National trends in prescription drug expenditures and projections for 2019

Auditing the prescription drug consumer price index in a changing marketplace

Changes in the dynamics of prescription drug markets have raised issues regarding whether the United States Bureau of Labor Statistics' (BLS') Prescription Drug Consumer Price Index (CPI-Rx) has adequately kept up with the evolving marketplace. The CPI-Rx limits its sampling frame to retail outpatient outlets and excludes prescription pharmaceuticals dispensed in non-retail settings such as hospitals, physician/clinic outpatient facilities, and nursing homes. Thus, the CPI-Rx overlooks the increasingly important specialty pharmaceuticals dispensed in non-retail settings, whose transactions are instead captured in the overall hospital and professional services component of the medical care CPI. Specialty drugs now account for about 55% of all U.S. drug spending, double the share of a decade earlier. To the extent specialty drug price growth differs from that of traditional pharmaceuticals, the CPI-Rx could provide an inaccurate measure of overall drug price inflation. We calculate a chained Laspeyres CPI using data from the Merative™ MarketScan® Databases for the years 2010-2019 and IQVIA-designated specialty drugs and offer evidence showing that by not sampling specialty drugs in non-retail settings, the CPI-Rx has understated overall U.S. prescription drug inflation by just under 75 basis points annually. We discuss implications for health care policy and suggest the BLS examine the feasibility of publishing an overall pharmaceutical price index incorporating both traditional and specialty pharmaceuticals dispensed in retail and non-retail settings.

Patient Out-of-Pocket Costs Following the Availability of Biosimilar Versions of Infliximab

After market exclusivity ends for biologic drugs, biosimilars-follow-on versions made by other manufacturers-can compete with lower prices. Biosimilars have modestly reduced prescription drug spending for US payers, but it is unclear whether patients have directly experienced any savings. In this study we assessed whether availability of biosimilar infliximab was associated with lower out-of-pocket (OOP) costs, using claims from a national data set of commercially insured patients from 2014 to 2018. We used two-part models, adjusting for patient demographics, clinical characteristics, insurance plan type, and calendar month. Compared with the reference biologic, there was no difference in the percentage of biosimilar claims with OOP costs (30.1% vs. 30.8%; adjusted odds ratio (aOR) 0.98, 95% confidence interval (CI), 0.84-1.15, P = 0.84) or the average nonzero OOP cost (median $378 vs. $538, adjusted mean ratio (aMR) 0.97, 95% CI, 0.80-1.18, P = 0.77). The percentage of claims with OOP costs was lower after biosimilar competition (30.7% vs. 35.0%, aOR 0.96, 95% CI, 0.94-0.99, P = 0.003), but average nonzero costs increased (median $534 vs. $520, aMR 1.04, 95% CI, 1.01-1.07, P = 0.004). Thus, early biosimilar infliximab competition did not improve affordability for patients. Policymakers need to better assure that competition in the biosimilar market translates to lower costs for patients using these medications.

Pursuing Pharmacoequity: Determinants, Drivers, and Pathways to Progress

The United States pays more for medical care than any other nation in the world, including for prescription drugs. These costs are inequitably distributed, as individuals from underrepresented racial and ethnic groups in the United States experience the highest costs of care and unequal access to high-quality, evidence-based medication therapy. Pharmacoequity refers to equity in access to pharmacotherapies or ensuring that all patients, regardless of race and ethnicity, socioeconomic status, or availability of resources, have access to the highest quality of pharmacotherapy required to manage their health conditions. Herein the authors describe the urgent need to prioritize pharmacoequity. This goal will require a bold and innovative examination of social policy, research infrastructure, patient and prescriber characteristics, as well as health policy determinants of inequitable medication access. In this article, the authors describe these determinants, identify drivers of ongoing inequities in prescription drug access, and provide a framework for the path toward achieving pharmacoequity.

Non-adherence to guideline recommendations for insulins: a qualitative study amongst primary care practitioners

Background

Guideline adherence is generally high in Dutch general practices. However, the prescription of insulins to type 2 diabetes mellitus patients is often not in line with the guideline, which recommends NPH insulin as first choice and discourages newer insulins. This qualitative study aimed to identify the reasons why primary care healthcare professionals prescribe insulins that are not recommended in guidelines.

Methods

Digital focus groups with primary care practitioners were organised. A topic list was developed, based on reasons for preferred insulins obtained from literature and a priori expert discussions. The discussions were video and audio-recorded, transcribed verbatim and coded with a combination of inductive and deductive codes. Codes were categorized into an existing knowledge, attitudes and behaviour model for guideline non-adherence.

