parallels DEFINING
A closer look at year-over-year patterns in drug utilization
and spend within the public exchange population The Health Insurance Marketplace (HIM), or public exchange, opened in 2014, and introduced many new individuals to health insurance. Prime Therapeutics (Prime) has had the opportunity to serve more than 1 in 6 of these new health care consumers. As we near the end of the second year of the exchange’s existence, we’re already seeing patterns emerge. We compared this new population’s medicine use and drug spend in the first half of 2014 to the same period in 2015. We discovered a number of interesting parallels — and a few significant differences.
A snapshot of midyear trends • A comparison of midyear trends in 2014 and 2015 • A longitudinal look at 18-month data • A prospective look at the impact of PCSK9 inhibitors
2014 vs. 2015 DEF I N I N G
Top drug categories
Contrary to the similarities found in usage, significant differences emerged when we ranked the top drug categories by total spend. The biggest change between 2014 and 2015 was among drugs used to treat depression. This category moved out of the top 10 (from position seven in 2014, to position 14 in 2015). Other major moves on the list: • Hepatitis C spend ramped up to eclipse diabetes
The top drug categories, when measured by utilization, remained largely the same for January through June 2014 versus the same period in 2015. Four of the top 10 categories did shift slightly: • Diabetes moved up to the fourth position. • High cholesterol moved down to position five. • ADHD moved up to position 10.
as the number one category. • Autoimmune spend moved up to the fourth position, with a notable increase in per member per month (PMPM) spend. • High blood pressure drugs shifted out of the top 10, to number 11, despite a slight increase in PMPM spend. • Cholesterol drugs rose to the ninth position,
• Insomnia moved out of the top 10 to position 11.
despite a utilization decrease of nearly 20 percent.
Top 10 drug categories by utilization (midyear)
Top 10 drug categories by total cost (midyear)
2014
2015
2014
2015
1
High blood pressure 23.75%
High blood pressure 18.50%
1
Diabetes 10.29%
Hepatitis C 11.56%
2
Pain 11.74%
Pain 8.66%
2
Hepatitis C 9.41%
Diabetes 10.91%
3
Depression 10.44%
Depression 8.20%
3
HIV 9.07%
HIV 9.70%
4
High cholesterol 9.45%
Diabetes 7.37%
4
Pain 6.18%
Autoimmune 7.36%
5
Diabetes 8.84%
High cholesterol 7.15%
5
Autoimmune 6.11%
Pain 5.84%
6
Estrogens and osteoporosis Estrogens and osteoporosis 4.90% 3.97%
6
Cancer (pills) 3.99%
Cancer (pills) 4.46%
7
Seizure 4.59%
Seizure 3.65%
7
Depression 3.84%
MS 3.74%
8
Gastrointestinal disorders 3.69%
Gastrointestinal disorders 3.04%
8
Multiple sclerosis (MS) 3.77%
Respiratory 3.17%
9
Respiratory 3.04%
Respiratory 2.54%
9
Respiratory 3.63%
High cholesterol 2.84%
10
Insomnia 1.94%
ADHD 1.46%
10
High blood pressure 3.50%
ADHD 2.71%
= category ranking change
2
Specialty drugs
The top 10 specialty drugs
The approval of several new specialty drugs in the latter
accounted for:
half of 2014 contributed to a major shift in the ranking of top drugs by utilization. The most significant change came from drugs used to treat hepatitis C. Among them, Harvoni, approved in November of 2014, surged to become one of the top three most-used specialty drugs in less than a year. Two other new drugs, Xeljanz (treatment for rheumatoid arthritis) and Xeloda
20.96%
of all drug spend
(treatment for breast and colon cancer), also moved onto the list of the 10 most-used specialty drugs. Analyzing the top-ranking specialty drugs by spend, we found that one of the newest hepatitis C drugs — Harvoni — became the top drug by total cost for the first half of 2015. Despite a utilization rate of just 0.02 percent, Harvoni had the highest spend among all drugs, not just the specialty category. Gleevec, a cancer drug,
0.13%
of all claims
also made it into the list at number nine.
