Prescription Drugs Spending Distribution and Cost Drivers Steve Kappel January 25, 2007
Introduction Why Focus on Drugs? Compared to other health care spending: Even faster annual growth Higher reliance on out-of-pocket spending Some health insurance doesn t cover drugs High cost-sharing requirements Caps and other benefit maximums Uninsured
Sources of Numbers Vermont-specific Department of Banking, Insurance, Securities and Health Care Administration National Total spending figures from Office of the Actuary, CMS Detailed information from Medical Expenditure Panel Survey (MEPS) conducted by the federal Agency for Healthcare Research and Quality (AHRQ)
All Other V e r m o n t 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Distribution of Health Care Spending by Type, Vermont, 2005 Physicians Drugs and Supplies Administration / Net Nursing Home Dental Other Professional Home Health Hospitals
Health Care Spending by Source of Funds, Vermont, 2005 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% Drugs and Supplies All Health Care 15.0% 10.0% 5.0% 0.0% Out of Pocket Insurance Medicaid Medicare All Other *
Health Care Spending Growth, Vermont, 1997-2005 25.0% 20.0% Change From Previous Year 15.0% 10.0% Drugs and Supplies All Other Health Care CPI 5.0% 0.0% 1997 1998 1999 2000 2001 2002 2003 2004 2005
Drugs and Supplies as Percent of Total Health Spending, Vermont, 1996-2005 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 1996 1997 1998 1999 2000 2001 2002 2003 2004
Growth in Prescription Drug Spending, US, 1961-2015 20.0% Projected 18.0% 16.0% Change from Previous Year 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 1961 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011 Year
Drug Spending in the US Population 64.4 percent have expense (2003) Mean $611, median $62 Top 10% 64.2 percent of all spending Top 30% 93.6 percent of all spending Bottom 50% 0.7 percent of all spending
Top-Selling Drugs In 2004, the top 10 drugs (based on total spending) accounted for 19.2% of all drug spending in the US Lipitor has been the top seller since 2000. Spending on this drug nearly tripled from 2000 to 2004.
Pharmacy Spending, Top 10 Conditions, United States, 2004 $Millions Total Prescribed Medicines Percent of Total Prescribed Total Medicines Meds % Total Hypertension $37,854.88 $22,012.05 3.9% 11.5% 58.1% Mental Disorders $51,974.25 $21,267.06 5.4% 11.1% 40.9% COPD & Asthma $48,689.94 $15,916.98 5.1% 8.3% 32.7% Hyperlipidemia $21,317.42 $15,374.46 2.2% 8.1% 72.1% Diabetes $30,702.76 $13,645.85 3.2% 7.1% 44.4% Upper GI disorders $21,502.76 $12,032.63 2.2% 6.3% 56.0% Other $20,741.05 $10,694.36 2.2% 5.6% 51.6% Osteoarthritis $34,888.42 $8,192.08 3.6% 4.3% 23.5% Heart Conditions $90,043.98 $7,971.67 9.3% 4.2% 8.9% Infectious Diseases $14,670.28 $5,381.83 1.5% 2.8% 36.7% GRAND TOTAL $963,882.00 $190,973.00 19.8% Source: MEPS Note: these are the top 10 conditions ranked on spending on prescribed medication
Brand and Generic Between 1999 and 2003 spending on brand name drugs rose from $75.5 billion to $141 billion (88%). In the same period, generic spending rose form $18.8 to $36.6 billion (95%). Generic share increased slightly, from 24.9% to 26%.
COX-2 Inhibitors New type of analgesic, reportedly fewer GI complications, introduced in 1998 1997 total spending on NSAIDs was $3.2 billion 2003 NSAIDs other than COX-2 had fallen slightly, to $3 billion (constant dollars). COX-2 spending was $5.5 billion Proportion of people using other NSAIDs fell from 10.9% to 8.2%, COX-2 users 4.7%
Health Care Cost Drivers Prices the amount paid for the same product over time Utilization the quantity of product purchased Intensity the mix of different products purchased Include new drugs here or separate?
Relative Contribution of Drivers Several studies have looked at this, with similar results Express Scripts does an annual Drug Trend Report the 2005 version was released in June of 2006 Different way of measuring drivers
2001 2002 2003 2004 2005 Avg. Ann Inflation* 5.6% 7.5% 6.6% 6.0% 5.3% 6.2% Units / Script** 0.0% -0.1% 0.3% 0.2% 0.1% 0.1% Brand / Generic^ -1.4% -2.3% -2.6% -2.6% -2.7% -2.3% Therapeutic Mix^ 4.4% 5.3% 2.6% 3.7% 0.8% 3.3% COST / SCRIPT 8.7% 10.5% 6.8% 7.3% 3.4% 7.3% Utilization** 6.3% 6.3% 6.8% 2.9% 4.0% 5.2% SAME DRUGS 15.6% 17.4% 14.1% 10.4% 7.5% 12.9% New Drugs^ 1.0% 1.0% 0.5% 0.3% 0.4% 0.6% TOTAL 16.7% 18.6% 14.7% 10.7% 7.9% 13.7% Price* 5.6% 7.5% 6.6% 6.0% 5.3% 6.2% Utilization** 6.3% 6.2% 7.1% 3.1% 4.1% 5.4% Intensity^ 4.0% 3.9% 0.4% 1.3% -1.5% 1.6% Source: Express Scripts, 2005 Drug Trend Report, Exhibit 19
A Closer Look at Prices Tremendous variation U.S. and other countries Brand prices are usually higher in the U.S. Generic prices are usually lower in the U.S. Among payers in the U.S. The lowest prices are usually paid by the V.A., about 45% of list price Medicaid pays an estimated 60% of list price PBMs pay an estimated 80%
The Pharmaceutical Supply Chain Manufacturers Wholesalers Retail Pharmacies Chain Independent Mail-order Non-Retail Providers Hospitals HMOs Nursing Homes Consumers Source: CBO
Three Key Price Measures -1 Average Manufacturer Price Average price paid by wholesalers or retailers who purchase directly from manufacturers Real number Reported to CMS, used to calculate Medicaid rebates Value of rebates is excluded
Three Key Price Measures - 2 Wholesale Acquisition Cost (WAC) Manufacturer s publicized list price Probably closest to the price wholesalers charge retailers
Three Key Price Measures - 3 Average Wholesale Price (AWP) Published average list price paid by retailers who purchase from wholesalers Frequently used by Medicaid programs to calculate brand drug reimbursement Vermont pays AWP minus 11.9% plus a dispensing fee Most closely approximates retail price
Rebates Basic idea sell at a lower price, without lowering prices (just like cars) Medicaid Rebates guarantee that Medicaid will get the same price for each drug as the lowest price charged to any private purchaser. Calculation by CMS, no public information
Rebates Some Medicaid programs, including Vermont, have used preferred drug lists to negotiate supplemental rebates from manufacturers. These rebates are based on the ability of PDLs to move substantial volume from one manufacturer to another.
Rebates PBMs Pharmacy Benefit Managers (PBMs) also rely on rebates from manufacturers Concerns that PBMs do not always pass the full value of rebates onto their customers
Tomorrow Approaches to controlling pharmacy spending Evaluation of the effect of those approaches
Questions?