Americans in public exchange plans are using their benefits, especially for prescription drugs, although in some ways it's different than other health plan segments.
"People are pretty savvy in maximizing their benefits," said Jennifer Polinski, director of foundational research at CVS Health. Polinski, a former Harvard Medical School epidemiologist, has combed through the data on the 1 million-plus Americans covered in public exchange plans served by CVS' pharmacy benefits management plan.
Before 2015, "there was a lot of concern that new enrollees would be sick, have mental health conditions, need a lot of expensive medicines and potentially threaten the viability" of the exchange program, Polinski said at America's Health Insurance Plans Institute in Nashville.
There are still concerns, but so far, its seems that health plans have manageable drug costs and exchange members have pretty good access to a wide range of medicines.
Looking at the data on exchange members' drug trends, CVS tracked about 800,000 who had enrolled in 2014 and about 700,000 who had enrolled in 2015, some for the first time. As it happens, their drug utilization was different.
In 2014, 28 percent of new enrollees in plans with the CVS PBM used at least one prescription and 8.7 percent filled at least one prescription per month. In the first half of 2015, 21 percent have have used at least one prescription and 12.6 percent get at least one Rx per month.
Among those who enrolled in 2014, 40 percent of drug costs were paid for out-of-pocket by exchange members, compared to 50 percent for those who first enrolled in 2015. "They have to get their feet wet before they really navigate the benefit" and "find their lowest cost options," Polinski said.
Exchange members are using more generic drugs than non-exchange commercially-insured populations on the CVS PBM--88 percent compared to 83 percent. Only 1.1 percent of exchange members use mail order Rx, compared to 3 percent of other commercial members, but 1.9 percent of exchange members use the 90 day maintenance choice, compared to 1.4 percent of commercial members.
This suggests "we're getting them on a path to better adherence, particularly for speciality drugs," Polinski said.
By december 2014, 0.7 percent of exchange enrollees were using speciality drugs. That's not a lot of consumers, but "speciality really drives exchange plan spending," Polinski said. Speciality medicines came with monthly out-of-pocket costs of $139 for members who enrolled in 2014--and $281 new enrollees in 2015.
There was some pent-up demand for HIV medications the first of the exchanges, with 0.26 percent of the exchange population using antiretroviral therapies in 2014 compared to 0.16 percent in 2015, according to the CVS data.
In terms of the average percentage of CVS PBM's drug spending, HIV medications are on top. They account for 11 percent of costs for new enrollees in 2015 (17 percent of those in 2014), while cancer drugs account for 5 to 6 percent, arthritis-related biologic DMARTs account for 7 to 8 percent, and antipsychotics for 2.5 percent.
Hepatitis C medications accounted for 11 percent of average spending last year and 18 percent this year. Rather than prescribing Sovaldi for all hepatitis C patients, it seems some physicians may have waited until Harvoni, Sovaldi all-oral version, became available late last year, Polinski said.
All in all, HIX members' average drug costs on a per member per month basis are "very similar" to those in commercial plans, but costs are increasing over time at a slightly more dramatic rate, especially for speciality drugs, she said.
"Thoughtful benefit design coupled with adherence programs is really needed," Polinski said.