Results

Four focus groups with eleven general practitioners, twelve practice nurses, six pharmacists, four diabetes nurses and two nurse practitioners were organised. The prescription of non-recommended insulins was largely driven by argumentation in the domain of attitudes. Lack of agreement with the guideline was the most prominent category. Most of those perspectives did not reflect disagreement with the guideline recommendations in general, but were about advantages of non-recommended insulins, which led, according to the healthcare professionals, to better applicability of those insulins to specific patients. The belief that guideline-recommended insulins were less effective, positive experience with other insulins and marketing from pharmaceutical companies were also identified as attitude-related barriers to prescribe guideline-recommended insulins. One additional category in the domain of attitudes was identified, namely the lack of uniformity in policy between healthcare professionals in the same practice. Only a small number of external barriers were identified, focusing on patient characteristics that prevented the use of recommended insulins, the availability of contradictory guidelines and other, mostly secondary care, healthcare providers initiating non-recommended insulins. No knowledge-related barriers were identified.

Conclusions

The prescription of non-recommended insulins in primary care is mostly driven by lack of agreement with the guideline recommendations and different interpretation of evidence. These insights can be used for the development of interventions to stimulate primary care practitioners to prescribe guideline-recommended insulins.

Deregulation on branded and generic drugs price and its effect: a study of Chinese pharmaceutical market

Purpose

This research studies the effect of deregulation of price cap in pharmaceutical market. Price regulation (either through price cap or reference price) is common practice in the pharmaceutical market but recently there are increasing voices calling for deregulation claiming that deregulation could help in lowering drug price and increase revenue of pharmaceutical firms. Upon those callings, Chinese government removed the price cap regulation in June 2015. The author uses this natural policy experiment to study this effect.

Design/methodology/approach

In this study, the author applied the interrupted time series analysis (ITSA) on the revenue data of nine categories of both generic and branded drugs in China from March 2011 to August 2016 (the time frame includes both before and after of the initialization of the deregulation) and analyzed the effect of deregulation.

Findings

The results showed that, whether the revenue of drugs will increase or decrease after the deregulation of price cap depends on the level of competition and the change of patterns of the branded and generic drugs are different. When HHI (Herfindahl–Hirschman index) is sufficiently low (competition is high), revenue does not change as a result of deregulation, when HHI is moderately low (moderate competition), revenue from generic drugs will decrease significantly and revenue from branded drugs will increase significantly, and when HHI is high (low competition), revenue from generic drugs will increase significantly and revenue from branded drugs will decrease significantly.

Originality/value

This is a unique study with a unique data set. Most previous studies focus on regulation of drug price and analyze how this may affect drug revenue; however, this is a natural policy experiment of de-regulation. Moreover, previously most studies focus on reference pricing regulation and this is price-cap, a different mechanism that is rarely studied. The originality/value is high of this article.

Investigating Prescription Medication Expenditures and Level of Perceived Health Status among Older Adults with Pain in the United States

Background: the objective of this retrospective, cross sectional study was to assess the relationship between different levels of perceived health status and prescription medication expenditures among United States adults aged ≥50 years with self-reported pain. Methods: using 2019 Medical Expenditure Panel Survey (MEPS) data, four levels of perceived health status were formed (excellent, very good, good, and fair/poor health). Differences between characteristics in the groups were compared using chi square tests. Adjusted linear regression models, using logged positive annual prescription medication expenditures, were constructed to assess differences in prescription medication expenditures between levels of perceived health. Results: a total of 4826 individuals were included in the study. Adjusted linear regression analysis indicated those who reported excellent health had 65.8% lower annual prescription medication expenditures than those with fair/poor health. Those with very good health had 49.7% lower annual prescription medication expenditures than those with fair/poor health, while those with good health had 27.2% lower annual prescription medication expenditures than those with fair/poor health. Conclusions: better perceived health status was generally associated with relatively lower prescription medication expenditures. Further research is needed to investigate if this pattern is also observed for other categories of healthcare expenditures and in other populations.

Medication Use and Storage, and Their Potential Risks in US Households

Background: Medications stored in US households may pose risks to vulnerable populations and the environment, potentially increasing societal costs. Research regarding these aspects is scant, and interventions like medication reuse may alleviate negative consequences. The purpose of this study was to describe medications stored in US households, gauge their potential risk to minors (under 18 years of age), pets, and the environment, and estimate potential costs of unused medications. Methods: A survey of 220 US Qualtrics panel members was completed regarding medications stored at home. Published literature guided data coding for risks to minors, pets, and the environment and for estimating potential costs of unused medications. Results: Of the 192 households who provided usable and complete data, 154 (80%) reported storing a medication at home. Most medications were taken daily for chronic diseases. The majority of households with residents or guests who are minors and those with pets reported storing medications with a high risk of poisoning in easily accessible areas such as counters. Regarding risk to the aquatic environment, 46% of the medications had published data regarding this risk. For those with published data, 42% presented a level of significant risk to the aquatic environment. Unused medications stored at home had an estimated potential cost of $98 million at a national level. Implications/Conclusions: Medications stored at home may pose risks to vulnerable populations and the environment. More research regarding medications stored in households and their risks is required to develop innovative interventions such as medication reuse to prevent any potential harm.

