Exchange Plans: Three Pharmacy Trends to Watch

Jun 15, 2016
Express Scripts latest Exchange Pulse™ Report reflects on two years of data, and annual trend tracking, to uncover opportunities for Exchange plans.
  • Public Exchanges

New Pill Bottle

Hard to believe, but more than two years have passed since Americans began using Public Health Exchange benefits.  In the midst of continuous uncertainty surrounding the Affordable Care Act (ACA), more than nine million Americans enrolled in an Exchange benefit in 2015, and for many, it was a benefit they never had before.

Pharmacy data offers swift, real-world insight into the health and well-being of this nascent population. As the pharmacy benefit manager for one-third of the Exchange population, we’ve periodically documented early utilization and spending patterns in our series of Exchange Pulse™ Reports, to offer plans a read on how enrollees are using the benefit.

In our latest Exchange Pulse report, we focus on select trends that are having the biggest impact on plans. Equipped with two years of data, we can track year-over-year increases and decreases in pharmacy utilization and cost, like we do for commercial, Medicare and Medicaid plans. This trend information helps plans see how the benefit is evolving, identify areas where we may see increased growth, and create a plan of action for those areas.

The long-term future of exchange plans will continue to evolve, but that doesn’t mean health insurers cannot plan for the near-term. The following three pharmacy insights are ones that plans need to pay close attention to ensure they continue to offer an affordable and meaningful benefit, and be ready for any new challenges presented by this ever-changing healthcare environment:

1. There’s a lot more runway for increased spending on traditional medications. Utilization, particularly for traditional medications, was one of the biggest factors driving spending in 2015, accounting for more than half of the $99 per member per year (PMPY) increase in spending between 2014 and 2015. Yet despite representing a majority of the spending increase, spending on traditional medications still significantly lags the traditional medication spending we see among commercially insured plans. In addition, only one-third of Exchange members have visited a primary care physician in the first two years of this benefit.  All this means plans should prepare for continued growth in the use of traditional medications as more enrollees learn how to use their benefit and begin to seek medical care.


2. HIV and hepatitis C remain the costliest specialty categories, but spending is beginning to normalize. When the Exchanges first opened, enrollees who were unqualified for health coverage due to a pre-existing condition began to use their new benefit immediately, causing an initial surge in the use of medications for HIV and hepatitis C. While those two conditions still lead specialty spending, the population of enrollees with other chronic conditions is beginning to grow, mirroring trends we see in commercial prescription medication use. Specifically, diabetes and inflammatory conditions, the top two costliest therapy classes for commercial plans, are the third and fourth costliest classes for Exchange plans.

Top 10 Therapy  

3. Silver plan prescription spending grew the fastest over the past two years. Platinum- and gold-level plans, favored by enrollees with costly chronic conditions, had higher overall drug spend. However, silver plans, the most popular metal level plan in the Exchanges, saw the greatest spending growth between 2014 and 2015 – 20.5% – as more enrollees began using their benefit. Yet another signal that the majority of Exchange enrollees are becoming more comfortable with their benefit and will begin using it more.

PMPY by metal 

What should plans do now to prepare for 2017?

1. Drive down costs to help lower premiums. Plans that leverage formulary, utilization and channel management tools can help mitigate increases in medication use by ensuring patients receive the right drug at the right cost, and at the most cost-effective dispensing channel.

2. Focus on the growing therapy classes, particularly in specialty. As the population of patients with other specialty conditions and diabetes continues to grow, plans will need to closely manage their specialty pharmacy benefit, leveraging medical benefit management and other strategies, along with condition-specific, personalized pharmacy care, like that offered by Accredo.

Additionally, innovative programs, such as those offered in Express Scripts’ SafeGuardRxSMprogram, can help manage spend for diabetes, inflammatory conditions and oncology. Combining innovative reimbursement strategies with clinical care programs and risk sharing, Express Scripts helps plans manage the most costly therapy classes and helps protect plans from budget uncertainty.

3. Enhance member care. A population new to healthcare coverage should be surrounded with care to ensure proper medication use and reduce waste. Educating patients, coordinating care and encouraging medication adherence, like our pharmacists do in our Therapeutic Resource Centers®, delivers better health outcomes and helps create a positive healthcare experience, which can go a long way to creating the type of plan loyalty we see in Medicare plans.

Author Bio

Julie Huppert
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