First Look: 2015 Public Exchange Plan Rx Trends

Jul 1, 2015
Third edition of the Express Scripts Exchange PulseTM Report shows specialty medication spending grew rapidly since the inception of the health exchanges, but a healthier population of enrollees in 2015 may help plans better balance their risk.
  • Public Exchanges
  • Contraceptives
  • High Blood Pressure/Heart Disease
  • HIV
  • Diabetes
  • Hepatitis C

New enrollees in Public Health Insurance Exchange plans spent less on medications in the first quarter of 2015 compared to the same time a year ago, which is good news for exchange plans looking to balance their risk.

However, our recent Exchange Pulse™ report reminds us 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.

Specialty Medication Spend is Significant and Growing

Spending on high-cost specialty medications grew 24% in just a year – nearly three times the growth rate seen in traditional health plans – largely attributable to hepatitis C medications, which are now the third costliest therapy class among exchange plans.

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.

Exchange plan costs were 16% higher per member per month compared to traditional health plans, largely due to the increased specialty drug spending among exchange plan enrollees.

High-cost hepatitis C drugs Harvoni® and Sovaldi® were the two most expensive specialty drugs for exchange plan members. Harvoni, which came to market in October 2014, represented 6.4% of the total pharmacy spend among exchange plans. Plans that implement the Express Scripts Hepatitis Cure Value ProgramSM can expect reduced spending in this class in 2015.

Top 10: Conditions Pharmacy Spend

Exchange Plans Super Spending

High Cost Patients 50K Rx Spend in 2014

There were a higher proportion of patients with high annual medication costs in exchange plans. In 2014, just 5% of exchange plan patients accounted for more than 68% of total prescription drug spending. In addition, 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.

New Trends Emerge in 2015

While high-cost specialty medication use in exchange plans grew significantly between March 1, 2014 and March 1, 2015, 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, helping plans achieve a more balanced risk pool, which will help them sustain benefit offerings in the future.

When compared to the first quarter of 2014, the number of new exchange plan enrollees who used at least one prescription medication declined 18% in the first quarter of 2015.

New exchange enrollees in Q1 2015 also had 34% fewer adjusted specialty pharmacy claims than enrollees in Q1 2014, which resulted in Q1 2015 exchange enrollees spending 21% less out-of-pocket overall on medications, and 20% less out-of-pocket on specialty medications compared to Q1 2014.

Exchange plan costs were 36% lower per member per month in Q1 2015 compared to Q1 2014.

Plan Costs Per Member and Per Utilizer Per Month

Additional key trends seen in Q1 2015:

  • 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 ages 18 to 64, HIV prevalence declined 11% compared to Q1 2014.

Medication Non-Adherence a Concern for Exchange Plans

Percent of Patients Non Adherent to Therapy Class

Medication non-adherence affects both exchange and traditional health plan patients; however, early data suggest that across most traditional and specialty therapy classes, medication non-adherence is higher in exchange plans compared to traditional health plans:

  • Medication non-adherence was high in four of the top 10 costliest conditions for exchange plans: diabetes, high blood pressure, hepatitis C and HIV.
  • 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.

Opportunities for Exchange Plans

Exchange plans have an opportunity to make medications more affordable and accessible by more closely managing the benefit. For example, using Express Scripts home delivery pharmacy has a proven ability to improve medication adherence among patients with chronic conditions, and specialist pharmacists in our Therapeutic Resource Centers® are uniquely able to help patients, particularly those new to therapy, with their medications.

Given the comorbidities that are common among patients who use specialty medications, exchange plans also have an opportunity to better identify and manage their risk. Express Scripts Risk Adjustment Program closes the gap in medical diagnosis and is vital for optimizing risk and member outcomes.

Exchange plans face unique challenges, and 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.

Author Bio

Julie Huppert
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