Improving Antibiotic Stewardship in Acute Appendicitis through Risk-Based Empiric Treatment Selection

Background: Empiric antimicrobial treatment selection for management of appendicitis is based on patient risk of infection with drug-resistant pathogens. Per Surgical Infection Society (SIS) guidelines, only high-risk patients should receive extended spectrum antibiotics. After observing substantial use of piperacillin-tazobactam at an academic medical center, a quality improvement initiative was developed targeting standardization of antibiotics for uncomplicated appendicitis. Patients and Methods: A project was performed to improve antibiotic stewardship in acute appendicitis treatment using plan-do-study-act methodology. We designed educational materials to guide risk-based empiric antimicrobial treatment selection for adult patients presenting with appendicitis. Implementation began January 1, 2020. High-risk criteria included presence of sepsis, presence of one or more comorbidities, and health-care-associated appendicitis. Retrospective chart review included adult patients admitted for appendectomy between January 1, 2019 and December 1, 2020. Pre-/post-implementation analysis and run chart analysis were performed. Primary outcome was the proportion of patients receiving the correct antibiotic. Secondary outcomes included antibiotic cost. Patients treated pre-/post-implementation were compared using univariable analysis, with statistical significance set at p < 0.05. Results: Of the 138 patients, 85 patients were in the pre-implementation group and 53 in the implementation group. The implementation group was 19.1% more likely to receive the correct antibiotic (pre = 31.8%; post = 50.9%; p = 0.03). Average cost per patient was reduced $13.25 (pre = $23.68 ± $18.76; post = $10.43 ± $8.45; p ≤ 0.0001). There were no differences in complications (pre = 2.4%; post = 0%; p = 0.26) or re-admissions (pre = 2.34%; post = 1.9%; p = 0.86). Conclusions: After an educational initiative to raise awareness about SIS guidelines for empiric antibiotic treatment for acute appendicitis, we observed an increase in the number of patients receiving the appropriate antibiotic. Prescribing habits were altered with no adverse impact on clinical outcomes. The next phase will address sustainability by incorporating an electronic medical record order set to integrate just-in-time education within the provider workflow.

Payer Perspectives on Intravenous versus Subcutaneous Administration of Drugs

The coronavirus disease 2019 (COVID-19) pandemic has brought increased attention to vulnerable populations such as older or immunocompromised patients and heightened the focus on alternatives to intravenous (IV) formulations, particularly those that may be administered in a non-clinical setting. Among these alternative formulations are subcutaneous (SC) injections, which comprise an increasing share of commercialized and pipeline therapies. While much has been published about the benefits and limitations of IV versus SC administration to patients and health systems, less attention has been given to payer considerations regarding these routes of administration. Accordingly, this article provides payer perspectives on some of the key differences between IV and SC administration as they relate to management and billing, cost, treatment adherence and safety, and patient preference and quality of life. The benefits and limitations of these drug administration routes to key healthcare stakeholders—namely patients, physicians, and payers—are also discussed. Considerations of relevance are highlighted, including the potential for misalignment of stakeholder interests and countervailing factors that may impact decision-making about IV and SC formulations.

100 years of Insulin: Why is Insulin So Expensive and What Can be Done to Control Its Cost?

The discovery of insulin 100 years ago and subsequent improvements in insulin formulations and delivery devices have changed the lives of people with diabetes. Unfortunately, the average price of insulin in the United States has nearly tripled over the past decade, and the high cost of insulin has become a barrier to diabetes treatment. On the 100th anniversary of insulin's discovery, this life-saving treatment is financially out of reach for as many as one-third of people with diabetes. The challenge now is to ensure that insulin is available for all people with diabetes who need it. We explore reasons for the high cost of insulin and recommend some clinical and policy interventions to improve insulin access and affordability.

Opioid Prescribing in United States Health Systems, 2015 to 2019

OBJECTIVES

Health systems (nonfederal hospitals and clinics) are the second major source for drug expenditure in the United States. Opioids prescribed in these healthcare settings are commonly short-acting opioids that can lead to persistent opioid use. Nevertheless, there are no national data that describe trends in opioid use and the associated expenditure in health systems. Therefore, the objective of this article was to describe opioid use and expenditures in US health systems from 2015 to 2019.

METHODS

We used data from IQVIA National Sales Perspectives to describe prescription opioid expenditure and use in health systems (nonfederal hospitals and clinics).

RESULTS

Over the 5-year study period, health systems dispensed a total of 6.55 billion units of opioids (26.88% decrease) with an associated expenditure of $3.33 billion (26.78% decrease). Relative to all opioid formulations in our study, oxycodone, hydrocodone, and fentanyl were the opioids with the highest use in US health systems. All opioid prescriptions decreased except fentanyl use, which increased by 29.80% in clinics. The use of abuse-deterrent formulations of opioids decreased by 51.00% over the study period, although the decrease seems to be driven mainly by long-acting oxycodone (brand name Oxycontin).

