3 Pharmacy Trends to Watch in Public Exchange Plans

Express Scripts’ most recent (June 2016) Exchange Pulse Report presents 2 years of the company’s data and trend tracking that reflect its experience as a pharmacy benefit manager for a third of the more than 9 million Americans enrolled in an insurnace exchange benefit in 2015.

The Exchange Pulse Report focuses on 3 select trends that are having the biggest impact on plans and tracks year-over-year increases and decreases in pharmacy utilization and cost. The 3 insights highlighted in the report are those that the company believes health plans need to understand to ensure they continue to offer an affordable and meaningful benefit and be ready for any new challenges presented by the changing healthcare environment.

Prescription drug spending between 2014 and 2015 increased at a much higher rate among health exchange plans compared with commercial plans, Medicare, and Medicaid plans. An important factor to consider is that many enrollees in the public exchange plans had never had a drug benefit before, and many enrollees are seeking treatment for pre-existing and newly diagnosed conditions and are still only beginning to fully understand and take advantage of their benefits. The 3 trends the report highlights are:

• Trend 1: Utilization (especially for traditional medications), not increasing unit costs, was a primary driver of the exchange’s 14.6% spending increase in 2015. Utilization accounted for more than half of the $99 per-member-per-year increase in spending between 2014 and 2015. Even though utilization represented a majority of the spending increase, it was still significantly less than spending on traditional medications among commercially insured plans. Notably, only one-third of exchange members have visited a primary care physician in the first 2 years of the benefit, so as enrollees learn how to use their benefit and begin to visit their providers, plans should prepare for continued growth in the use of traditional medications.

• Trend 2: HIV and hepatitis C are the most costly specialty medication categories. Spending is beginning to normalize, the report noted, because there was an initial surge in the use of HIV and hepatitis C medications as enrollees previously unqualified for health coverage because of pre-existing conditions immediately used their new benefits. The third and fourth most costly classes for exchange plans are diabetes and inflammatory conditions.

• Trend 3: The fastest-growing prescription plan over the past 2 years was the silver plan. Platinum- and gold-level plans had higher overall drug spending, but silver plans—the most popular metal-level plan in the Exchanges—experienced the greatest spending growth between 2014 and 2015 (20.5%).

The report also made several recommendations for plans to prepare for the near future.

• To help lower premiums, plans should leverage formulary, utilization, and channel management tools to help lessen increases in medication use. Be sure patients get the right drug at the right costs and from the most cost-effective dispensary.
• Focus on growing therapies classes, especially specialty therapies, because plans will need to closely manage the specialty pharmacy benefit as the population of patients with specialty conditions and diabetes grows. Leverage medical benefit management and other strategies, along with personalized pharmacy care. Other programs can help manage spending for patients with diabetes, inflammatory conditions, and cancer by combining innovative reimbursement strategies with clinical care programs and risk sharing.
• Ensure proper medication use and waste reduction by enhancing care to members new to healthcare coverage. Educating patients, coordinating care, and encouraging medication adherence is critical to delivering better health outcomes and helping create plan loyalty and a positive healthcare experience.