Medication costs: currently, a payer problem, but soon to be a patient problem

On May 12, NBC News reported that more Americans are taking home $100,000+ each year in prescriptions.  A few key points jump out from the article:

  • “500,000 people took home $50,000 in prescriptions in one year.” Despite that making up just .02% of the American population it equaled $250 billion dollars.
  • “139,000 people took home more than $100,000 in prescriptions in one year.” That group makes up only .004% of the American population and that cost translated into $13.9 billion dollars.
  • “Patients are almost never bearing these high costs. Insurance plans covered more than 98 percent of the costs for patients whose drugs cost $100,000 or more in 2014.”

What’s happening within the first cohort who are utilizing more than $50k in prescriptions each year?

  • More than a third of them were being treated for 10 or more different medical conditions
  • 90% were using specialty medications

The majority of the cohort are using specialty medications as denoted in yellow.  More than a 1/3 are managing 10 or more conditions as seen by the grey outline. PBM Blog 5.15.2015

While  health plans may be covering most of the cost now, what does the future hold?

Health plans don’t want to shoulder this increase alone, so they’re shifting costs to patients. Last year, nearly 1 in 4 employer-sponsored health plans included specialty drugs in a payment tier for which consumers paid a percentage of the drug cost instead of a set co-payment. In 2006, only 5 in 100 employer plans had such a specialty tier. The trend, say benefit managers, will continue.”

With specialty pharmaceutical costs predicted to grow from $290 per member, per year (PMPY) in 2012 up to $845 PMPY by 2018 due to the drug class’ strong pipeline and price inflation, it may be inevitable that costs will shift even more, and patients will be absorbing these costs.  As a result, patients not only will be managing the complexities of their conditions, but also will be expected to juggle the complexities of related costs.

To learn more about Eliza’s solutions for specialty medication, refill reminders, or medication adherence, request a mini-case study.

Allison Unger, works as Eliza’s Vice President PBM Solutions & Strategy.  She has been at Eliza since 2007 focusing on how health engagement management improves medication adherence outcomes.  Allison holds a BA in Communications from the University of Kentucky, is obsessed with Goats of Anarchy, and regularly takes selfies with her Westie, Maxamillion.


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