CONCLUSIONS

Opioid use and expenditures in health systems have been decreasing following national trends from retail pharmacies. Nevertheless, fentanyl use increased in clinics and was prescribed at higher proportions in nonfederal hospitals than other opioids, which warrants further investigation.

Exploring polypharmacy with artificial intelligence: data analysis protocol

BACKGROUND

Polypharmacy is common among older adults and it represents a public health concern, due to the negative health impacts potentially associated with the use of several medications. However, the large number of medication combinations and sequences of use makes it complicated for traditional statistical methods to predict which therapy is genuinely associated with health outcomes. The project aims to use artificial intelligence (AI) to determine the quality of polypharmacy among older adults with chronic diseases in the province of Québec, Canada.

METHODS

We will use data from the Quebec Integrated Chronic Disease Surveillance System (QICDSS). QICDSS contains information about prescribed medications in older adults in Quebec collected over 20 years. It also includes diagnostic codes and procedures, and sociodemographic data linked through a unique identification number for each individual. Our research will be structured around three interconnected research axes: AI, Health, and Law&Ethics. The AI research axis will develop algorithms for finding frequent patterns of medication use that correlate with health events, considering data locality and temporality (explainable AI or XAI). The Health research axis will translate these patterns into polypharmacy indicators relevant to public health surveillance and clinicians. The Law&Ethics axis will assess the social acceptability of the algorithms developed using AI tools and the indicators developed by the Heath axis and will ensure that the developed indicators neither discriminate against any population group nor increase the disparities already present in the use of medications.

DISCUSSION

The multi-disciplinary research team consists of specialists in AI, health data, statistics, pharmacy, public health, law, and ethics, which will allow investigation of polypharmacy from different points of view and will contribute to a deeper understanding of the clinical, social, and ethical issues surrounding polypharmacy and its surveillance, as well as the use of AI for health record data. The project results will be disseminated to the scientific community, healthcare professionals, and public health decision-makers in peer-reviewed publications, scientific meetings, and reports. The diffusion of the results will ensure the confidentiality of individual data.

Real-World Six-Year National Cost-Minimization Analysis of IncobotulinumtoxinA and OnabotulinumtoxinA in the VA/DoD Healthcare Systems

Purpose

This study sought to perform a real-world, long-term cost-minimization analysis for incobotulinumtoxinA (Xeomin^®) versus onabotulinumtoxinA (Botox^®), given the established non-inferiority when utilized at similar doses.

Methods

The Department of Veterans Affairs (VA) and Department of Defense (DoD) national healthcare systems were included in this analysis. Real-world purchase data for incobotulinumtoxinA were used to estimate the direct drug costs between calendar years 2014 and 2019. Publicly available federal pharmaceutical prices (Federal Supply Schedule and Big 4) were used. The primary outcome was the difference in total direct costs nationally for incobotulinumtoxinA (real-world) versus having hypothetically utilized onabotulinumtoxinA (projected) for similar utilization. Sites utilizing ≥100 vials (of 100 Unit equivalents) of incobotulinumtoxinA annually were categorized as “major adopters”. IncobotulinumtoxinA 50 Unit vials were assumed to be an alternative to a 100 Unit vial of onabotulinumtoxinA for 50% of such vial purchases in the base case scenario to account for differences in wastage.

Results

Over the six-year study time frame, 156 sites (76.8%) utilized incobotulinumtoxinA of the 203 total VA healthcare systems and DoD medical centers. Of these sites, 67 were major adopters for at least one year, with a mean of 3.4 years spent as a major adopter over the study period. Average annual savings per major adopter was $105,782. IncobotulinumtoxinA costs for all VA/DoD sites was $46.39 million for the six-year period versus a projected $71.92 million onabotulinumtoxinA cost—a total savings of $25.53 million (35.5% relative reduction). Approximately, 82.8% of savings stemmed from lower drug acquisition cost ($21.14 million) and 17.2% of savings ($4.39 million) was related to reduced wastage. It was estimated that a total of 9958 extra onabotulinumtoxinA 100 Unit vials would have been wasted during the six-year period, translating to the need for a 5.9% increase in vial purchases versus incobotulinumtoxinA.

Conclusion

Meaningful cost savings were realized related to incobotulinumtoxinA adoption over a long-term time frame in the VA/DoD healthcare systems.

Exploration of Overdose Risk Score and Postoperative Complications and Health Care Use After Total Knee Arthroplasty

IMPORTANCE

The adverse outcomes after total knee arthroplasty (TKA) associated with preoperative prescription drug use (ie, use of narcotics, sedatives, and stimulants) have been established but are not well quantified.

