Health execs must brace for autoimmune drug changes

October 5, 2016

A comprehensive understanding of this rapidly increasing drug class is essential to integrate pharmacy and medical claim information.

Autoimmune specialty drugs now account for about $1 of every $10 of combined drug expense through the medical and pharmacy benefits in a commercially insured population, according to research presented at the Academy of Managed Care Pharmacy (AMCP) Nexus, on October 4, in National Harbor, Maryland.

Kevin Bowen, MD, MBA, principal health outcomes researcher at Prime Therapeutics and colleagues studied the prevalence of use and cost of autoimmune specialty drugs using integrated medical and pharmacy data.

Among 12 clients with a total average of 13.8 million commercially insured members per month, all members continuously enrolled from 2012 to 2015 were identified along with all of their medical and pharmacy benefit claims. The study members consisted of all individuals continuously enrolled from 2012 to 2015.

“Integrated analysis of medical and pharmacy claims is essential for this category of drugs because more than 25% of autoimmune specialty drug use is paid through the medical benefit and medical claims diagnosis coding provides a means of determining what conditions were treated with drugs covered by pharmacy claims,” Bowen told Managed Healthcare Executive.

The autoimmune drug class is one of the fastest growing, with this study finding a doubling in autoimmune drug expenditures and a 38% increase in utilization, in the most recent four years.

“Indication for drug therapy was assigned using an automated algorithm that examines all medical claims for autoimmune drug users,” Bowen said. “For example, for members with only pharmacy claims for autoimmune specialty drugs, the algorithm selects the most frequently coded indication on medical claims by the prescriber(s) for the pharmacy drug.”

The number of users and sum of plan plus member payments (i.e., allowed costs) without adjustment for rebates or coupons was calculated by year, by claim bill type (i.e., pharmacy benefit, medical claim for professional services, or medical claim for facility services), by indication, and by drug.

There are now 15 specialty autoimmune drugs along with many traditional generic drugs to treat autoimmune conditions such as Crohn’s disease, ulcerative colitis, psoriasis, psoriatic arthritis, ankylosing spondylitis, juvenile idiopathic arthritis and rheumatoid arthritis.

During the 2012 to 2015 study period, the FDA approved three new specialty autoimmune drugs, with a fourth approved in March 2016.

“With more than 15 autoimmune drugs, it is essential for payers and insurers to focus utilization and cost management on this rapidly increasing drug class,” Bowen said. “Medical claim provider information and diagnosis coding can also be used to categorize autoimmune drug use by indication, which may be helpful in designing strategies to manage cost effective use and for indication-based pricing.”

The good news for patients and health plans is that competition among drugs with the same indications may provide pharmacy benefit managers with new means of negotiating better prices and encourage use of the most cost-effective therapies, according to Bowen.

“Evaluation of potential strategies for this extremely important category of drugs should begin with a comprehensive understanding of their current use,” Bowen said. “To have a comprehensive understanding of use of these drugs is essential to integrate pharmacy and medical claim information.”