Public exchange – digging deeper into the data

In 2014, Prime, together with our Blue Cross and Blue Shield (Blue) Plan owners and clients, served 1 in every 6 individuals who purchased health care through the public exchanges. Earlier this year, we published our 2014 public exchange report, Defining evolution. The report explored the differences between our commercial and public exchange member populations, and it uncovered some significant findings.

Our new white paper, Defining variance, dives deeper. In it, we explore differences in demographics, use and spend within the five different levels of coverage — identified as “metallic levels.” This analysis revealed more detailed insights and distinctions — and also a few surprises.

In 2014, Health Insurance Marketplace (HIM) members could choose from five different plans.

Demographic differences

Prime’s 2014 public exchange membership was 42.6 years old and 56 percent female, on average. As expected, catastrophic plan members were much younger. They were also the only group to have fewer females (49 percent) than males. Bronze and silver members were both near the average age. Surprisingly, gold and platinum members skewed slightly younger.

Utilization and spend variances

Public exchange members filled 14.9 prescriptions annually and at a cost of $85.43 per month, on average, in 2014. Catastrophic and bronze plan members use and spend was much lower than average. Silver was similar to average. Gold and platinum members drove the highest use and spend, with their percent of spend more than twice as large as their percent of the total HIM population.

85 percent of public exchange members received subsidies in 2014.[1]

Specialty medicines

Specialty drug spend was elevated for HIM members. Per prescription, their specialty medicines cost 117 times more than their traditional drug, more than double the average per member per month cost.

Each metallic level had a unique mix of specialty drug use, and spend was largely driven by the type of specialty drugs used.

Gold and platinum members used the most specialty medicines, outpacing other levels nearly two to one. Despite the lowest use, catastrophic plan members drove the highest cost per prescription, on average, at nearly $16,000 per specialty fill. This can be attributed to a higher use of expensive, blockbuster medicines such as Sovaldi and Harvoni.

Prime and our Blue Plan owners and clients showed increased HIM membership growth during the 2015 enrollment season. Together, we added 550,000 new members. As the HIM continues to evolve, we remain committed to studying this population and sharing our findings, so we can work collaboratively to design benefits to serve this unique population.

Dive deeper and uncover coverage-tier insights that can help in planning for future HIM benefit design success. Read Defining variance: A closer look at 2014 public exchange member demographics, utilization and spend by metallic level.

CVS Health buys Target's pharmacy business: Why it matters. Click here. 

[1] Demko, P., and J.N. Frank (2014, May 3). 85% of ACA enrollees got subsidies. Modern Healthcare. Retrieved from

blog comments powered by Disqus