OBJECTIVE

To test the association of preoperative overdose risk score (ORS) with postoperative health care use.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted using data on a consecutive sample of individuals who underwent primary TKA from November 2018 through March 2020 at a tertiary care health system. Data were collected using the Orthopaedic Minimal Data Set Episode of Care, a validated data-collection system for all elective orthopedic surgical interventions taking place within the health care system. Outcomes were assessed at 90 days postoperatively. Individuals whose preoperative baseline characteristics or ORS were not provided or who declined to participate were excluded. Data were analyzed from September through October 2020.

EXPOSURE

Patient-specific preoperative ORS, as measured using NarxCare, associated with patterns of prescription drug use.

MAIN OUTCOMES AND MEASURES

Associations between patient-specific ORS categories and 90-day postoperative health care use (ie, prolonged hospital length of stay [LOS; ie, >2 days], nonhome discharge, all-cause 90-day readmission, emergency department [ED] visits, and reoperation) were evaluated. Outcomes were also compared between a group of individuals with ORS less than 300 vs those with ORS 300 or greater who were propensity score matched (4:1; caliper, 0.1) using demographic characteristics (ie, age, sex, race, body mass index, and smoking status) and baseline comorbidities.

RESULTS

Among 4326 individuals who underwent primary TKA, 2623 (60.63%) were women, 3602 individuals (83.26%) were White, the mean (SD) BMI was 32.8 (6.9), and the mean (SD) age was 66.6 (9.2) years; 90-day follow-up was available for the entire cohort. The predominant preoperative diagnosis was osteoarthritis, occurring among 4170 individuals (96.4%). For individuals with an ORS of 300 to 399, there were significantly higher odds of a prolonged LOS (odds ratio [OR], 2.03; 95% CI, 1.46-2.82; P < .001), nonhome discharge (OR, 2.01; 95% CI, 1.37-2.94; P < .001), all-cause 90-day readmission (OR, 1.56; 95% CI, 1.01-2.42; P < .001), and ED visits (OR, 1.62; 95% CI, 1.11-2.38; P = .01) compared with individuals who were prescription drug naive (ie, ORS = 0). Individuals in the highest ORS category (ie, ORS ≥ 500) had the highest ORs for prolonged LOS (OR, 3.71; 95% CI, 2.00-6.87; P < .001), nonhome discharge (OR, 4.09; 95% CI, 2.02-8.29; P < .001), 90-day readmission (OR, 4.41; 95% CI, 2.23-8.71; P < .001), and 90-day reoperation (OR, 6.09; 95% CI, 1.44-25.80; P = .01). Propensity score matching confirmed the association between an ORS of 300 or greater and the incidence of prolonged LOS (244 individuals [11.6%] vs 130 individuals [23.0%]; P < .001), nonhome discharge (176 individuals [8.4%] vs 93 individuals [16.4%]; P < .001), all-cause 90-day readmission (119 individuals [5.7%] vs 65 individuals [11.5%]; P < .001), and all-cause ED visits (198 individuals [9.4%] vs 76 individuals [13.4%]; P = .006).

CONCLUSIONS AND RELEVANCE

This study found that higher ORS was associated with increased health care use after primary TKA. These findings suggest that an ORS of 300 or greater could be used to designate increased risk and guide the preoperative surgeon-patient discussion to modify prescription drug use patterns.

A framework for graduate and postgraduate specialty pharmacy training

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

There is a growing need for specialty pharmacy leaders within integrated delivery networks (IDNs). Traditional training for students and residents has not met the demand for pharmacy leaders in this space. This article describes the partnership between UW Health (UWH) and the University of Wisconsin School of Pharmacy (UWSOP) in developing a specialty pharmacy elective course at UWSOP and in creating a postgraduate residency training program at UWH. Future directions for the partnership are discussed.

Summary

Members of the leaderships of UWH and UWSOP met to discuss expanding coursework related to specialty pharmacy business fundamentals at UWSOP. This meeting led to the development of a 2-credit elective course beginning in spring 2017. The course focused on marketplace economics, channel strategies, and specialty pharmacy practice development. Additionally, UWH identified the need to provide postgraduate training to meet the increasing demand across IDNs for specialty pharmacy leaders. The residency program was initiated in 2013 and received accreditation in 2016. The residency provides experience in specialty pharmacy leadership, managed care, finance, the revenue cycle, accreditation, and the supply chain. Future partnership opportunities include creation of a longitudinal student pharmacist track and joint project coordination between UWSOP students and UWH residents.

Conclusion

This partnership has provided a pathway for students to gain expertise in specialty pharmacy business fundamentals as well as postgraduate training opportunities for future specialty pharmacy leaders. IDN and school of pharmacy partnerships can expand educational opportunities for future specialty pharmacy leaders and help fulfill the market gap in specialty pharmacy leaders.

