Break autoimmune (AI) into indication-specific info for actionable strategy

Prime uses integrated medical and pharmacy data and breaks down largest drug category (autoimmune) into indication-specific information; this maximizes data available for clinical programs and value-based negotiations

Autoimmune drugs are nearly 20% of total drug spend through the medical and pharmacy benefits. And one of the fastest growing expenditure drug categories with a 32% increase over 15 months.

But autoimmune is a diverse category of many drugs and many conditions; this study looked at 29 different drugs:

• Each drug is approved to treat one to nine different AI conditions.
• Some drugs are covered on a medical benefit; others on a pharmacy benefit.
• Collectively less than 1% of commercially insured members use one of these therapies.
• An individual’s AI drug therapy may have significantly different average costs, depending on the condition.
• Some conditions have generic drugs or biosimilars available for treatment; others do not.

Among a 15 million-member commercial population, Prime looked at individuals taking one or more autoimmune drugs – in 2Q2020 the count was 614 per 100,000.

Prime examined and cross referenced integrated medical and pharmacy claims data and available UM information. With this detailed analysis, Prime was able to separate use of the 29 drugs into disease categories. This allowed Prime to track treatment cost by condition.

For many autoimmune conditions, the drug costs alone make up most of a member’s total cost of care.

The analysis also showed variability in drug costs by diagnosis. One drug’s cost may vary widely per patient by indication because of different dosing, site of care, frequency, duration of use, and more. This presents an opportunity for health plans to encourage the most cost-effective treatments through indication-based preferred drug lists and pricing.

This also has impact for value-based contracting. With this data, Prime can differentiate a drug’s indication and cost valuation for pharmaceutical manufacturer value-based contracting discussions.

Based on this groundbreaking research, Prime now offers autoimmune condition-specific reporting to its health plan clients. Tracking treatment costs by condition makes the development of care management and clinical programs more effective.

Prime analytics help clients identify safe, cost-effective use of therapies and provide them with insights to make data-driven business decisions.