Based on the findings, Prime, a pharmacy benefit management company, is calling for the use of pharmacist case management to optimize medication use and reduce costs.
The study was recently presented by Prime researchers at the Academy of Managed Care Pharmacy’s (AMCP) Managed Care & Specialty Pharmacy 30th Annual Meeting in Boston.
For the study, Prime analyzed pharmacy and medical claims data for 15 million insured members, 226 of whom had at least one claim for an HAE medication during the first half of 2016. These patients were followed for 12 months after their first HAE drug claim to establish medication use patterns, emergency room and hospital visits, and total costs of care.
Annual total cost of care averaged $409,925 per person, with HAE medication costs making up $395,507, or 97%, of the total. All other medical and pharmacy costs averaged $14,418 (3%) of the total care costs.
Among the 226 members with at least one HEA medication claim, 111 or 49% met criteria for continuous enrollment. Of those 111 members, 48, or 49%, made claims for two or more HAE medications. More than $1 million was spent on medication for each of 10 members, who accounted for 30% of the total $43.9 million spent on HAE medication on Prime’s commercial books. Half of the medication expenditures were billed through the pharmacy benefit and half through the medical benefit.
“Because HAE drugs are processed on both the medical and pharmacy benefit, it’s essential to have integrated medical and pharmacy claims data to clearly understand patterns of use and comprehensively manage these members,” Catherine Starner, Prime’s health outcomes consultant senior principal, said in a press release.
“With drug costs driving 97 percent of HAE treatment expenses, we do not believe medical costs can be lowered through use of HAE drugs. Rather, diligent pharmacist case management following a patient’s first use of HAE drugs must be provided to help ensure appropriate use and realize cost savings regardless of which benefit (medical or pharmacy) the HAE drug is billed,” she said.
Prime manages pharmacy benefits for employers, health plans, and government programs including Medicaid and Medicare. The company processes claims and offers clinical services for people with complex medical conditions. It serves more than 27 million people and is owned by 18 Blue Cross and Blue Shield Plans, and affiliates or subsidiaries of those plans.
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