Certain specialty drugs and a trend in opioid use have the potential to cost millions of dollars a year, according to research conducted by Prime and presented at the 27th annual Academy of Managed Care Pharmacy (AMCP) conference in early April.
The nationally recognized research draws attention to significant drug cost and safety issues, and highlights opportunities to improve care through utilization management programs.
Prime presented four new studies. Two studies look at rare conditions for which new specialty drugs have been developed in recent years. This focus on “orphan” specialty drugs for rare diseases is providing new hope for patients. But these drugs often carry steep price tags.
Prime researchers found that two 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. And, a new combination drug pending U.S. Food and Drug Administration (FDA) approval could treat genetic mutations in up to half of people with cystic fibrosis. But if the combination drug carries the same price tag, the new medicine could add $150 million a 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 cystic fibrosis 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.
A second study looks at four specialty drugs approved for 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, both medical and pharmacy benefit claims were reviewed to track how these drugs are being used. 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 studies, Prime researchers suggest using care and utilization management strategies, such as prior authorization and quality limits. These strategies could help improve safety and care for members, reduce the chance of medication waste, and thereby reduce costs.
The third study focused on opioids (painkillers). Prime found that a significant number of members are taking these medicines for low back pain, headache and fibromyalgia, despite medical guidelines recommending against their prolonged use for these conditions. The research showed that 8.8 percent of members had at least one opioid claim during the study period. 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.
A fourth study, investigating controlled substances, notes that overdose deaths have doubled in the past decade. More than 50 percent of these deaths are related to prescription drugs. 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.
This research has helped Prime develop thoughtful, member-specific clinical solutions, designed to work seamlessly for Blues Plans and employer groups.
 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.