Top 10 specialty drugs by percent of specialty utilization (midyear) 2014
2015
1
Humira (arthritis) 18.39%
Humira (arthritis) 21.24%
2
Enbrel (arthritis) 15.01%
3
Top 10 specialty drugs by percent of specialty spend (midyear) 2014
2015
1
Sovaldi (hepatitis C) 28.59%
Harvoni (hepatitis C) 28.57%
Enbrel (arthritis) 14.81%
2
Humira (arthritis) 9.01%
Humira (arthritis) 10.99%
Sovaldi (hepatitis C) 5.76%
Harvoni (hepatitis C) 6.06%
3
Enbrel (arthritis) 7.28%
Sovaldi (hepatitis C) 7.41%
4
Copaxone (MS) 4.86%
Copaxone (MS) 4.99%
4
Olysio (hepatitis C) 4.42%
Enbrel (arthritis) 6.91%
5
Tecfidera (MS) 2.72%
Tecfidera (MS) 3.61%
5
Copaxone (MS) 4.11%
Copaxone (MS) 3.82%
6
Ribavirin (hepatitis C) 2.05%
Capecitabine (cancer) 2.22%
6
Revlimid (cancer) 2.58%
Tecfidera (MS) 2.88%
7
Gilenya (MS) 1.88%
Sovaldi (hepatitis C) 1.77%
7
Tecfidera (MS) 2.41%
Revlimid (cancer) 2.45%
8
Revlimid (cancer) 1.64%
Revlimid (cancer) 1.71%
8
Gilenya (MS) 1.62%
Stelara (arthritis) 1.65%
9
Xeloda (cancer) 1.52%
Gilenya (MS) 1.60%
9
Stelara (arthritis) 1.61%
Gleevec (cancer) 1.65%
10
Rebif (MS) 1.44%
Xeljanz (arthritis) 1.55%
10
Xyrem (sleep disorders) 1.52%
Xyrem (sleep disorders) 1.44%
= drug ranking change
3
DEF I N I N G
An 18-month
point of view In addition to our year-over-year analysis, Prime looked at utilization
A clearer view of Prime’s public exchange population
and spend for the entire year of 2014,
A longer analysis period allowed us to better
as well as the first six months of
use their pharmacy benefits:
2015. During this 18-month period,
• They pay a relatively low share of pharmacy costs.
total pharmacy spend exceeded $2.2 billion dollars. Our assessment included a review of more than 30 million adjusted claims filled by public exchange
understand how our public exchange members
The majority of spend (85.65 percent) was paid by the health plans, with members paying only 14.35 percent of total costs out-of-pocket. For specialty drugs filled by public exchange members, health plans paid a much higher share of costs — 96.37 percent, on average. • They’re heavy users of generic drugs. The generic utilization rate (GUR) during the 18-month span was 85.99 percent. This supports
members between January 2014 and
Prime’s initial assessment that the exchange
June 2015. Expanding our analysis
correlates with the GUR for Prime’s commercial
to 18 months allowed for a deeper
time period.
dive into the public exchange population, and a fuller picture of patterns emerging over time.
population is cost-conscious. This number also members (81.45 percent) during the same • They have a higher rate of severe, chronic conditions. Specialty drug prescriptions accounted for just 0.44 percent of the claims reviewed. Yet that small percent of claims accounted for 29.73 percent of total spend. With nearly a third of total spend in the specialty drug category, it’s clear this population continues to have a higher rate of people living with severe, chronic conditions, such as hepatitic C, HIV and cancer, than the commercial membership.
4
Trends emerge
quarter one and quarter two, respectively. As in 2014, we expect utilization to rise in the
With the launch of the public exchanges in the
second half of 2015.
first quarter of 2014, utilization peaked with a per
Similar to utilization, spend over the full 18-month
member per year (PMPY) utilization average of
time period fluctuated between quarters. For the first
12.6 prescriptions filled — 23.5 percent higher than
quarter of 2014, spend averaged $80.84 PMPM. That
Prime’s commercial population. This initial, heavy
number then dipped in quarter two and rose again
use made it clear that many new members were
in quarters three and four. Like utilization, spend
underserved. Some may never have had health
in quarter one of 2015 was lower than at the end of
insurance before the exchanges were created.
2014. As the year went on, spend rose sharply and
Over the next three quarters in 2014, this PMPY
outpaced utilization. Midway through 2015,
utilization fell to as low as 10.6 prescriptions filled,
spending averaged $101.71 PMPM.
then rose again to peak in the last quarter of 2014
Although Prime’s commercial population spend
at 12.9 average prescriptions filled. This is likely
also trended upward, spend growth for the public
due to members meeting their deductibles, which
exchange membership was much steeper. We
reduced their share of costs for prescriptions filled later in the year. The new year saw a small reduction in utilization to a PMPY average of 11.5 and 11.9 for
attribute much of this to an older population, the introduction of newly approved drugs with extraordinarily high price tags, and sicker individuals signing up late in the enrollment period. We anticipate this trend will continue through the
Quarter-over-quarter PMPM spend and per member per year (PMPY) utilization
second half of the year.
