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Analysis of its members’ covered lives show the effect of expensive specialty drugs on insurance plans
It should be self-evident that as the pharma industry brings more highly expensive specialty drugs—especially those for rare diseases—to market, the number of patients using them would increase. Still, Prime Therapeutics, a leading group purchasing organization (GPO) owned by a number of Blue Cross and Blue Shield insurance plans, took the time to analyze this trend. According to their about-to-be-released study, the number of so-called “drug super spenders—patients whose annual pharmaceutical claims total $250,000 or more annually—has risen 63% between 2016 and 2018.
Prime's study analyzed over 17 million commercially-insured members with a least one month of eligibility in the calendar years 2016, 2017, and 2018. In 2018, 4,869 were classified as drug super spenders. While small in numbers, this group of drug super spenders grew 63% percent from 2,994 members in 2016 and resulted in $800 million in additional drug costs. In that same timeframe, the number of drug super spenders with drug costs over $750,000 increased 38%, and drug costs for members over $750,000 increased to $417 million in 2018 from $297 million in 2016.
"With continued growth in treatments for rare diseases, including one-time treatments that may carry million-dollar price tags, it's very likely that health care cost will become even more skewed, with a smaller and smaller fraction of insured members accounting for a larger and larger portion of the total health care cost," said Jonathan Gavras, MD, SVP, chief medical officer at Prime. Insurance plans, especially for self-insured employers, will have hard choices as this trend continues. Prime Therapeutics notes that its consultative services, including moving infusion settings from the hospital to the home, and modified benefit plan design, can help control costs. “We must work to ensure drug and gene therapies are priced appropriately to the value they provide, obtained and billed via the cost-effective channel with the highest quality patient management, and value-based contracts are in place to recoup costs if the drug or gene therapy does not maintain effectiveness," says Gavras.
The study will be formally presented at the upcoming Academy of Managed Care Pharmacy (AMCP) Nexus meeting (Oct. 29-Nov. 1, National Harbor, MD); a poster is available here.