Generational Impact on Prescription Drug Trend: Part 2

In Part 1 of “Generational Impact on Prescription Drug Trend,” we identified overall generational trends in prescription drug use along with top therapeutic classes common across multiple age bands, and sought to understand what impact the economy has had on trend at a generational level. In Part 2 we continue to explore how member age demographics affect prescription drug trends, provide top therapeutic classes by generation, and take a more in-depth look at the specific behaviors associated with each of the 6 generations of Americans (see

Sidebar

).

METHODS

This was a retrospective study of 558.9 million prescription claims in a computerized database. The study population was 25.9 million members across a multitude of funded benefit prescription plans administered by CVS Caremark. The plan sponsors included Medicaid, national and local employers, health plans, managed care organizations, insurance companies, unions, and government agencies located throughout the United States with prescription claims for all months between January 1, 2007, and December 31, 2008. The generational trend was categorized by age bands: 83 and older, 63 to 82 years, 44 to 62 years, 30 to 43 years, 18 to 29 years, and 17 years and younger. The utilization trend was based on average days supply and gross cost (which includes both plan sponsor and member contributions) and is reported on a per member per month (PMPM) basis. Medicare Part D plans were excluded. Note that the trend includes member contribution (gross trend) and specialty drugs. The plan sponsors had average eligibility changes limited to within ±15% period over period.

GENERATIONS

GI Generation (Age 83 and Older)

The GI Generation, born between 1900 and 1925, is the generation of Americans that fought and won World War II, later to become the “Establishment” and the parents who had a generation gap with their Baby Boomer children. From youth to old age, the GI Generation commanded the admiration and respect of older and younger generations. They became America’s first Boy Scouts and Girl Scouts, and half a century later, America’s first senior citizens.¹

During this time, the US Food and Drug Administration (FDA) was created; major pharmaceutical breakthroughs include the introduction of aspirin and insulin.²

As we discussed in Part 1 of this Drug Trends article, proton pump inhibitors and lipid-lowering agents (statins) are common in multiple generations (GI, Silent, and Baby Boomer).

Antidementia Agents. Antidementia agents ranked third with the GI Generation (see

Table 1

). According to the Alzheimer’s Association, as many as 5.2 million Americans are living with disease, and 10 million Baby Boomers will be diagnosed with it in their lifetime. Every 71 seconds, someone is diagnosed with Alzheimer’s disease, which the Centers for Disease Control and Prevention (CDC) reported in June 2008 has surpassed diabetes as the sixth leading cause of death in this country.³

Most Americans fear cancer the most and Alzheimer’s disease second, but this order is reversed for those age 55 years and older. Alzheimer’s is the disease they most fear, according to a survey by Harris Interactive.⁴

Silent Generation (Age 63-82)

The Silent Generation, who were born between 1926 and 1945, consist of the “traditionalists.” They personify the American values of hard work, personal sacrifice, law and order, conformity, and delayed gratification. Technologically, they are characterized by their lack of exposure to computers.⁵ The name Silent Generation was coined in the November 5, 1951, cover story of Time magazine to refer to the generation coming of age at the time, born during the Great Depression or World War II.⁶

In 1938, the Food, Drug, and Cosmetic Act broadened the FDA’s authority and instituted important safety regulations.² Synthetic cortisone was made available in 1944. Drug therapy was otherwise still limited both in the number and scope of the conditions that could be treated.

HMG-CoA Reductase Inhibitors. The HMG-CoA reductase inhibitor (statin) class was ranked 1st for the Silent Generation (see

Table 2

), 2nd for the Baby Boomers and the GI Generation, and 10th for Generation X. The class continues to experience growth as the population ages and studies advocate proactive utilization. A recent study found that continuous treatment with statin drugs reduced the risk of death in patients with high cholesterol by 45% over 4 to 5 years. An article about the study notes, “People who hadn’t yet been diagnosed with heart disease and those who had already been diagnosed both showed the reduction in death if they took the drugs 90% of the time, when compared with patients who took the drugs less than 10% of the time.”⁷ The authors concluded that the benefits of statins were greater than clinical trials had previously suggested.

