Prime Therapeutics finds biologic therapy accounts for vast majority of Crohn’s disease, ulcerative colitis total cost of care

Analysis of medical, pharmacy drug claims shows adherence to high-cost biologic therapies associated with twofold decrease in hospitalizations

March 26, 2019

EAGAN, Minn. – Two new studies by pharmacy benefit manager (PBM) Prime Therapeutics LLC (Prime), using real-world medical and pharmacy data, show biologic therapy (BT) accounts for more than 70 percent of the total cost of care for members with either Crohn’s disease (CD) or ulcerative colitis (UC). Those who were adherent to BT for 12 months had approximately twofold lower associated risk of hospitalization.

Crohn’s disease and ulcerative colitis are autoimmune diseases that affect the digestive tract. Clinical trials have shown BT therapy helps reduce hospitalization risk in moderate to severe CD or UC, but little is known of the real-world hospitalization rates or difference in rates among members who are adherent and non-adherent to BT therapies. Five BT treatments have Food and Drug Administration (FDA) approval for CD and four treatments are FDA-approved for UC.

For both studies, Prime analyzed integrated pharmacy and medical claims data for its 15 million commercially insured members to identify individuals below age 65 who were continuously eligible from July 2014 to June 2018. Based on validated criteria, CD and UC were defined as all who had greater than or equal to five medical claims and a majority of the 10 most recent coded claims contained a diagnosis code for CD or UC.

The first study found BT accounts for the vast majority of either CD or UC total cost. CD and UC each have a prevalence of 2 per 1,000 members. BT was twice as common among members with CD (49 percent) as among members with UC (25 percent). For members with CD receiving any BT, mean total cost of care was $80,236; of that total, BT cost was $59,048 (74 percent) and all other cost was $21,187 (26 percent). Mean total cost of care for members with UC was $75,157; of that, BT cost was $53,698 (71 percent) and all remaining cost was $21,459 (29 percent).

The second, bronze award-winning study, found members treated with BT for CD or UC who were adherent to therapy for 12 months had approximately twofold associated lower odds of hospitalization. To avoid one hospitalization an estimated 11 members with CD would need to be treated and adherent, while 15 members with UC would need to be treated and adherent.

“Understanding the value of a treatment relative to its cost is critical for costly drugs like BT, especially in high-spend drug categories like autoimmune, where BT exceeds 70 percent of the total cost of care” said Kevin Bowen, M.D., M.B.A., principal health outcomes researcher for Prime. “Although, CD and UC 12-month post hospitalization costs are considerable, the BT wholesale acquisition cost (WAC) is more than $50,000 per year. And, from this analysis, 11 CD or 15 UC individuals would need to be moved from non-adherent to adherent status to prevent one hospitalization, thus plan sponsors incur substantial biologic drug cost investment to prevent a hospitalization. With this high cost of BT therapy investment to avoid a hospitalization it is imperative to ensure BT price to value be assessed and value-based contracting explored.”

Prime researchers will present these studies at the Academy of Managed Care Pharmacy’s (AMCP) Managed Care & Specialty Pharmacy 31st Annual Meeting March 25-28 in San Diego.

Download AMCP research poster (autoimmune #1)
Download AMCP research poster (autoimmune #2)

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