Prime Therapeutics Study Shows Growth in Number of Drug "Super Spenders"

October 10, 2019
The Center for Biosimilars Staff

A small, yet rapidly growing segment of commercially insured US patients have drug costs of more than $250,000 each year, and this group could account for 15% of all drug expenditures in the next 5 years.

A small, yet rapidly growing segment of commercially insured US patients have drug costs of more than $250,000 each year, and this group could account for 15% of all drug expenditures in the next 5 years.

Those findings come from a new Prime Therapeutics LLC report that analyzed more than 17 million commercially insured members who had at least 1 month of eligibility in 2016 to 2018. In total, 4869 patients were what Prime calls “super spenders,” or patients with claims totaling more than $250,000 annually.

While the patients who fall into this category are relatively few in number, Prime says the group grew by 63% from 2016, and their spending resulted in $800 million in added drug costs, which were defined as the plan plus member cost share after network discounts (rebates and coupons were not included). The number of patients whose costs were more than $750,000 each year also increased by 38%.

In part, emerging treatments for rare diseases have led to these increases in spending. Patients with inherited single-gene disorders accounted for 31%—or $243 million—of the total increase, with the greatest increases observed for patients with hemophilia, cystic fibrosis, and hereditary angioedema.

Cancer therapies also accounted for a substantial amount of spending (48% or $378 million), with drugs that target breast cancer, multiple myeloma, and lung cancers among the top categories of spending.

Remaining spending largely comprised biologics, including anti-inflammatory biologics and the rare disease drug eculizumab, which has biosimilar contenders in the pipeline, as well as treatments for pulmonary hypertension and multiple sclerosis.

“With continued growth in treatments for rare diseases, including one-time treatments that may carry million-dollar price tags, it’s very likely that health care cost will become even more skewed, with a smaller and smaller fraction of insured members accounting for a larger and larger portion of the total health care cost,” Jonathan Gavras, MD, senior vice president, chief medical officer at Prime, said in a statement. “We must work to ensure drug and gene therapies are priced appropriately to the value they provide, obtained and billed via the cost-effective channel with the highest quality patient management, and value-based contracts are in place to recoup costs if the drug or gene therapy does not maintain effectiveness.”

According to Prime, management of high costs will include utilization management strategies, as well as “proactive conversations with providers and members regarding opportunities to optimize care and the benefit design.”

Reference

Bowen K, Gleason PP. Drug super spenders: 2016 to 2018 growth in number of members and total pharmacy plus medical benefit drug cost for members with extremely high annual drug cost in a 17 million member commercially insured population. Presented at: AMCP Nexus 2019; October 29 to November 1, 2019; National Harbor, Maryland.