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Healthier patients begin utilizing exchange plans


"The Express Scripts Exchange Pulse" report compares prescription medication use among exchange plan enrollees to those who are enrolled in a traditional health plan benefit.

While high-cost specialty medication use in exchange plans grew significantly throughout 2014, we may be seeing the start of a new chapter with this program, where healthier Americans who use fewer prescription medications are engaging with these plans, according to a new study by Express Scripts.

Related: Managed care industry needs to know where exchanges are headed

"The Express Scripts Exchange Pulse" report compares prescription medication use among exchange plan enrollees to those who are enrolled in a traditional health plan benefit. The analysis examined medication trends from January 1, 2014 to March 31, 2015, and also compared trends in Q1 2015 to those seen in Q1 2014. The analysis is based on more than 100 million de-identified pharmacy claims administered by Express Scripts during these periods.

Study findings

The study found that new exchange plan enrollees spent less on medications in the first quarter of 2015 compared to the same time one year ago: The number of new exchange plan enrollees who used at least one prescription drug declined 18% in the first quarter of 2015.

However, when evaluating exchange plan medication trends between March 31, 2014 and March 31, 2015, researchers found that spending on high-cost specialty medications grew 24%-compared to 8% growth in traditional health plans-largely attributable to hepatitis C drugs, the third costliest therapy class among exchange plans.

"The findings highlight an opportunity for exchange plans to make medications more affordable and accessible by more closely managing the benefit, encouraging the use of home delivery pharmacy and other proven clinical pharmacy programs, which can help boost medication adherence and foster better disease management,"  Julie Huppert, VP of healthcare reform at Express Scripts, tells Managed Healthcare Executive. "This data is also useful in helping exchange plans identify gaps in risk management, and in preparing future bids."

"If these trends continue, plans can achieve a more balanced risk pool, which will help them sustain benefit offerings in the future," Huppert adds. "That said, the majority of these exchange plan enrollees are among our country’s sickest patients, and need all of the care and support possible to achieve better health."


Next: Study reveals opportunities for exchange plans


Study reveals opportunities for exchange plans

One key opportunity for exchange plan managers is improving adherence, Huppert says. "While medication non-adherence affects both exchange and traditional health plan patients, our research shows that across most traditional and specialty therapy classes, medication non-adherence was higher in exchange plans compared to traditional health plans.  And it was high in four of the top 10 costliest conditions for exchange plans: diabetes, high blood pressure, hepatitis C and HIV."

Related: Exchanges need improvements - With crises in the past, focus turns to upgrades

Other findings include:

  • 34% of exchange plan patients with high blood pressure-the most prevalent traditional condition on the exchanges-were non-adherent to medication therapy, compared to 29% among traditional health plan patients.

  • 27% of exchange plan patients treated for HIV-the most prevalent specialty condition among exchange plans-were non-adherent to medication therapy, compared to 25% of health plan patients.

Additional key trends seen in Q1 2015 included:

  • Spending on hepatitis C medication increased 96% compared to Q1 2014.

  • Oral contraceptive use increased 29%, likely due to the younger average age of exchange enrollees in Q1 2015.

  • While still the most common specialty condition, particularly among enrollees aged 18 to 64 years, HIV prevalence declined 11% compared to Q1 2014. 


Next: Exchange plan claims compared to traditional plan claims


Exchange plan claims compared to traditional plan claims

Data from the 15-month analysis shows specialty medications accounted for 42% of all pharmacy spending among exchange plans. Nearly 53% of exchange plan specialty pharmacy claims were for HIV, compared to 20% for traditional health plans. In addition, exchange plan costs were 16% higher per member per month compared to traditional health plans, largely due to increased specialty drug spending among exchange plan enrollees.

Related: ACA Exchanges: Price still king

High-cost hepatitis C drugs Harvoni (ledipasvir/sofosbuvir) and Sovaldi (sofosbuvir) were the two most expensive specialty drugs for exchange plan members. Harvoni represented 6.4% of the total pharmacy spend among exchange plans.

There were a higher proportion of patients with high annual medication costs in exchange plans. In 2014, only 5% of exchange plan patients accounted for more than 68% of total prescription drug spending. Additionally, the proportion of exchange plan patients with 2014 annual medication costs exceeding $50,000 was nearly two times more than commercially insured patients, and more than three times more than Medicaid patients.

Exchange plan patients with more than $50,000 in 2014 annual medications costs paid 2.2% of the costs of their medications out-of-pocket in 2014, and exchange plan patients with annual medications costs at or exceeding $100,000 in 2014 paid 1.7% of their total costs out-of-pocket. Their plans covered the remainder of the costs.

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