Correlation Between Changes in Brand-Name Drug Prices and Patient Out-of-Pocket Costs

IMPORTANCE

List prices set by manufacturers for brand-name prescription drugs in the US have been increasing faster than inflation, although confidential manufacturer rebates offset some of these increases. Most commercially insured patients pay at least some out-of-pocket costs for prescription drugs, and higher patient spending is associated with lower adherence and worse health outcomes.

OBJECTIVE

To examine whether price changes for brand-name drugs are correlated with changes in patient out-of-pocket spending and whether this association varies by insurance benefit design.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study of 79 brand-name drugs with available pricing data from January 2015 to December 2017 was conducted, with data obtained from a national commercial insurance claims database.

EXPOSURES

Change in the list prices set by manufacturers and estimated net prices after rebates among non-Medicaid payers.

MAIN OUTCOMES AND MEASURES

Change in median out-of-pocket spending among all patients and stratified by insurance pharmacy benefit design, including high-deductible insurance plans and plans with any amount of deductibles or coinsurance.

RESULTS

Among 79 drugs, median increases were 16.7% (interquartile range [IQR], 13.6%-21.1%) for list prices, 5.4% (IQR, -3.9% to 11.7%) for net prices, and 3.5% (IQR, 1.4%-9.1%) for out-of-pocket spending from 2015 to 2017. Changes in list prices were correlated with changes in net prices (r = 0.34; P = .002). Overall, changes in out-of-pocket spending were not correlated with changes in list prices (r = 0.14; P = .22) or net prices (r = 0.04; P = .71). Among 53.7% of patients who paid any drug deductible or coinsurance, median out-of-pocket spending increased by 15.0%, and changes were moderately correlated with changes in list prices (r = 0.38; P = .001) but not net prices (r = 0.06; P = .62).

CONCLUSIONS AND RELEVANCE

Some commercially insured patients who pay only prescription drug copayments appear to be insulated from increases in drug prices. However, more than half of patients pay deductibles or coinsurance and may experience substantial increases in out-of-pocket spending when drug prices increase. Among these patients, there was no evidence that manufacturer rebates to insurers are associated with patients' out-of-pocket spending. Policies to rein in unregulated annual increases in list prices for brand-name drugs may have important consequences for patient out-of-pocket spending.

Intravenous levothyroxine stewardship program at a tertiary academic medical center

PURPOSE

Based on the pharmacokinetic profile of levothyroxine, a 3-day hold guideline for adult patients ordered for intravenous (IV) levothyroxine was implemented at a tertiary academic medical center. The purpose of this study was to evaluate the impact of the implementation of an IV levothyroxine hold guideline.

METHODS

This single-center, retrospective analysis identified patients ordered for IV levothyroxine during a 13-week period before and after implementation of the guideline. The primary outcome was guideline adherence, defined as full implementation of the 3-day hold. Secondary outcomes included the number of IV levothyroxine administrations avoided in the post-guideline group, extrapolated yearly cost avoidance (EYCA) after guideline implementation, reasons for guideline non-adherence, and number of safety reports involving IV levothyroxine.

RESULTS

A total of 166 and 134 patients met inclusion criteria for the pre- and post-guideline groups, respectively. Guideline adherence was observed in 94 (70.1%) patients, resulting in 276 vials saved in the 13-week post-guideline period, which translated to an EYCA of $139,877. Forty orders (29.9%) were non-adherent to the guideline, with the most common reason stated as nil per os (NPO). No difference in safety outcomes was seen between the pre- and post-guideline groups, as evidenced by 1 safety report in each group.

CONCLUSION

We observed a high rate of adherence to an IV levothyroxine hold guideline. This was associated with a substantial cost savings over the study period with no increase in reported safety events. To our knowledge, this is the first published report of an inpatient IV levothyroxine 3-day hold guideline.

Analyzing the costs of developing and operating an integrated health-system specialty pharmacy: The case of a centralized insurance navigation process for specialty clinic patients

Purpose

Direct and indirect costs related to the growth of specialty pharmacy services and the insurance navigation process for specialty clinic patients are discussed, and development and implementation of a pharmacy-driven and system-wide prior authorization (PA) processing center within a health system are described.

Summary

Expensive specialty drugs require PA. Due to the concentration of specialists, health systems with multiple specialties experience higher PA burden and resulting care delays. Although clinic staff typically handle PA requests, health-system specialty pharmacies are well positioned to support patients, clinic staff, and physicians by assuming responsibility for the PA process entirely. University of Utah Health established its Pharmacy Ambulatory Clinical Care Center (PAC3) to centralize PA processing for selected specialty and primary care clinics within the health system. In fiscal year 2019, the PAC3 team (10 pharmacy technician and 1.5 pharmacist full-time equivalents) completed over 13,000 PAs. The pharmacy labor cost increase was significant; however, the benefits gained from increased services, quality, and financial strength surpassed all costs associated with the implementation and maintenance of the pharmacy operation. Other tangible benefits included decreased delays in therapy initiation, increased patient satisfaction, increased clinic visits, and increased staff and provider satisfaction and engagement.

