Apr. 9—Early enrollees in new government-run marketplaces appeared sicker than most insured, based on their medical claims data, a study found.

Express Scripts, one of the largest U.S. pharmacy benefit management companies, examined drug claims on the federal- and state-run health insurance marketplaces created by the Affordable Care Act (ACA) and found that in the first two months of the new coverage, specialty medication use was greater among enrollees in the marketplaces, or exchanges, than in other commercial health plans. Approximately 1.1 percent of total prescriptions in exchange plans were for specialty medications, compared with 0.75 percent in commercial health plans, a 47 percent difference.

The study examined drug payments because unlike medical claims that can take several months to process, pharmacy claims adjudicate in real time.

Specialty medications are especially significant, according to Express Scripts, because they comprise less than 1 percent of all U.S. prescriptions but account for more than a quarter of the country’s total pharmacy spending.

More than six in every 1,000 prescriptions in the exchange plans were medications to treat HIV, or nearly four times more than in commercial health plans.

Other exchange-plan findings include a 35 percent higher proportion of pain medication use among enrollees, a 27 percent higher use of anti-seizure medication, a 14 percent higher use of antidepressants, and a 31 percent lower use of contraceptives. 

Exchange Enrollees Affected by Higher Co-Pays

The higher drug spending among early marketplace enrollees met the expectations of some healthcare policy experts, who predicted the sickest patients were most likely to persevere with enrollment efforts despite massive early technical failures in most exchanges because of their large healthcare costs.

However, such enrollees may not have benefitted as much as anticipated, because the express Scripts analysis also concluded that patients in exchange plans paid a greater percentage of their pharmacy costs than the commercially insured due to higher deductibles and out-of-pocket charges.

"As a result, health insurers' per-member pharmacy costs so far this year are nearly 35 percent higher for their commercial plans versus their exchange plans," the report stated.

That enrollee cost finding echoed a previous analysis by Avalere Health, a healthcare consultant. The analysis found that in February, 59 percent of Silver plans on the exchanges use percentage-based coinsurance rather than fixed-cost co-pays for specialty drugs. Extensive use of coinsurance “often results in high costs for patients with chronic illness who need biologics and other products on the specialty tier,” Dan Mendelson, CEO of Avalere, said in a statement.

The report was based on a national sample of more than 650,000 de-identified pharmacy claims for patients enrolled in exchange plans with pharmacy benefit coverage administered by Express Scripts.

Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter @rdalyhealthcare.


Publication Date: Wednesday, April 09, 2014