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Study Finds Utilizing Integrated Medical and Pharmacy Data Improves Ability to Forecast Use of High-cost Specialty Treatments

SAN FRANCISCO, April 20, 2012 /PRNewswire/ -- Health insurers should use both medical and pharmacy data to forecast specialty medication utilization and improve outcomes for members, according to a new study by pharmacy benefit manager Prime Therapeutics (Prime). The study will be presented today at the Academy of Managed Care Pharmacy (AMCP)'s 24th Annual Meeting & Expo in San Francisco.

Pharmacy benefit managers (PBMs) have experienced a rapid rise in expensive specialty prescription drug use within the past few years. In 2011, specialty drugs comprised 0.5 percent of all claims but 15.2 percent of all prescription benefit expenditures across Prime's member network. In addition, the average specialty per-prescription cost was $2,637 in 2010 and total paid per capita increased 12.9 percent from 2010 ($10.24 to $11.36 per member per month). Previous studies have estimated that specialty medication drug spend could increase from 20 percent to 50 percent by 2030, highlighting the need for health insurers to better understand how to trend and forecast these costs due to rapid growth rate.

"Specialty drugs offer life-saving treatment for patients with chronic illnesses, but they also carry a huge price tag, continuing to rise by double digits each year," said Patrick Gleason, PharmD, director of clinical outcomes assessment at Prime. "Health insurers and plan sponsors need to be able to forecast these costs and also ensure the best outcomes for their members. For example, it's critical that insurers understand that of the 81.9 percent of members with Hepatitis C identified as untreated many are likely to receive care in the near future because new drugs have recently become available."

According to Prime's analysis, it may be easy to identify prevalence and treatment rates via International Classification of Disease, Ninth Revision (ICD9), procedure code and pharmacy claims for some diseases. However, more sophisticated algorithms may be needed to properly identify treatment candidates for other conditions. The study suggested that identifying where gaps in care exist through the use of pharmacy and medical data, can help health plans enhance outcomes for members using specialty medications.

To identify specialty condition prevalence, diagnosis and treatment, researchers from Prime reviewed integrated pharmacy and medical data from 2.6 million commercial and Health Maintenance Organization (HMO) members. Fifteen specialty conditions/drug classes were identified and defined internally.

Of the continuously enrolled members, the prevalence among the 15 specialty conditions ranged from a low of 13 members per 100,000 in hemophilia to 1,607 members per 100,000 in cancer. The majority of conditions (12 of 15) were found in less than 200 per 100,000 members. A low percentage of members identified with cancer were defined as currently treated (13.8 percent). This finding is understandable as cancer patients may be receiving palliative care or in remission. The conditions/drug classes with the highest percentage of treated members were transplant/immunosuppressants (94 percent), cystic fibrosis (93 percent) and HIV (92.8 percent). The most untreated condition was macular degeneration (7 percent).

"Based on the prevalence, number of members treated and drug spend found in the study, it is becoming increasingly apparent that health insurers need to understand treatment patterns for cancer and autoimmune conditions," Gleason said. "For example, the second most common specialty condition of Rheumatoid Arthritis (RA)/Psoriasis had less than half (44.0%) of patients treated with a specialty drug. Increasing the use of drugs in only a small percent of this untreated population would have a dramatic impact on expenditures. Utilizing specialty medication analyses based on medical and pharmacy data allows health insurers to identify important trends and patterns in the specialty drug space that may have a significant impact on members."

Prime Therapeutics is a pharmacy benefit management company dedicated to providing innovative, clinically-based, cost-effective pharmacy solutions for clients and members. Providing pharmacy benefit services nationwide to nearly 20 million covered lives, its client base includes Blue Cross and Blue Shield Plans, employer and union groups, and third-party administrators. Headquartered in St. Paul, Minn., Prime Therapeutics is collectively owned by 13 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those Plans. Learn more at

SOURCE Prime Therapeutics
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