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ACA/59% Use Specialty Meds Prescriptions:
HIV/HCV Prominent-Express Scripts Report
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Download the PDF here
An October report from Express Scripts, the nation's largest manager of pharmacy benefits, has found that people who gain insurance coverage through the law's exchanges are much more likely to use expensive drugs known as specialty drugs.
"SPECIALT Y MEDICATI ON USE AND SPENDING IS HIGHER,
ESPECIALY FOR HIV....
Health exchange members are 59% more likely to have filled a prescription for
a specialty medication. HIV is the top specialty condition for health exchange
members aged 18 to 64, particularly among those who live in a zip code with a low
median income. Nearly 3 out of 5 specialty claims overall are for HIV medications.
Additionally, compared to health exchange members without HIV, those who take
HIV medications are also much more likely to be taking drugs for hepatitis C,
hepatitis B, viral infections and smoking cessation."
"The use of high-cost specialty drugs significantly impacts the level of care
provided as well as the cost burden for plan sponsors and members. With
additional high-cost drugs for hepatitis C being planned for late 2014 and 2015,
Express Scripts will continue to monitor this category carefully."
"Implications
As our 2013 Drug Trend Report indicates, despite comprising less than 1% of all U.S. prescriptions, specialty medications account for more than 25% of total pharmacy spend. While these figures are consistent with the costs seen in commercial health plans, specialty claims in health exchange plans contribute to 38% of total spend.
Greater use of HIV and hepatitis C medications is likely a driving factor for specialty costs in the health exchange population. It's also important to note that some individuals with HIV had been receiving care through federally funded programs, such as the Ryan White HIV/AIDS program, so a portion of the increased spending on HIV drugs
may represent a shifting of payment from federal sources to private health insurers."
"Implications
Health exchange members in the lowest average income group use a higher percentage of specialty medications, particularly for HIV. Those with HIV are more likely to have other chronic health issues, so treating these complex conditions will greatly impact overall quality and cost of care. Many health exchange members with HIV are also new to insurance and new to the drug treatment regime to manage this disease state. As reported by Kaiser Health News in September 2014, the Centers for Disease Control and Prevention found that although 75% of people with HIV are linked to care within 3 months of diagnosis, only 50% retain that care. It is critical for plan sponsors to provide members with clinical programs that ensure optimal use and adherence, and appropriate management of these complex, high-cost medications.
The Express Scripts Immunology Therapeutic Resource Center is dedicated to helping members with infectious diseases like HIV. The specialist pharmacists who work there are certified in caring for HIV patients and have training and experience in identifying factors that may lead to therapy failure and resistance. They coordinate with the patient and the person's healthcare team to address drug interactions, side effects, abnormal doses and therapy omissions. They also identify unnecessary therapy changes that may result in drug waste. As an industry best practice, Express Scripts recommends working with specialist pharmacists in treating chronic conditions like HIV."
"Implications
We continue to see a higher percentage of claims that are fully paid by health exchange members, reflecting the fact that these plans are more likely to have higher deductibles. In addition, member cost-share continues to be greater in health exchange plans, which is likely due to plan design and higher copayments.
Interestingly, while expensive brand and specialty drugs are driving member cost-share higher, there is a statistically significant difference in the generic fill rate between health exchange and health plan members. Again, plan design appears to be a key factor driving this difference.
We attribute the lower plan costs for exchange members to two factors. First, to contain costs, 41% of our exchange health plan partners have implemented home delivery and 48% have implemented narrow networks. Second, commercially insured health plan programs tend to be more robust with richer health benefits, which drive up costs.
We will continue to monitor the health exchange dynamics around deductibles and out-of-pocket maximum amounts. As the health exchange population meets these limits, it is expected that insurers will be required to pick up all remaining costs associated with their members' healthcare."
Obamacare enrollees use more expensive prescriptions (HIV, HCV)
By Philip Klein | October 20, 2014 | 5:00 am
http://www.washingtonexaminer.com/obamacare-enrollees-use-more-expensive-prescriptions/article/2554912
One of the key factors that will determine the success of President Obama's healthcare law is whether there are enough young and healthy enrollees to offset the costs of covering older and sicker participants, particularly those with pre-existing conditions.
An October report from Express Scripts, the nation's largest manager of pharmacy benefits, has found that people who gain insurance coverage through the law's exchanges are much more likely to use expensive drugs known as specialty drugs.
"Health exchange members are 59One of the key factors that will determine the success of President Obama's healthcare law is whether there are enough young and healthy enrollees to offset the costs of covering older and sicker participants, particularly those with pre-existing conditions.
An October report from Express Scripts, the nation's largest manager of pharmacy benefits, has found that people who gain insurance coverage through the law's exchanges are much more likely to use expensive drugs known as specialty drugs.
"Health exchange members are 59% more likely to have filled a prescription for a specialty medication," the report read. "HIV is the top specialty condition for health exchange members aged 18 to 64, particularly among those who live in a zip code with a low median income. Nearly 3 out of 5 specialty claims overall are for HIV medications. Additionally, compared to health exchange members without HIV, those who take HIV medications are also much more likely to be taking drugs for hepatitis C, hepatitis B, viral infections and smoking cessation."
Specialty drugs made up 1.3 percent of claims but accounted for 38 percent of spending on prescription drugs on the exchanges, the report found.
The average age of enrollees on Obamacare exchange plans, at nearly 44, was seven years greater than those who gained coverage outside the exchange, and 30 percent of health exchange members were between the ages of 55 and 64, compared to 15 percent among people with outside health plans.
That said, the study also found that people who signed up for coverage later in the open enrollment period had a "lower prevalence of chronic conditions, such as heart disease, depression, high cholesterol and diabetes, and a lower prevalence of specialty conditions, such as cancer and multiple sclerosis." This supports the observation, which has been backed up by other data, that those who signed up for coverage through Obamacare the earliest were older, while younger applicants waited to apply.
A lawsuit is seeking to stop congressional staffers from enrolling in D.C.'s exchange
The conservative legal group Judicial Watch has filed a taxpayer lawsuit against the District of Columbia's Health Benefit Exchange Authority, challenging the participation of thousands of members of Congress, staffers, and their families in the small business exchange.
House and Senate workers were pushed into the exchange under a provision of Obamacare that sought to make sure Congress was subjected to the same health insurance that they were imposing on the rest of the nation. D.C. prohibits businesses with more than 50 employees from enrolling in the small business exchange. The lawsuit argues that because Congress employs up to 20,000 people, it should be illegal for staffers to enroll.
The suit was filed in D.C. Superior Court on behalf of Kirby Vining, a D.C. taxpayer.
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