Conclusion

Increased PA requests associated with specialty drugs have placed considerable stress and staff burden on specialty clinics within health systems. However, development and implementation of an efficient PA processing infrastructure within a health-system specialty pharmacy may reduce the burden, increase financial strength, and improve the patient experience.

US rheumatologists' beliefs and knowledge about biosimilars: a survey

Objectives

We sought to evaluate perceptions of biosimilar products among US rheumatologists who prescribe TNF-α inhibitors, given that 10 TNF-α inhibitor biosimilars and two rituximab biosimilars have Food and Drug Administration (FDA) approval.

Methods

A 19-question self-administered online survey was conducted from 6 May to 1 June 2019, and fielded by WebMD, LLC. Rheumatologists (n = 9050) who were members of Medscape.com and its partner panels were invited to participate. Likert and other rating scales were used to collect responses, which were summarized descriptively.

Results

Responses were obtained from 320 board-certified US rheumatologists, 85% of whom were fellows of the ACR. Nearly all respondents were familiar with the FDA definition of a biosimilar product and were aware that an infliximab biosimilar was FDA approved; fewer realized that adalimumab, etanercept and rituximab biosimilars were also FDA approved. Most respondents (84%) were aware that an approved biosimilar was not automatically deemed interchangeable by the FDA. Rheumatologists were more likely to initiate biosimilar treatment for a biologic treatment-naïve patient with RA (73%) than they were to switch to the biosimilar for a patient with RA doing well on the reference product (35%).

Conclusions

The results of this survey suggest that US rheumatologists have a good understanding and acceptance of biosimilar products, particularly for the initiation of treatment in biologic-naïve individuals. They were hesitant to switch from a reference product to a biosimilar for a patient doing well on the reference product. Additional education on biosimilars is required to help inform treatment decisions by rheumatologists.

A plain language summary of this article has been uploaded as supplementary material, available at Rheumatology online.

Single-Center Experience of Outcomes and Prescribing Patterns of IV Immunoglobulin Use in Critically Ill Patients

Supplemental Digital Content is available in the text.

Previous literature has not compared prescribing practices of IV immunoglobulin in medical ICU survivors and nonsurvivors. The objective of this study was to study IV immunoglobulin use in patients admitted to a medical ICU evaluating differences between hospital survivors and nonsurvivors in regards to level of evidence supporting use, prescribing patterns, and cost.

Spending on Hepatitis C Antivirals in the United States and Canada, 2014 to 2018

OBJECTIVES

Hepatitis C virus (HCV) antivirals have been shown to be highly effective with minimal adverse effects, but they are costly. Little is known about the national spending on this drug class in either Canada or the United States, 2 countries with different drug pricing regulations. Thus the objective of this study was to compare drug expenditure on HCV medications in the United States and Canada.

METHODS

This was a retrospective cross-sectional study using the IQVIA National Sales Perspectives (United States) and Geographic Prescription Monitor (Canada) databases, which contains prescription transactions from American and Canadian pharmacies. All prescription claims for the period between January 1, 2014, and June 30, 2018, were used to describe HCV antiviral expenditure in both countries.

RESULTS

The United States and Canada spent $59.7 billion and $2.8 billion on HCV medications, respectively. Population-adjusted HCV medication costs were higher in the United States ($1 million per 100 000 population) compared with Canada ($0.4 million per 100 000 population).

CONCLUSIONS

Although the rates of HCV infection are similar in the 2 countries, these findings highlight the differences in both the reimbursement utilization policy for HCV treatments in the countries and the major differences in drug pricing policies. As policies to reduce drug spending in the United States are explored, this article highlights the potential cost implications of implementing Canadian index pricing.

National trends in prescription drug expenditures and projections for 2020

Purpose

To report historical patterns of pharmaceutical expenditures, to identify factors that may influence future spending, and to predict growth in drug spending in 2020 in the United States, with a focus on the nonfederal hospital and clinic sectors.

Methods

Historical patterns were assessed by examining data on drug purchases from manufacturers using the IQVIA National Sales Perspectives database. Factors that may influence drug spending in hospitals and clinics in 2020 were reviewed, including new drug approvals, patent expirations, and potential new policies or legislation. Focused analyses were conducted for specialty drugs, biosimilars, and diabetes medications. For nonfederal hospitals, clinics, and overall (all sectors), estimates of growth of pharmaceutical expenditures in 2020 were based on a combination of quantitative analyses and expert opinion.

