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Early exchange enrollees were sicker, sought costlier drugs, study says


By Paul Demko
Posted: April 9, 2014 - 3:00 pm ET
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Many of the individuals who rushed to buy health insurance plans during the early months of open enrollment, despite the technological problems involved, were dealing with significant medical issues that may have previously locked them out of the insurance marketplace, a study suggests.

Individuals who signed up for insurance coverage during the early months of state and federal exchange operations were filling prescriptions that are more expensive than those who have employer-based coverage, according to the new study by Express Scripts.

Exchange customers also are more likely to seek relief from depression, HIV and pain, but they are less likely to purchase contraceptives, the study found.

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Approximately 1.1% of prescription claims filed in January and February for exchange enrollees were for specialty drugs. That compares to 0.75% for individuals who get coverage through the workplace—a 47% difference.

Specialty drugs are generally used to treat chronic or complex diseases such as multiple sclerosis or hepatitis C. Although they represent a tiny fraction of the prescriptions filled, they compose a disproportionate amount of the cost. Specialty drugs accounted for only 1% of prescriptions filled but more than 25% of total pharmacy expenditures, according to a 2013 report by Express Scripts.

Insurers expected pent-up demand for drugs and other treatments because many of the newly insured were previously unable to obtain coverage, said Elaine Corrough, a fellow with the Society of Actuaries.

Pharmaceutical claims are a leading indicator of what the exchange population might look like. That’s because they’re processed almost immediately and provide credible information about which medical conditions individuals are seeking treatment for once they can obtain cheaper drugs.

Express Scripts found that six out of every 1,000 prescriptions filled were for medications designed to treat HIV. That’s nearly four times the rate of prevalence in other commercial plans.

Among the 10 costliest drugs sold to exchange customers, six were specialty drugs. By comparison, specialty drugs represented four of the top 10 costliest drugs for individuals who obtain coverage through their jobs. Both lists include Sovaldi, a treatment for hepatitis C approved by the FDA in December and can cost $84,000 for a full 12-week treatment.

Exchange customers are paying significantly higher out-of-pocket costs for drugs than their counterparts with employer-based coverage. During the first two months of claims, individual costs for drugs were 35% higher for individuals who obtained coverage through the government-run marketplaces.

The data from Express Scripts offers a limited view of the exchange population. It includes only claims made in January and February, so individuals who enrolled after Jan. 15 are not represented. Most analysts predict—and early metrics suggest—that later enrollees will be younger and less costly than those who obtained coverage shortly after the state and federal exchanges opened for business.

The findings are based on 650,000 pharmaceutical claims made in January and February by customers with commercial plans purchased through the exchanges. Those claims were split among roughly 423,000 individuals.

Insurers have little time to process the limited information available about their new insurance customers before proposing their rates for the 2015 enrollment period, which begins Nov. 15. Most states require that they submit proposed products to regulators by May 1.

State regulators will then scrutinize the plans and can require health plans to provide additional data to justify the rates.

Follow Paul Demko on Twitter: @MHpdemko


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