Formulary design important to statin users


New data sheds some light on the role of future insurance coverage options in total healthcare expenditures for patients on statin therapies.

Amanda Forys, MSPH, and her colleagues within Xcenda’s Reimbursement Strategy & Tactics consulting team, estimated future insurance enrollment for currently uninsured patients on statin therapy using data from the 2010 Medical Expenditure Panel Survey (MEPS). The findings were presented in mid-October at AMCP Nexus 2013: Connecting Health Care and Innovation, San Antonio, Texas.

This study was done to examine the impact of the Affordable Care Act on uninsured patients who are taking statin medications. Specifically, this study assessed the likelihood of patients who obtain new forms of coverage through health insurance exchanges and Medicaid expansion and estimated their out-of-pocket costs under new healthcare reform policies.

The researchers used a proprietary model developed by Xcenda that predicts future insurance coverage and out-of-pocket costs for the currently uninsured patient population, and applied this model to patients in the MEPS database receiving statin medication. A financial analysis was then performed based on expected health insurance exchange and Medicaid expansion cost-sharing guidelines and government subsidies to estimate the amount of out-of-pocket costs these patients are likely to pay for their statin medications and other prescription drugs.

Based on patient characteristics and the costs of therapies used, the researchers estimated that by 2018, patients will enroll in the following:  

• 19% of the sample patients will enroll in Medicaid

• 42% will enroll in health insurance exchanges

• 39% will remain uninsured              

“Additionally, we estimated costs of therapy for these patients once they enroll in insurance plans,” Forys said.

Medicaid enrollees using statin therapies are projected to spend an average of 20% of prescription drug costs (estimated to be nearly $1,600 total per year) on statins, health insurance exchange enrollees an average of 17%, and the uninsured an average of 19%.

“This is an example of how those enrolling in Medicaid or health insurance exchanges may still have challenges affording their prescription medications, and how important formulary design will be to patient access,” Forys said. “Additionally, understanding costs of care during the care and prescribing process is important as well, due to concerns of patient adherence to therapy [ie, if patients stop taking therapies due to cost], and also understanding the types of assistance manufacturers can offer some patients who have a difficult time affording their medication.”

The majority of uninsured individuals will likely enroll in health insurance exchanges or remain uninsured, according to Forys.

“There will be less enrollment in Medicaid as a result of the Supreme Court’s decision to make expansion optional at the state level,” she said. “For those taking statins, these drugs will likely account for approximately one-fifth of patients’ total drugs costs regardless of if they have health insurance exchanges or Medicaid coverage or no coverage at all. Manufacturers and the pharmacy community will need to further understand the costs associated with patients who have enrolled in Medicaid or health insurance exchanges and the population that will continue to remain uninsured to ensure product coverage and assess potential access issues.”

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