I just want to highlight and raise some data caveats about the Express Scripts data set concerning pharmacy/prescription costs for Exchange patients. There are some interesting nuggets in the data.
Our early analysis reveals that, in January and February, use of specialty medications was greater among Exchange enrollees versus patients enrolled in a commercial health plan. Approximately 1.1% of total prescriptions in Exchange plans were for specialty medications, compared to 0.75% in commercial health plans, a 47% difference.
More than six in every 1,000 prescriptions in the Exchange plans were for a medication to treat HIV. This proportion is nearly four times higher in Exchange plans than in commercial health plans.
The proportion of contraceptives was 31% lower in Exchange plans
What can we infer from these data points? There are a couple of inferences. The first is that early Exchange population is sicker than the typical person covered in an employer sponsored health plan. We can infer this from the higher use of specialty drugs, and the higher use of HIV drugs. This was expected.
The second is that the average age of the early Exchange utilization pool is older than the average age of the typical person covered by an employer sponsored health plan. The tell here is the much lower use of contraceptives. Contraceptives are heavily used by women between their late teens to early 40s. Prescription contraceptive useage spikes in the twenties and steadily declines as women either have children, have permanent birth control, enter menopause or use barrier methods. If prescription contraceptive usage has cliff-dived, it is probably because there are fewer 53 year olds who need or want to use it.
So what does this mean?
Does the data suggest a pharmaceutical death spiral?
No, as there is one other massive caveat in the dat set, and that is the population examined.
The analysis is based on a national sample of more than 650,000 de-identified pharmacy claims from Jan. 1, 2014 through Feb. 28, 2014 [my emphasis] for patients enrolled in a Public Health Insurance Exchange
We know one critical thing about the population being analyzed.
The people who were eligible for this analysis were the first adapters of Exchange insurance. The January cohort being studied are are the two million or so people who signed up on the Exchange in October, November and December. They are the people who were so desperate and self-identifying as needing insurance that they were willing to keep on coming back again and again until the fucked up website worked well enough for them. Of course, we should expect this group to have higher than expected claim utilization. The February cohort is the January cohort plus the people who signed up on the Exchanges by January 15th. This is another million or so individuals. This cohort should be slightly healthier and slightly younger than the January only cohort.
The Express Scripts data is reflecting a limited universe of claims utilization by people who self-identified as needing insurance now. We know from enrollment data that January eligible individuals skewed old and skewed female. We knowfrom the February data the risk and utilization pool was slightly younger. The March enrollment surge pushed the average age of the entire Exchange risk pool down further still, and the April extended blue box enrollment will probably reduce the average age again.
Express Scripts data is confirming what the enrollment demographic data suggests. The older and sicker signed up first and got care first. The younger and healthier are coming in late. This is not surprising.