Platelet Aggregation Inhibitors. This class ranked 3rd among the Silent Generation and 4th among the GI Generation.

Baby Boomers (Age 44-62)

Baby Boomers were born between 1946 and 1964, and are more optimistic economically, largely because they did not experience the Great Depression. They are better educated. Women of this generation worked outside the home in greater numbers. Baby Boomers are more comfortable with technology, growing up within the age of computers. They are an individualistic generation, with a focus on self and a tendency to reject authority. Hectic lifestyles are common for baby boomers, with their leisure time infringed upon by the various demands of life.⁸

Tetracycline became available in 1955, and the first oral contraceptive, Enovid, was launched in 1960.² Much of the direct-to-consumer (DTC) advertising is targeted toward the 44+ consumer and plays on the Boomers’ characteristics of proactive wellness and preventive prescription drug use.

Consider the size of the Baby Boomer population segment—78 million—and their exceptional buying power. Today, however, rather than entering a period of economic certainty, job security, and peak earning years, many Baby Boomers are facing layoffs as corporations downsize. Retirement funds, when saved, have been significantly impacted by the market’s instability. The Boomers’ financial status is even more uncertain because they are a spending generation, who liberally use credit to finance purchases.⁸

Baby Boomers will research all options and most likely provide their healthcare providers with articles or references relating to their treatment options. As people mature, they spend more in drugstores, usually for prescription medicine. Drugstores should benefit from aging Baby Boomers, not only for prescriptions, but also for health and beauty aids. This generation has a strong desire to counter the aging process and retain its youth. This group kept fit in their early years and will continue to maintain a healthy lifestyle. Boomers’ aging also will support increased medical services, particularly specialties such as optometrists and plastic surgeons.⁸

For decades pharmaceutical manufacturers have focused their research and marketing programs on drugs that target the Boomers. Specific examples include Viagra for impotence and Lipitor for high cholesterol, both billion-dollar blockbusters. Entire classes have arisen around hair-growth remedies, osteoporosis treatments, and arthritis pain therapies.⁹

The use of proton pump inhibitor ulcer drugs and lipid-lowering statins among Baby Boomers has reached a level of pervasiveness that will likely continue for the rest of their lives, if the patterns established by the older Silent and GI generations are any indication of what to expect.

The Baby Boomers’ 2008 gross trend was 3.1% and the utilization trend was nearly flat at 0.2% (see

Table 3

). Insulin utilization trends increased 8.3%, and the miscellaneous anticonvulsant (eg, gabapentin [Neurontin] and Lyrica) utilization trend increased 11.1%.

Antihypertensive Combinations. The antihypertensive combinations are ranked 3rd for Baby Boomers, 4th for the Silent Generation, 10th for the GI Generation, and 20th for Generation X. The overwhelming majority of hypertensive patients are receiving multiple layers of therapy for their hypertension.¹⁰ Use of combination therapy has been identified as a trend and a growth driver in the treatment of hypertension because it helps to build patient compliance by reducing the pill burden and the level of side effects.¹¹ Key drugs in this class include the generic drug lisinopril-hydrochlorothiazide, Diovan HCT, generic Lotrel (amlodipine and benazepril), and Benicar HCT.

Serotonin-Norepinephrine Reuptake Inhibitors. All the generations have at least 1 antidepressant class in the top 20 therapeutic classes. The more recent serotoninnorepinephrine reuptake inhibitor class of antidepressants are more popular among the Baby Boomers (ranked 5th), Generation X (ranked 6th), Generation Y (ranked 8th), and the Silent Generation (ranked 19th in 2008, up from 27th in 2007).

Cymbalta currently is approved for depression, generalized anxiety disorder, diabetic nerve pain, and fibromyalgia. It was the third most heavily DTC-promoted drug in 2008, with more than $156 million having been spent.¹²

Opioid Agonists. Opioid agonists ranked 6th among Baby Boomers and 8th among Generation X. Recently published results of a survey conducted by researchers from the Boston University School of Medicine found that 2.2% of respondents in 2006 said they took opioids at least 5 days a week for the past month, part of a rising trend since the 1.6% reported in 1998. Half of these regular users had been taking the drugs that often for 2 years or more and one-fifth said they had been taking them for at least 5 years. An additional 2.9% of respondents said they had used opioids fewer than 5 days a week over the past month. The survey’s overall percentages translate into 10 million individuals taking opioids and 4.3 million taking them regularly. Researchers also said those who took opioid pain drugs were likely taking other medications, including additional painkillers and antidepressants.¹³ Key drugs in this class include OxyContin and the generics fentanyl and tramadol.

