Several new studies will be presented by Prime Therapeutics LLC (Prime) researchers at the Academy of Managed Care Pharmacy (AMCP) 27th Annual Meeting and Expo in San Diego April 7-10. The studies draw attention to drug cost and safety issues, and highlight opportunities to improve care through utilization management programs.
Two studies look at rare conditions for which new specialty drugs have been developed in recent years. The increasing focus on “orphan” specialty drugs for rare diseases is providing new hope for patients, yet these drugs often carry steep price tags.
Assessing cystic fibrosis prevalence and total cost of care
In the first study, Prime researchers found that ground-breaking treatments for cystic fibrosis may significantly increase pharmacy benefit costs. Currently, the drug ivacaftor (Kalydeco®) is available to treat a type of genetic mutation found in about 4 percent of people with cystic fibrosis, at an annual cost of $300,000 per person with the condition. A new combination drug pending U.S. Food and Drug Administration approval could treat genetic mutations in up to half of people with cystic fibrosis. But if the new drug carries the same price tag, providing the new medication could add $150 million per year in new costs, just for Prime members and their health plans. Nationally, it could cost our health system more than $3.8 billion to treat those with the 508del genetic mutation who are age 12 and older. If the new combination drug gets approved for all ages it could cost as much as $4.5 billion per year to treat the estimated 15,000 people with the 508del cystic fibrosis genetic mutation.
Integrated analysis of HAE drug utilization and spend
A second study looks at four specialty drugs approved to treat a rare condition called hereditary angioedema (HAE). HAE affects 20 in 1 million Americans and causes life-threatening edema or swelling. Because the drugs can be either infused in a medical facility or self-injected, it’s necessary to review both medical and pharmacy benefit claims to identify how these drugs are being used. Researchers from Prime found that even though HAE is rare, use of HAE drugs added more than $69 million in drug costs over two years. During that time, annual costs to treat members nearly tripled.
In both of these studies, Prime researchers suggest using care and utilization management strategies, such as prior authorization and quantity limits. These strategies could help improve safety and care for members, and reduce the chance of medication waste and thereby reduce costs.
Usage patterns for short acting opioids
In the third study, Prime researchers found a significant number of members are taking opioids (painkillers) for conditions such as low back pain, headache and fibromyalgia, despite medical guidelines recommending against their prolonged use for these conditions. Prime found 8.8 percent of members had at least one opioid claim during the study period, and the most common diagnosis was low back pain. Programs to identify these members and help them find the most appropriate pain treatment could improve safety and reduce costs for members and plan sponsors, according to study authors.
Relationship of controlled substance score to health care utilization and total costs
A fourth study, previously presented at Pharmacy Benefit Management Institute’s annual conference in March, will also be shared. As drug overdose deaths have doubled in the past decade with more than 50 percent related to prescription drugs,1 Prime uses a controlled substance (CS) score to identify high risk CS drug use. Through analysis of the CS score, Prime found a significant association between CS scores and health outcomes (hospitalizations and emergency room visits), CS drug costs, and total cost of care.
Visit the links above to see the research posters presented at AMCP.
- CDC Home & Recreational Safety. Prescription Drug Overdose in the United States: Fact Sheet. http://www.cdc.gov/homeandrecreationalsafety/overdose/facts.html Accessed Feb 3, 2015.