$120
15 12.9
12.6
$90
$80.84
10.6 $72.37
11.9 11.5
11.3
$100.09 $84.00
$101.71 $89.69
10
$60
5 $30
$0
1Q2014 Spend (PMPM)
2Q2014
3Q2014
4Q2014
1Q2015
2Q2015
0
Utilization (average prescriptions PMPY)
5
DEF I N I N G
The impact of
PCSK9 inhibitors This past summer, the U.S. Food and Drug Administration approved two new drugs in a class of powerful cholesterol-lowering medicines. Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are intended for people with extremely high cholesterol levels, and for individuals with heart disease who can’t lower their cholesterol levels effectively with statins and other therapies alone. According to the American College of Cardiology
are statin-intolerant or can’t lower their low density
and the American Heart Association (AHA), people
lipoprotein (LDL or “bad” cholesterol) by 50 percent
older than 50 are more likely to have high cholesterol
with statins alone. In these cases, PSCK9 inhibitors
or already have heart disease. Both organizations
have been shown to significantly lower LDL.
recommend treatment with statin drugs for these
Prime’s public exchange members have an older
individuals.
average age (41.9 years), versus Prime’s commercial
Statins are the most cost-effective and clinically
population (35.4 years). This makes public exchange
appropriate treatment for most people. But they’re
members more likely to be prescribed medicine to
also one of the most underutilized medicines. Only
lower cholesterol, including PCSK9 inhibitors. With
1 in 5 people at risk for cardiovascular disease are
the significant price tag of these drugs — annual
following the AHA recommendation and taking a
per-patient costs can top $14,000 — we forecast a
high-dose statin regularly. However, some patients
significant impact to spend moving forward.
Potential PCSK9 cost impact based on utilization management (UM) criteria one year post-launch
SCENARIO 3
Minimal UM SCENARIO 2
Moderate UM
$ $ $ $ $
SCENARIO 1
Comprehensive UM
$ Utilization (per 1,000 members): PMPM cost: 6
1.1
4.6
8.5
$1.34
$5.60
$10.31
$ $ $ $ $ $ $ $ $ $
Future impact In creating our forecast, we used data from our 1.9 million public exchange members. Within the public exchange population (as of June 2015): • Forty percent of members were 50 to 64 years of age. • The estimated prevalence of heart disease
number of public exchange members who may be eligible for PCSK9 inhibitors — these new drugs pose a threat to health care affordability. Prime is working to manage the high cost of PSCK9 inhibitors by optimizing statin therapy, when appropriate. Today, all of Prime’s clients are aligned with successful PCSK9 strategies. But managing drug costs is just one piece of the puzzle. Proactively
(atherosclerotic cardiovascular disease) was
managing care is just as important. Effective
1.9 percent.
utilization management strategies and support to
• The estimated prevalence of high cholesterol (heterozygous familial hypercholesterolemia or homozygous familial hypercholesterolemia) was 0.22 percent. Based on the estimated prevalence of heart disease and high cholesterol in this population, we determined that these new drugs have the potential to significantly impact spend among public exchange
drive adherence can help make sure the right people get the right medicine at the right time — fostering improved health outcomes and a lower overall cost of care.
The new PCSK9 drugs can cost as much as
members. By August 2016 (one year post-launch), approximate PMPM costs could be between $1.34 and $10.31. This increase could total between $2.5 and nearly $20 million in spend.2 The new PCSK9 drugs can cost as much as 50 times more than highly effective (for most), yet highly
more than statins.
underutilized statins. Given the cost — and the
Conclusion Data from the first 18 months of the public exchange
ultra-expensive, PSCK9 inhibitors threatens to push
has revealed definite trends in utilization and spend
spend in this segment even higher.
among this new population.
As the Health Insurance Marketplace continues to
While utilization for the top 10 drugs has remained
evolve and mature, Prime will remain dedicated to
relatively consistent, spend has shifted significantly.
proactively managing pharmacy costs — helping to keep
Specialty medicine utilization and spend continues
health care affordable, improve member outcomes and
to increase due in large part to newer, more
enable a sustainable health care system.
effective — and more expensive — hepatitis C drugs and other biologic medicines. And, an older-skewing population coupled with the introduction of new 7
REFERENCES K.L. Bowen, P.P. Gleason. (2015). Statin Therapy, Intensity, Adherence and Number of Distinct Statins Tried Among Commercially Insured Adults with Atherosclerotic Cardiovascular Disease Continuously Enrolled Before and After 2013 ACC/AHA Cholesterol Guideline.
1
K.L. Bowen, P.P. Gleason. (2015). PCSK9 inhibitors Utilization Forecast Health Insurance Marketplace (HIM) Public Exchange.
2
Walker, T. (2015, September 2). High cost of new PCSK9 inhibitors could plague payers. Modern Medicine. Retrieved from http://www.modernmedicine.com/managed-healthcare-executive/news/high-cost-new-pcsk9inhibitors-could-plague-payers#sthash.xiAdI5r6.dpuf
3
All brand names are the property of their respective owner.
About Prime Therapeutics Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and delivers medicine to members, offering clinical services for people with complex medical conditions. Headquartered in St. Paul, Minn., Prime serves more than 26 million people. It is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. Prime has been recognized as one of the fastest-growing
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