Results

In 2019, overall US pharmaceutical expenditures grew 5.4% compared to 2018, for a total of $507.9 billion. This increase was driven to similar degrees by prices, utilization, and new drugs. Adalimumab was the top drug in US expenditures in 2019, followed by apixaban and insulin glargine. Drug expenditures were $36.9 billion (a 1.5% increase from 2018) and $90.3 billion (an 11.8% increase from 2018) in nonfederal hospitals and clinics, respectively. In clinics, growth was driven by new products and increased utilization, whereas in hospitals growth was driven by new products and price increases. Several new drugs that will likely influence spending are expected to be approved in 2020. Specialty and cancer drugs will continue to drive expenditures.

Conclusion

For 2020 we expect overall prescription drug spending to rise by 4.0% to 6.0%, whereas in clinics and hospitals we anticipate increases of 9.0% to 11.0% and 2.0% to 4.0%, respectively, compared to 2019. These national estimates of future pharmaceutical expenditure growth may not be representative of any particular health system because of the myriad of local factors that influence actual spending.

Forecasting drug utilization and expenditure: ten years of experience in Stockholm

Background

Operating under constrained budgets, payers and providers globally face challenges in enabling appropriate and sustainable access to new medicines. Among payer initiatives aiming to improve preparedness of healthcare systems for the introduction of new medicines, drug utilization and expenditure forecasting has played an increasingly important role. This study aims to describe the forecasting model used in Region Stockholm and to evaluate the accuracy of the forecasts produced over the past decade.

Methods

In this repeated cross-sectional study, we compared the predicted pharmaceutical expenditure with actual expenditure during the entire available follow-up period (2007–2018) both for overall drug utilization and for individual therapeutic groups. All analyses were based on pharmaceutical expenditure data that include medicines used in hospitals and dispensed prescription medicines for all residents of the region.

Results

According to the forecasts, the total pharmaceutical expenditure was estimated to increase between 2 and 8% annually. Our analyses showed that the accuracy of these forecasts varied over the years with a mean absolute error of 1.9 percentage points. Forecasts for the same year were more accurate than forecasts for the next year. The accuracy of forecasts also differed across the therapeutic areas. Factors influencing the accuracy of forecasting included the timing of the introduction of both new medicines and generics, the rate of uptake of new medicines, and sudden changes in reimbursement policies.

Conclusions

Based on the analyses of all forecasting reports produced since the model was established in Stockholm in the late 2000s, we demonstrated that it is feasible to forecast pharmaceutical expenditure with a reasonable accuracy. A number of factors influencing the accuracy of forecasting were also identified. If forecasting is used to provide data for decisions on budget allocation and agreements between payers and providers, we advise to update the forecast as close as possible prior to the decision date.

How The ACA Reframed The Prescription Drug Market And Set The Stage For Current Reform Efforts

The Affordable Care Act contained a range of provisions that altered prescription drug access and affordability for patients, payers, and providers. Yet the act stopped short of instituting systemic changes in the pricing of drugs, in part to address concerns that more fundamental changes might disrupt the development of new medicines. Looking back a decade after the Affordable Care Act became law, we found that new drug approvals have accelerated and the therapeutic advances embodied in some novel medicines are substantial-as are the prices that companies are charging for them. The lack of affordability of prescription drugs has become an increasing challenge for American patients and payers, particularly those with limited budgets. In this article we consider how things have changed in the past decade and how missed opportunities in the Affordable Care Act's passage figure prominently in the current drug pricing debate.

Real-World Evaluation of Dosing in Patients Converted From Insulin Glargine (Lantus) to Insulin Glargine (Basaglar)

Background: Basaglar, insulin glargine (BGlar; Eli Lilly, Indianapolis, IN), a follow-on biologic, was developed after the patent for Lantus, insulin glargine (LGlar; Sanofi-Aventis, Paris, France) expired. Objective: To compare the dosing and hemoglobin A_1C (A1C)-lowering effects of BGlar compared with LGlar in a real-world setting. Methods: Adult patients, at 5 clinics, with type 1 (T1DM) or type 2 diabetes mellitus (T2DM) who were converted from LGlar to BGlar were included in this retrospective observational study. The primary outcome compared mean basal insulin dose (U/d) from the date of conversion to 6 months. Basal insulin and total daily insulin doses were also compared from baseline to 3- and 12-months postconversion, as also change in A1C, body weight, and estimated monthly acquisition costs of basal insulin. Results: Of the 225 patients included, 56% were male, and 81% had T2DM. The mean conversion dose (U/d) of LGlar was 46.3 ± 32.7. There was no significant difference in the mean BGlar dose (U/d) at 6 months (45.9 ± 33.5; P = 0.52), nor was there a statistical difference at 3 or 12 months. There were no significant differences in change in A1C at any time point. The estimated monthly acquisition cost of BGlar was significantly less than that for LGlar at conversion ($286 vs $341, P < 0.001) and 6 months ($290 vs $351, P < 0.001) respectively. Conclusion/Relevance: The results of this retrospective study suggest that BGlar resulted in similar glycemic outcomes compared with LGlar in a real-world setting and may be a preferable option in a value-based health care environment.