Utilization, Cost Trends, and Member Cost - Share for Self-Injectable Multiple Sclerosis Drugs-Pharmacy and Medical Benefit Spending From 2004 Through 2007
Utilization, Cost Trends, and Member Cost - Share for Self-Injectable Multiple Sclerosis Drugs-Pharmacy and Medical Benefit Spending From 2004 Through 2007
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利用、成本趋势和会员成本 - 自注射多发性硬化症药物的份额 - 2004 年至 2007 年的药房和医疗福利支出
DOI：
10.18553/jmcp.2007.13.9.799
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发表时间：
2007
期刊：
影响因子：
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通讯作者：
Steven V. Johnson
中科院分区：
文献类型：
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作者：
April M Kunze;Brent W. Gunderson;P. Gleason;A. Heaton;Steven V. Johnson
背景技术背景：1993年，干扰素β-1b成为美国食品和药物管理局批准的4种自我注射多发性硬化症（MS）药物中的第一种。最初作为医疗费用支付，可自我注射的MS药物越来越多地被认为是专业药物，并且通常在药房福利下支付。自我注射的MS药物价格昂贵，2007年每位患者每月花费约2,000美元。目的：（1）确定自我注射MS药物的价格和使用趋势，（2）合并医疗和药房索赔数据，以获取自我注射MS药物的总医疗保健支出，以及（3）计算具有药房福利的会员的自付成本份额。方法：一个药房福利经理，为大约180万商业会员提供综合医疗索赔，约占其900万商业会员总数的20%，分析了从2004年1月开始到2007年9月结束的45个月期间的自我注射MS药房索赔，以及42个月期间的综合医疗和药房索赔。从2004年1月开始至2007年6月结束的一个月期间。900万成员是分布在美国各地的10个蓝十字蓝盾保健计划的受益人，180万成员参加了北方平原各州的1个蓝十字蓝盾保健计划。使用药房声明中国家药物代码（NDC）编号的通用产品标识符（GPI）代码识别自我注射MS药物。最多90天供应的邮购药房索赔被计为3项索赔，最多34天供应的社区药房索赔被计为1项索赔。使用医疗保健通用程序编码系统（HCPCS）代码从医疗声明中识别自我注射MS药物：J1595用于格拉替雷，J1830用于皮下干扰素β-1b，Q3026用于皮下干扰素β-1a，Q3025和J1825用于肌内干扰素β-1a。研究结果：对于仅从药房索赔获得数据的约900万成员，这4种自我注射MS药物约占2004年药房福利支出总额的1.8%，2005年为1.9%，2006年为2.3%，2007年为2.4%。每名会员每月平均批发价由2004年第一季的1.11元上升至2007年第三季的1.74元，升幅为56.8%。在45个月的测量期间，利用率持平，每月每100 000名成员约有82-83项索赔。每单位的平均年价格上涨幅度从干扰素β-1a的8.9%到干扰素β-1b的13.3%不等。2004年，会员支付的每笔药店报销费用中位数为15美元，2005年和2006年为20美元，2007年前9个月为25美元。对于180万同时拥有药房和医疗福利索赔的成员，医疗福利占2004年MS自我注射剂总支出的2.5%，2005年和2006年为2.0%，2007年为1.2%。结论：可归因于自我注射MS药物的所有药房支出的百分比从2004年的1.8%增加到2007年的2.5%。在近4年的时间里，几乎所有的自我注射MS药物支出的增加都归因于药物价格的上涨，因为PMPM的使用基本上没有变化。成员的平均成本份额约为自我注射MS药物总成本的1%。
BACKGROUND: In 1993, interferon beta-1b became the first of 4 self-injectable multiple sclerosis (MS) drugs to be approved by the U.S. Food and Drug Administration. Initially covered as a medical expense, self-inject able MS drugs are increasingly considered specialty pharmaceuticals and are often covered under the pharmacy benefit. Self-inject able MS drugs are expensive, costing approximately $2,000 per month per patient in 2007. OBJECTIVES: To (1) determine the trends for price and utilization of self-injectable MS drugs, (2) meld medical and pharmacy claims data to capture total health care spending on self-injectable MS drugs, and (3) calculate the out-of-pocket cost-share for members with pharmacy benefits. METHODS: A pharmacy benefits manager with integrated medical claims for approximately 1.8 million commercial members, about 20% of its total of 9 million commercial members, analyzed self-injectable MS pharmacy claims for a 45-month period beginning in January 2004 and ending in September 2007 and integrated medical and pharmacy claims for a 42-month period beginning in January 2004 and ending in June 2007. The 9 million members are beneficiaries of 10 Blue Cross Blue Shield (BCBS) health plans distributed throughout the United States and the subset of 1.8 million members are enrolled in 1 BCBS health plan in the Northern Plains states. Self-injectable MS drugs were identified using Generic Product Identifier (GPI) codes for the National Drug Code (NDC) numbers on pharmacy claims. Mail order pharmacy claims with up to a 90-day supply were counted as 3 claims, and community pharmacy claims dispensed with up to a 34-day supply were counted as 1 claim. Self-injectable MS drugs were identified from medical claims using Healthcare Common Procedure Coding System (HCPCS) codes: J1595 for glatiramer, J1830 for subcutaneous interferon beta-1b, Q3026 for subcutaneous interferon beta-1a, and Q3025 and J1825 for intramuscular interferon beta-1a. RESULTS: For the approximately 9 million members with data from pharmacy claims only, these 4 self-injectable MS drugs accounted for approximately 1.8% of total pharmacy benefit spending in 2004, 1.9% in 2005, 2.3% in 2006, and 2.4% in 2007. The mean average wholesale price (AWP) per member per month (PMPM) increased by 56.8%, from $1.11 PMPM in the first quarter of 2004 to $1.74 PMPM in the third quarter of 2007. Utilization was flat at about 82-83 claims per 100,000 members per month during the 45-month measurement period. The average annual price increase per unit ranged from 8.9% for interferon beta-1a to 13.3% per year for interferon beta-1b. Members paid a median out-of-pocket cost per pharmacy claim of $15 in 2004, $20 in 2005 and 2006, and $25 in the first 9 months of 2007. For the 1.8 million members with both pharmacy and medical benefit claims, the medical benefit accounted for 2.5% of total spending on MS self-injectables in 2004, 2.0% in 2005 and 2006, and 1.2% in 2007. CONCLUSIONS: The percentage of all pharmacy expenditures that was attributable to self-injectable MS drugs increased from 1.8% in 2004 to 2.5% in 2007. Nearly all of the increase in spending on self-injectable MS drugs over the nearly 4-year period was attributable to drug price increases because PMPM utilization was essentially unchanged. The median member cost-share was approximately 1% of the total cost of self-injectable MS drugs.