90 of 200 Highest Expenditure Drugs Had Copayment Coupons; More than Half had no Generic Substitute
Study by: Karen Van Nuys, Geoffrey Joyce, Rocio Ribero, and Dana P. Goldman
Prescription copayment coupons are distributed by drug manufacturers to help patients lower out-of-pocket costs on specific therapies. They have been at the center of recent debates over whether they contribute to rising drug spending or improve access. A new white paper analyzes the copayment coupon landscape for the top 200 drugs (by spending) in 2014, finding that 90 (all branded drugs) had coupons available. Of these, 49 percent had a generic equivalent or close generic substitute available, while 51 percent did not. Twelve percent of the coupons available were for drugs with no close therapeutic substitute of any kind. In an accompanying Health Affairs Blog post, the authors write these findings have important implications for the current policy discussions: “In some cases, coupons may be increasing overall drug costs without improving patients’ health, while in other cases they may be providing patients with access to essential or life-changing medications. The key takeaway is that any policy interventions need to be carefully tailored to varying scenarios.” Full study here.
New HHS Guidelines Underpay Insurers
Study by: Stan Dorn, Bowen Garrett, and Marni Epstein
In order to protect individuals who have recently undergone major life events, such as getting married, having a baby, or losing a job, the Affordable Care Act (ACA) allows major life events to trigger special enrollment periods (SEPs) during which individuals can enroll in Marketplace plans outside of the annual open enrollment period (OEP). However, the risk adjustment models used by HHS to reimburse insurers for SEP enrollees failed to take into account the fact that many enrollees were driven to enroll during SEPs as a result of short term, urgent health problems. In order to address the chronic underpayment for SEP enrollees, HHS implemented a new risk adjustment strategy in 2017 that reflects enrollment duration among other new factors. A new study evaluates the effectiveness of HHS’s new risk adjustment guidelines and finds that while the guidelines have reduced underpayment for members who enroll in plans during the OEP for only a short time, insurers are still not being adequately reimbursed for members who enroll during SEPs. The authors suggest that policymakers may need to increase risk-adjustment payments for SEP enrollees if they want insurance agencies to be proactive in enrolling qualifying individuals who would otherwise go without insurance. Full study here.
Expansion of Short-Term Limited-Duration Policies Estimated to Increase the Number of People Without Minimum Essential Coverage by 2.5 Million in 2019
Study by: Linda J. Blumberg, Matthew Buettgens, and Robin Wang
Significant policy changes to the Affordable Care Act have been made since 2017 including the latest proposed regulation increasing the maximum length of short-term, limited-duration (STLD) insurance policies to one year. A new research brief estimates the 2017 policy changes, including the elimination of the individual-mandate penalties, will lead to an additional 6.4 million nonelderly people being uninsured in 2019 (an increase of 2.3 percentage points). In addition, the proposed expansion of STLD policies would increase the number uninsured by 2.1 million and the number of people without minimum essential coverage by 2.5 million over current law. In the 43 states most affected by these changes, the ACA Marketplace premiums will increase by 18 percent, on average. In 6 states that expressly prohibit STLD plans, premiums are estimated to increase by an average of 8 percent. The authors estimate federal spending in 2019 will be 9.3 percent higher than under prior law with the elimination of the individual mandate penalties being the major contributing factor. Full study here.
Pharmacist-Provided Transition-of-Care Program Shown to be Cost-Saving, Reduced Readmissions
Study by: Weiyi Ni, Danielle Colayco, Jonathan Hashimoto, Kevin Komoto, Chandrakala Gowda, Bruce Wearda, and Jeffrey McCombs
Pre- and post- discharge medication management programs have been shown to reduce complications in the transition from inpatient to outpatient care, especially in high-risk populations. A new study evaluates a pharmacist-run transition-of-care (TOC) program that was developed to reduce unplanned hospital readmissions in the high-risk managed Medicaid population. They estimate the program resulted in cost-avoidance of over $4.3 million in total health care costs in the first six months and that by the end of year two, with the expansion of the program from 30 to 60 percent of the eligible population, savings reached over $4 per member per month, for a total of $25.6 million. A previous study of the program, which was implemented by Synergy Pharmacy Solutions for adult members of the Kern Health Systems managed health plan, found it reduced the risk of readmission by 32 percent within 6 months of the patient being discharged. Evaluations of TOC programs provide insight for stakeholders grappling with how to improve patient health outcomes while limiting costs. Full study here.
The Essential Scan is produced by the USC-Brookings Schaeffer Initiative for Health Policy, a collaboration between the Center for Health Policy at the Brookings Institution and the USC Schaeffer Center for Health Policy & Economics.