Drug super spender tsunami: An integrated medical and pharmacy benefits assessment

Abstract

BACKGROUND:

As new rare-disease drug therapy, gene therapies, and high-priced cancer drugs receive US Food and Drug Administration approval, there is an increasing potential for drug super spender individuals with more than $250,000 annual drug cost.

OBJECTIVE:

To categorize all members in a large, commercially insured population by their total annual combined drug costs from both medical and pharmacy benefits and to determine the trend in drug super spender prevalence.

METHODS:

Using a commercially insured population with integrated medical and pharmacy benefits, all unique members with any enrollment between January 2016 and December 2019 were identified. The sum of total cost for all pharmacy claims plus all medical benefit claim lines for drugs was determined for each member, for each calendar year. Cost was defined as the plan plus member liability at network-discounted price, with no further adjustment for any coupons or rebates. Descriptive statistics were used to describe the drug super spender growth.

RESULTS:

There was an average of 17.9 million members per year with at least 1 month of eligibility through the 4-year study period. In 2016, a total of 2,994 members with more than $250,000 drug cost per member accounted for $1,324 million drug spend. In 2019, there were 5,894 super spender members (97% increase), accounting for $2,579 million drug cost (95% increase), which was 9.6% of $26,618 million total drug spend.

CONCLUSIONS:

In this large, commercially insured population, a small (32 per 100,000) number of drug super spender members comprise a disproportionate portion of the total drug expenditures, at $1 of every $10 dollars of total drug expenditures. Health plans need to understand the drug super spender trend and develop strategies to maintain health care affordability.

Plain language summary

Drug costs are becoming a larger part of health care spend. Specialty drugs, some with a price exceeding $250,000 per year per person treated, are increasing. Our findings demonstrate the importance of identifying drug super spenders (ie, > $250,000/year in drug costs) and the impact they can have. Drug super spenders make up only 32 per 100,000 commercially insured individuals yet represent $1 of every $10 dollars spent on drugs. Managing drug super spenders is essential.