Exchange vs. Nonexchange Specialty Drug Use in Autoimmune Disorders

Some fascinating research has been published in the Journal of Managed Care and Specialty Pharmacy that has significant implications for the immunomodulatory marketplace, including biosimilars. In this article, researchers from HealthCore and Anthem found some real-world evidence that the costs and comprehensiveness of health insurance—and cost sharing—are linked to utilization and perhaps access to biologics to treat autoimmune diseases.

The specialty jmcp.2018.24.issue-1.coverdrug trend is increasing rapidly, and the autoimmune disorders (e.g., rheumatoid arthritis, psoriasis, inflammatory bowel disease, among others) are a significant slice of the specialty expenditure pie. It is assumed that access to, and utilization of, these agents may lower in those with higher deductibles and greater overall cost sharing. One excellent real-life laboratory to test this is in the health exchanges. Across the metal spectrum, premiums, deductibles, total cost sharing, and comprehensiveness of provider networks vary considerably. The researchers leveraged a large amount of data about Anthem subscribers in exchanges nationally and outside of exchanges. The resulting database for this study included 931,184 individuals across exchange plans and 2,682,855 insured through nonexchange Anthem plans.

Are Exchange Plan Members Really Sicker?

One of the expected hallmarks of exchange plan membership is that the population is sicker, requiring greater health expenditures (and greater risk) for the plan compared with people in nonexchange plans. The authors of this paper did not find much of a difference, however, between the groups. The exchange plans in general had an older membership (45.0 vs. 42.7 yr; P < .001) and greater female membership (52.7 vs. 49.0%; P < .001). However, their comorbidity scores and rates of the chronic inflammatory diseases investigated were very similar. Interestingly, their mean total health care expenditures were not significantly different ($2,792 vs. 2,783, respectively).

The most important finding was that despite these similarities, their use of biologic medications differed considerably. Broken down by plan category, the unadjusted utilization of specialty drugs to treat chronic inflammatory diseases (per 100,000 population) looked like this:

  • Nonexchange plans: 427 per 100,000 members
  • All exchange plans: 341 (20% below the nonexchange plan level)
  • Bronze plan: 132 (69% below the nonexchange plan level)
  • Silver plan: 326 (23% below the nonexchange plan level)
  • Gold plan: 579 (35.6% above the nonexchange plan level)
  • Platinum plan: 672 (57.5% above the nonexchange plan level)

Platinum vs. Bronze Plan: Morbidity Burden

When adjusted for demographics, previous use of nonspecialty drugs, comorbidities, and patient out-of-pocket drug costs, the variations decreased, but the step-wise progression remained (though gold plan members were found to be 1.4% less likely and platinum plan members were 12.6% more likely than nonexchange plan members to use a specialty drug for their autoimmune disease). They noted, “In our study, members enrolled in platinum plans had 2.4 times the comorbid conditions, 2.5 times the number of prescription fills, 3.3 times the prevalence of any chronic inflammatory diseases, and incurred 3.0 times higher total health care spending than members in bronze plans.”

One would expect higher deductibles and out-of-pocket costs have something to do with this trend. However, greater freedom in choosing providers and broader networks may well have an influence as well. It may also be that exchange plan members are more likely to try nonspecialty medications (e.g., methotrexate, prednisone, etc) before moving on to the biologics; yet, very few health plans fail to require other medications before these biologics are added to the mix.

The authors’ subanalysis of local markets found huge variations in specialty drug use, even though these were all Anthem plans with an assumed similar level of benefit (49% below to 75% above nonexchange plan specialty drug utilization in its local market). This demonstrates that despite the large populations analyzed, interpretation is highly complex and likely the result of many factors.

The study did not offer a breakdown of how many of these plans have a three-tier, four-tier, or five-tier benefit. Also, biologics that are covered on the medical rather than the pharmacy benefit are less likely subject to large out-of-pocket costs. On the other hand, these study results seem to suggest that less expensive biosimilars on a lower cost-sharing tier could improve access to biologics.

Leave a Reply