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Prime’s analysis of public health exchange

Examining a large, understudied group – those who receive cost-share subsidies.


“Defining Contrast," Prime’s fifth analysis of the public health exchange, shows that those who receive cost-share subsidies use prescription drugs differently than other public exchange members. These differences may reveal opportunities to more effectively serve these members while controlling costs. 

Two types of benefit subsidies

  • Premium subsidies: 85 percent of exchange members received these in 2016 
  • Cost-share subsidies : 60 percent of Prime’s exchange members received these in 2016 

Key findings include

  • Cost-share subsidized members fill 4.6 percent more prescriptions and have 13 percent higher drug spend than other public exchange members.
  • Cost-share subsidized members use 6.4 percent fewer specialty prescriptions; and specialty, as a percent of total spend, is 12.6 percent less than other public exchange members. But due to higher prevalence of high-cost hepatitis C scripts, the total per member per month (PMPM) specialty spend is higher. 
  • Cost-share subsidized members are using 10 percent fewer prescriptions since 2014 but spending has increased 40 percent. 

Public exchange members receiving cost-share subsidies are more likely to have higher future pharmacy risk scores than other exchange members due to the following factors: 

  • 9 percent more likely to be female than those not receiving cost-share subsidies
  • 1.4 years older, on average, than those not receiving cost-share subsidies
  • Higher utilization of drug categories, such as diabetes

Despite potential future higher pharmacy risk scores, the report concludes, there are many opportunities to alleviate financial burden. With the current risk adjustment payment model, innovative payers can effectively manage this population to control total cost and improve care. 

Serving 1 in 6 public exchange members nationally, Prime is a leader in public exchange market. “Defining Contrast” is Prime’s fifth analysis of this market. The report is based on data from 1.9 million public exchange members between January 2015 to June 2016.