.

For traditional drugs, that usually happens when generic versions become available. For more complex drugs known as biologics, competition may come from products called biosimilars.

But these competitors cannot enter the market right away. As a result, many of the drugs with especially high prices are newer medications that are still protected from competition.

Our research, which has tracked new drugs since 2008, has found that the prices of drugs when they first enter the market have increased substantially. This is true even after accounting for differences between the types of drugs approved today and those approved 10 or 15 years ago.

How do high drug prices affect individual patients?

Rome: The sticker price of a medication set by drug companies is not necessarily what a patient pays.  
 
A person’s out-of-pocket costs depend on their insurance plan, including deductibles, copayments, and coinsurance.

Even if patients only pay a small percentage of an extremely expensive drug, the costs can add up quickly. We know from research that high out-of-pocket costs are a major barrier to patients accessing treatment. The more patients must pay at the pharmacy counter, the less likely they are to take the medication.
 

Recent policy changes passed by Congress have placed a yearly limit on what patients enrolled in Medicare prescription drug plans pay out of pocket. I am studying how those changes affect access to expensive treatments, including medications for cancer and immunologic conditions. 

What first inspired your interest in prescription drug affordability?

Rome: During my internal medicine residency at Brigham and Women’s Hospital, I saw firsthand how medication costs affected patient care. My colleagues and I sometimes spent hours on the phone with insurance companies trying to secure coverage for newer blood thinners or diabetes treatments.

I continue to see these challenges in my primary care practice. Before the recent changes to Medicare prescription drug coverage, I cared for a patient who would stop taking their diabetes medication every fall because their monthly costs jumped to hundreds of dollars. They simply could not afford to take the medication consistently.

Experiences like that illustrate the connection between policy and patient care. As a researcher, I study how policies are designed. As a physician, I see how those policies affect people in their everyday lives.
 

Why should clinicians talk to their patients about medication costs?

Rome: The first priority should always be identifying the most appropriate treatment based on a patient’s medical needs. At the same time, clinicians need to recognize the realities of our health care system and understand that cost may prevent a patient from accessing the medications they prescribe.

We should ask patients whether they can afford their medications, remain aware of potential coverage limitations, and advocate for policies that improve access and bring costs down. 
 

How can health systems help clinicians provide more cost-effective care?

Rome: Health systems can help clinicians choose lower-cost treatments, particularly when several medically appropriate options are available. This may include encouraging the use of generic medications or helping clinicians understand when two similar products have very different prices.

At Mass General Brigham, pharmacy teams have been developing tools within our electronic health record to guide clinicians toward cost-effective options for conditions including diabetes, obesity, and insomnia. There are also new tools integrated with our electronic health record that provide information about a patient’s expected costs when a clinician prescribes a new medication.

These tools are helpful because clinicians generally do not have the time or resources to research the price of every medication during each patient visit. When several treatments are medically appropriate, better information can help us choose an effective option that may also be more affordable.
 

What policy changes could make prescription drugs more affordable?

Rome: The Inflation Reduction Act was an important step. It lowered out-of-pocket costs for people with Medicare and gave Medicare the authority to negotiate prices for certain medications.

However, Medicare generally cannot begin negotiating a drug’s price immediately after it is approved. That leaves an initial period during which manufacturers can continue to set high prices without negotiation or competition. Giving public programs greater ability to negotiate fair prices from the start could help address that challenge.

We also need insurance coverage that protects patients from unaffordable out-of-pocket costs, regardless of whether they have Medicare, Medicaid or private insurance.

At the same time, policies must address the total prices paid by insurers and government programs, since those costs eventually affect premiums and taxpayers.

Success would mean pursuing these goals together: Lowering the overall cost of medications and ensuring that what patients pay does not prevent them from receiving treatment. 
 

What do you hope people take away from this work?

Rome: Prescription drugs are some of the most important and effective tools at our disposal to treat a variety of health conditions. So high costs for these treatments has very tangible consequences. When patients cannot afford their medication, even the most clinically effective treatment will not improve their health.

We need policies, insurance systems, and clinical tools that make effective medications accessible to the people who need them. Clinicians also have an important role in recognizing affordability challenges and advocating for patients.