$52 billion and growing is the trend in high-cost pharmacy benefits, as more and more Americans use prescription drugs with expenses exceeding the U.S. median household income.
Last year, An estimated 576,000 Americans used medicines that cost more than $50,000, on a par with the country's median household income, according to analysis by Express Scripts.
The $50,000-plus population grew 63 percent since 2013, while the population of patients with drug costs over $100,000 almost tripled to 140,000--a warning for an aging America with a growing chronic disease burden.
The total cost impact to health plans and consumers for these $50,000-plus prescriptions was $52 billion, with health plans and sponsors paying about 98 percent of the total for the $100,000-plus population, according to Express Scripts.
Along with the population of high-cost medication users, the number of patients reaching their health plans' out-of-pocket maximums increased as well. Insured patients who used more than $100,000 worth of medications in 2014 paid on average just 1.7 percent of the total cost out-of-pocket. Across all drugs last year, patients paid an average of 13.5 percent of their total medication costs, down from 14.9 percent in 2013, according to the study.
"The profile emerging from this research shows these patients are overwhelmingly taking specialty medications, and have multiple comorbidities, prescriptions and prescribers," said Glen Stettin, MD, the drug benefit manager's VP for clinical, research and new solutions.
A population in need
Express Scripts, the country's largest PBM, studied drug claims for 31.5 million Americans covered in commercial, Medicare and Medicaid plans.
Of the 576,000 patients with more than $50,000 in drug costs, 90 percent were using speciality medications for a complex disease like cancer, arthritis or multiple sclerosis--and many also had numerous other conditions treated with prescription drugs, including hypertension, high cholesterol and diabetes.
Among those with $100,000 or more in spending, 30 percent were being treated for 10 or more different conditions, 60 percent were taking 10 or more different medications and 70 percent were given prescriptions from at least four providers.
Notably, Stettin said, the use of antidepressants was more than twice as prevalent as it is in the general population. About 30 percent of patients with more than $50,000 in annual spending were taking at least one antidepressant.
"Patients in these highest-spend categories are treating a complex condition along with other more common chronic conditions, such as diabetes or depression, which can leave them at risk for medication safety concerns and increased medical costs," Stettin said.
Almost 60 percent of the patients with drug spending of more than $100,000 were Baby Boomers, Americans ages 51 to 70, the study found. They "surpassed all other age groups as the highest-cost medication users," while the population of Medicare beneficiaries with annual drug costs at or exceeding $50,000 increased 63 percent.
Not surprisingly, hepatitis C saw a surge of spending last year, jumping 733 percent and accounting for 39 percent of the total patients with drug costs reaching $100,000, thanks to the breakthrough treatment Sovaldi.
Cancer patients accounted for 32 percent of those with annual medications costs above $100,000. Compounded medications were the third-largest contributor the spending among patients with high drug costs, Express Scripts found.
Among those with annual drug costs above $100,000, the proportion of patients using compounded medications grew 30 percent last year, and their costs quadrupled.
Ideas for management
For both cancer and compounded medications, there are a number of ways to improve the value of drugs for patients and the price sustainability, according Express Scripts' Stettin.
"Tightly managing the use of compounded medications offers a significant opportunity for payers to improve patient safety and reduce spending," Stettin writes. A lot of compounded medications, he argues, "add little or no value to patient outcomes, and in a growing number of cases, may actually put a patient's health at risk."
In 2012, contaminated batches of methylprednisolone, used for spinal steroid injections, caused a fungal meningitis outbreak that led to 64 deaths and 750 illnesses. Since then, compounding pharmacies have issued 50 recalls and the FDA has found more than 30 serious deficiency in various locations, as a USA Today review found.
Another opportunity Stettin sees is a chance to optimize new cancer breakthroughs by guiding patients towards targeted drugs with genomic-indications, preparing for biosimilars, and perhaps linking prices with outcomes--holding drug companies to their worth.
"What payers and patients pay for a therapy should align with the value that therapy will deliver to each individual patient," Stettin argues. "This value-based approach makes therapy more affordable and accessible for all patients. We have the scientific research to help guide the discussion, and coupled with the increasing number of available cancer therapies---including the potential of biosimilars--we now have the opportunity to advance this important value/care discussion for cancer and other complex conditions."