Prime Therapeutics studies: Integrated pharmacy, medical data inform effective drug therapy management for high-cost conditions

EAGAN, Minn. – Armed with insights from substantive, real-world data, Blue Cross and Blue Shield plans that partner with Prime Therapeutics LLC (Prime) are now more effectively making data-driven decisions to mitigate the high costs of autoimmune therapies for inflammatory conditions and multiple sclerosis (MS). Recently, Prime analyzed integrated pharmacy and medical claims data for specialty drug use in autoimmune conditions – the top cost drivers among all drug health care expenses. At 22% of all drug expenditures through the medical and pharmacy benefits among Prime’s commercially insured book of business, autoimmune therapy costs for inflammatory conditions and MS account for $6.7 billion annually.

Two separate Prime studies validated autoimmune therapy use was a material cost driver for health plans. With the drug therapies to treat autoimmune conditions being billed on both the medical and pharmacy benefits, a complete picture can be seen with integrated medical and pharmacy analytics. In addition, these findings are essential to comprehensive medical and pharmacy drug benefit management that health plans are charged with providing for their members.

Rising inflammatory autoimmune drug costs vary by condition

The first study looked at the drug use and cost trends for inflammatory autoimmune conditions including rheumatoid arthritis, psoriasis, ulcerative colitis and Crohn’s disease. Though less than 1% of Prime’s commercially insured members suffer from these conditions, the related drug treatments were approaching 20% of all drug spend through the medical and pharmacy benefit. The study showed the autoimmune drug category per member per month (PMPM) cost increased 32.2% ($7.70 PMPM increase) over 15 months.

Many autoimmune drugs are used to treat multiple conditions. The study’s real-world use patterns showed average member quarterly drug costs varied significantly by drug and by the condition treated. This presents an opportunity for health plans to encourage the most cost-effective treatments through indication-based preferred drug lists and pricing.

“It’s essential to analyze pharmacy and medical claims to manage top cost conditions for which drug costs alone make up most of a member’s total cost of care,” said Sarah Taylor, vice president and chief analytics officer for Prime. “Prime has made a significant investment in data and analytics as part of our transformation to a contemporary PBM model, focused on client- and member-centric offerings. Prime analytics help identify the safest, most effective use of therapies and provide clients with insights they need to forecast cost trends and make data-driven business decisions.”

Multiple Sclerosis DMD spend flat as medical benefit spend increase is offset by pharmacy benefit decrease

In the second study, Prime researchers analyzed pharmacy and medical claims use and cost trends for disease modifying drugs (DMD) used to treat multiple sclerosis (MS). The study is important because drug therapies make up more than 80% of the total cost of treating MS. In fact, the list price for most DMDs are about $80,000 a year, making MS the fourth highest combined medical and pharmacy benefits drug spend category among Prime’s commercially insured members.

In April 2018, professional treatment guidelines were published that recommend prescribing one of three highly active DMDs as first-line treatment for highly active MS. Since October 2018, the U.S. Food and Drug Administration (FDA) approved four new DMDs and two generics for existing DMDs. However, a 2017 ICER report had indicated DMDs were overpriced relative to their benefits. Considering the new guidelines, newly approved therapies, and ICER’s report, Prime’s study of integrated claims and real-world use patterns of DMDs offers knowledge Blue Plans can use to develop care programs for members and help ensure appropriate and cost-effective specialty therapies are used.

The highest rate of new starts to MS DMDs were ocrelizumab, dimethyl fumarate and glatiramer acetate products. Directing treatment-naive patients to generic and lower cost therapies represents a cost-saving opportunity for payers.

PMPM spending for MS DMDs remained relatively steady throughout the two-year study period, mostly because of the decreasing cost for Copaxone® – which is now generic and preferred under the pharmacy benefit. However, lower Copaxone® expenditure was offset by that of increasing Ocrevus® (infused in a medical setting) expenditures on the medical benefit. Prime’s earlier analyses showed members with MS had 8.3 times higher annual total health care expense than members without MS. More than 80% of the excess cost was due to DMD therapy.

“Our health outcomes and economic analyses are one way Prime provides value to Blue Plans,” said Catherine Starner, senior principal health outcomes consultant for Prime. “The importance of real-world data helps Blue Plans ensure members start and continue on the right path with a treatment that is most appropriate for them and is a good value.”

These findings will be presented at the Academy of Managed Care Pharmacy (AMCP) Virtual Annual Meeting April 12-16, 2021.