Insurers incur higher drug costs to cover exchange members

Report: Exchange members have more prescriptions, more costly drugs

Consumers who purchased public health insurance exchange plans used more medications, especially for treating hepatitis C and HIV, than individuals enrolled in commercial plans, according to a new report from pharmacy benefits manager Prime Therapeutics.

Based on the data--an average membership for both the public exchange and commercial populations--from Blue Cross Blue Shield companies, Prime Therapeutics determined that consumers who obtained coverage through public exchange plans are older and have more unmet healthcare needs. These characteristics usually lead to higher costs for insurers.

Pulic exchange consumers spent an average of $3 more on drugs and medications than commercial members--$85 per member, per month versus $82 per member, respectively. Individuals covered through public exchanges used an average of almost 12 prescriptions per member, per year, while commercial members used 10 prescriptions per member, per year. That's nearly a 14 percent difference.

Of the higher medication spending, hepatitis C drugs accounted for 10 percent and HIV medications made up 9 percent for public exchange consumers, compared to about 4 percent and 3 percent, respectively, for commercial plan members. 

"What was surprising to us was that two very small populations … would make up fully 19 percent of all the [spending] in our public exchange membership," Michael Showalter, chief marketing officer at Prime Therapeutics, told the Star-Tribune. "There was a huge unmet need, and people really needed coverage."

There's some good news for insurers. "I would expect over time that this is a bubble of sicker-than-average people," Showalter said. "As they continue to have coverage they will start to look more and more like the average U.S. population."

Despite the increased usage of HIV drugs and other specialty meds, insurers aren't necessarily spending more for their exchange plan members, primarily because those plans have higher out-of-pocket requirements, FierceHealthPayer previously reported. Plus, members' higher drug use now doesn't necessarily mean insurers will face rising medication costs in the future, Showalter added.

To learn more:
- here's the Prime Therapeutics report
- read the Star-Tribune article

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