Public exchange plan participants spent less money on medications in the first quarter of 2015 than the first quarter of 2014 amid changes in the demographic mix of enrollees, according to newly released data from Express Scripts Holding Company.
Researchers also spotted an 18% decline in 2015 exchange plan enrollees who use at least one prescription and 34% fewer adjusted specialty pharmacy claims than in 2014. And theyre generally sanguine about cost-control prospects down the road.
However, a 24% growth in specialty drugs in public exchanges was found to be nearly three times the rate of traditional health plans in the first 15 months of utilization, resulting in 16% higher monthly costs for exchange plan enrollees than traditional health plan participants. Specialty medications accounted for 42% of all Rx spending among exchange plans.
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The increase was largely traced to hepatitis C medications, the third-costliest Rx class among exchange plans. In addition, nearly 53% of specialty pharmacy claims in exchange plans were for HIV vs. 20% for traditional health plans.
Another key finding was a higher proportion of exchange plan enrollees with high annual Rx costs on vs. off the exchanges, as well as those costs surpassing $50,000 per patient in 2014 at nearly twice the rate of commercial plans and more than three times the rate of Medicaid.
What stood out most to Julie Huppert, VP for health care reform at Express Scripts, was an overall lower utilization of both traditional and specialty medications by exchange enrollees whose prescriptions were filled the first quarter of 2015.
That may indicate these individuals are actually healthier than those who enrolled for 2014, she says, noting that the data shows theyre also younger on average.
Newer enrollees were able to reduce their out-of-pocket costs on specialty drugs and overall medications and 20% and 21%, respectively, compared to those in the year-ago period. If this trend continues, Huppert expects a more balanced risk pool in the exchanges over the long term.
Despite the greater use of expensive drugs in exchange plans relative to traditional insurance options, she says these benefits are being well-managed and public exchanges are more likely to implement programs to ensure that theres cost management, such as through our home delivery pharmacy or specialty pharmacy, Accredo, which offers narrower networks.
In 2014, Huppert says public exchanges were expected to lure in older and sicker Americans who had pent up demand for insurance because of pre-existing conditions or an inability to afford coverage, particularly with tax credits. That accounted for higher costs in the first year.
But irrespective of whether health care consumers receive prescription drugs through public exchanges or employer-sponsored plans, she says the lesson is the same. It really comes down to smart formulary management, Huppert notes, adding that the key is immediately addressing high-cost medications as theyre brought to market.
One such example is Express Scripts Hepatitis Care Value Program through Accredo, which saves payers money by negotiating with specific manufactures for preferred medications. Another benefit is that pharmacists trained specifically in Hep C help patients administer their drugs and ensure compliance with medication regimens, which helps drive healthier outcomes.
The recent Exchange Pulse report from Express Scripts serves as a reminder that many exchange plan patients are using this benefit to manage serious and costly chronic illnesses, thus highlighting a critical need for exchange plans to closely manage the pharmacy benefit in this program, according to the PBM, which manages more than one billion prescriptions.
The robust pipeline of new, high-cost therapies will only amplify the hurdles to sustaining an affordable benefit. These strategies, and others, are critical for exchange plans looking to stay competitive in the marketplace.
