Levy M, Garden EB, Tomer N et al: A comparison of pharmaceutical prices for generic erectile dysfunction and benign prostatic hyperplasia medication in 2 socioeconomically disparate New York City neighborhoods. Urol Pract 2021; 9: 25.

Erectile dysfunction (ED) and benign prostatic hyperplasia (BPH) are 2 of the most common urological issues for aging men. First-line management for both ED and BPH involves medication therapy; however, medication pricing for uninsured patients remains high. High pricing, pricing variability and a poor understanding of medication pricing have been cited as barriers to medication adherence, which may lead to worse clinical outcomes.^1,2

Previous studies have identified significant cost differences in the cash prices for medications sold at chains and independent pharmacies in large geographic areas.^3,4 However, no study has focused on specific urban neighborhoods with unique socioeconomic statuses. We explored how pharmacy type (chain, independent) and neighborhood socioeconomic status may influence the cash prices for common urological medications in 2 socioeconomically disparate neighborhoods–the wealthier Upper East Side (UES) and poorer East Harlem (EH) neighborhoods of New York City.⁵

To answer this question, we contacted all chain (CP) and independent (IP) pharmacies in the UES and EH via phone call to obtain the cash price for a standardized 30-day supply of 14 medications (table 1). Median drug prices and variability in prices were analyzed based on pharmacy type (chain vs independent) and neighborhood (UES vs EH). Of the 96 total pharmacies across both neighborhoods, 81 (84.4%) responded, of which 29 (35.8%) were CPs and 52 (64.2%) were IPs. Though the total number of pharmacies in each neighborhood was similar (UES: 50; EH: 46), the distribution of CP:IP was significantly different between neighborhoods. The UES had a roughly even distribution with 23 CPs (56%) and 18 IPs (44%); however, EH had a significant skew toward independent pharmacies, with only 6 CPs (15%) and 34 IPs (85%).

When comparing medication prices based on pharmacy type, the average prices of 9/14 (64.3%) and 14/14 (100%) medications were significantly cheaper at IPs in the UES and EH, respectively. This suggests that pharmacy type may influence medication cash prices. Across both neighborhoods, the greatest variations in drug pricing were seen in the 2 ED medications studied: tadalafil 20 mg (UES: 15.0-fold; EH: 26.7-fold) and sildenafil 100 mg (UES: 8.4-fold; EH: 15.4-fold). Notably, a regimen of tadalafil 5 mg–typically utilized for men with BPH–did not show as much variability (UES: 4.2-fold; EH: 6.6-fold). Therefore, this may suggest that pricing variation may be greater for ED medications compared to BPH medications (table 1).

Table 1. Variability in medication pricing based on pharmacy type. Variability in median (IQR) prices of 14 common urological medications based on pharmacy type (CP and IP) for UES and EH neighborhoods of New York City. 5ARi, 5alpha reductase inhibitors; ER, extended release; IR, immediate release; PDE5i, phosphodiesterase 5 inhibitors.

When comparing prices based on neighborhood, CPs had standardized pricing across both the UES and EH, whereas medication pricing at IPs demonstrated significant variability between neighborhoods. Compared to EH, IPs in the UES charged significantly more for 9/14 medications (64.3%), suggesting that a neighborhood’s socioeconomic status may also influence medication cash prices (table 2).

Table 2. Variability in independent pharmacy medication pricing based on neighborhood. Variability in median (IQR) prices for IPs based on New York City neighborhoods (UES and EH). 5ARi, 5alpha reductase inhibitors; ER, extended release; IR, immediate release; PDE5i, phosphodiesterase 5 inhibitors.

These adjacent neighborhoods are unique in their demographic and socioeconomic makeups, representing opposite ends of the socioeconomic spectrum within the state of New York and across the country. The UES is 78% White with a median household income of over $130,000 (nearly twice the statewide median household income);⁶ in contrast, EH is 50% Latino, 30% Black and 12% White with a median household income of less than $32,000 (more than half the statewide median household income).⁷ Based on our findings, lower IP prices in the poorer EH neighborhoods suggest that prices may be appropriately tailored to the clientele’s economic needs. However, standardized and generally higher prices at CPs suggest these may be a less favorable option for uninsured patients looking to keep health care costs low.

IPs in EH had reduced prices, and there was a significantly greater number of independents than chains in EH, which on its surface appears to suggest that health care costs remain low in the lower income neighborhood. However, this skew in pharmacy type distribution may actually lead to hidden health care disparities for patients in EH, with some suggesting that a lack of chains can disadvantage residents of poorer neighborhoods by decreasing access to certain medications and the broader range of preventive health care services that chains can offer.⁸ So, while our study concluded that IPs in EH were generally less expensive, the EH patients may still be disadvantaged by having so few CPs, which provide more consistent health care support to their customers.

The main limitation of our study relates to its generalizability. Though comparing UES and EH pharmacies offers a unique analysis of opposite ends of the socioeconomic spectrum, these findings are not necessarily generalizable to New York City as a whole or to urban centers nationwide. Additionally, since this study focused on the uninsured patients who pay cash prices, these trends may not be generalizable to patients with complete or partial insurance coverage.

While our study identified trends in medication pricing at CPs and IPs, it does not consider pricing offered by online pharmacies, which have seen a sharp rise in use due to reduced prices and greater accessibility for all patients. Nor does it consider discount coupon programs, which offer reduced pricing at many CPs and IPs. We have begun to study how online pharmacies and discount programs can alter the pharmaceutical ecosystem to identify how providers can utilize these resources to optimize recommendations for their patients.

Ultimately, our findings should be considered in the continued efforts to improve patient education and reduce health care costs, particularly for the nearly 1 in 8 Americans who are uninsured. It is important that physicians educate their patients on the variability in pricing for many common medications to increase medication adherence.