Claims for specialty and HIV drugs higher among early enrollees

April 28, 2014

Specialty medications accounted for six of the top 10 drugs in exchange claims data

Pharmacy claims indicate that early exchange enrollees are sicker than the typical commercial population, according to data from Express Scripts.

Use of specialty medications and pain drugs was significantly higher among those who accessed benefits through exchange plans in January and February 2014. In fact, six of the top 10 costliest medications used by the enrollees were specialty drugs, compared to four of the top 10 in a typical commercial plan.

However, the data also indicates that insurers’ per-member pharmacy costs for the first two months of the year were nearly 35% lower for the exchange population comparatively, most likely because of higher out-of-pocket costs for members.

It’s no surprise to insurers that early signups included a higher number of members with immediate medical needs. A bigger question to watch over the next several months is whether the later enrollees will turn out to be healthy enough to balance the risk pool.

HIV drug claims

Among early enrollees, medications for HIV accounted for more than six of every 1,000 prescriptions, which is nearly four times higher than typical commercial plans, says Julie Huppert, vice president of healthcare reform for Express Scripts.

“The Ryan White program encouraged the HIV community to sign up through public exchanges for the benefits, especially those who didn’t have access to coverage before because they were denied because of pre-existing conditions, or those who could not afford it and now have subsidized assistance both with premiums and cost sharing,” Huppert says. “Those subsidies from the federal government would come first before any Ryan White funds, and this is one way they hope to elongate the finite funds.”

The proportion of pain medication was 35% higher in exchange plans, but she says it’s too soon to determine what is driving the utilization trend specifically.

“Given the insight we’ve been able to glean from pharmacy data-which is adjudicated in real time at the point of sale, unlike medical claims-it can help health insurers plan for the individuals and the prevalence of conditions that we’re seeing in the first few months of data when preparing their 2015 bids,” she says. “Knowing pain is a higher prevalence condition than in their traditional book of business-and it can be an expensive condition to treat, more so on the medical side than the pharmacy side-having that information going into their planning and rates for 2015 is important.”

Rates for the federally operated exchange must be filed in June, but some state exchanges have earlier deadlines. Participating health plans no doubt will be doing some guesswork.

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Part of the strategy will include optimizing pharmacy benefits to strike the right balance between access and cost control. Huppert says plans want optimal outcomes on the pharmacy and the medical side, but at the same time must do it “in a way that manages cost, so this can be a sustainable benefit for the long term.”

The Express Scripts analysis included 650,000 de-identified claims, and approximately 43% of the exchange enrollees in those claims were previously covered by the PBM. The remaining 57% could have been covered by other pharmacy programs or were uninsured.

“Bending the cost curve for the uninsured won’t happen overnight,” she says. “Just because they receive coverage now doesn’t make them less costly.”

Huppert says although the Congressional Budget Office had predicted many new enrollees in 2014 would be previously uninsured, the mix actually includes more insured members who have been redirected to the subsidized plans. The federal government didn’t track coverage status of healthcare.gov visitors who selected plans, and a reliable source of data might not be readily available for some time.