The market for prescription pain drugs was approximately $4.1 billion in 2007. Continued growth in the demand for prescription pain management products is projected because of the aging population, the increasing incidence of chronic pain conditions, increasing physician recognition of the benefits of pain management, and a steady stream of new pain products expected to enter the market.¹⁴

Insulins. Insulins ranked 10th among Baby Boomers and the Silent Generation; the class continues to be a contributor to gross trend. A 2007 study by the American Diabetes Association estimated that approximately 17.5 million Americans have been diagnosed with diabetes and that the number of people diagnosed with diabetes is growing by roughly 1 million per year. This study estimated that $27 billion is spent on care directly to treat diabetes.¹⁵

Results from a recent study conducted by epidemiologists from the National Institutes of Health and the CDC showed that nearly 13% of adults age 20 years or older have diabetes but that 40% of them have not been diagnosed. Researchers noted that diabetes is especially common in the elderly; nearly one-third of those age 65 and older have the disease. An additional 30% of adults have prediabetes, a condition marked by elevated blood sugar that is not yet in the diabetes range. Prediabetes, which causes no symptoms, substantially raises the risk of a heart attack or stroke and of developing type 2 diabetes. Type 2 diabetes accounts for up to 95% of all diabetes cases and virtually all cases of undiagnosed diabetes. The study also found that diabetes is rare in young people age 12 to 19 years, but about 16% of these have prediabetes.¹⁶

Generation X (Age 30 to 43)

Born between 1965 and 1978, Generation Xers grew up during the end of and after the Cold War. A Wikipedia article notes that “this generation saw the inception of the home computer, the rise of video games, and the Internet as a tool for social and commercial purposes.”¹⁷ Members of Generation X value self-reliance, informality, and techno literacy; they are more skeptical; and are not intimidated by authority, rules, and the chain of command.

A major new class of agents to treat gastrointestinal disorders, the H2 blockers, was created with the launch of Tagamet in 1976; it was the first drug developed to treat a condition that normally would have required a substantial lifestyle change (in the form of a very bland diet) or surgical intervention.²

The Generation X gross trend in 2008 was 3.3%; their utilization trend was −0.4% (see

Table 4

).

Multiple Sclerosis. Multiple sclerosis agents ranked 5th with Generation X and 8th with Baby Boomers. SG Cowen Consultants say that there is a growing trend toward earlier treatment of multiple sclerosis with these disease-modifying agents, but compliance rates can be highly variable and discontinuations common.¹⁸ Key drugs in this class include Copaxone, Avonex, and Rebif.

Merck KGaA became the leading contender in the race to release the first oral medicine for multiple sclerosis, after the company announced promising results from a late-stage clinical trial. Merck KGaA said its cladribine pill met the primary goal of a company-run study on 1326 patients with relapsing-remitting multiple sclerosis. The drug currently is used in injectable form to treat leukemia.¹⁹ The approval of oral cladribine would likely have an impact on the drug trend for Generation X and Baby Boomers.

Generation Y (Age 18-29)

Members of Generation Y (also referred to as the Millennials), born between 1979 and 1990, are younger than age 30 years and tend to be a relatively affluent, highly educated, and practical-minded group. After all, they have been raised in a technologically advanced society.⁵ Nearly half (approximately 40%) of the millennial generation grew up in or lives in a single-parent household, where surveys show them to be deeply involved in family purchases at every level. Members of Generation Y are said to demonstrate positive social habits, valuing diversity and teamwork—an outgrowth, perhaps, of the fact that roughly one-third of this population segment is other than Caucasian.²⁰

In 1987, Prozac was the first selective serotonin reuptake inhibitor brought to market for the treatment of depression and other mental illnesses. In 1997, the ban on DTC advertising was lifted in the United States.²

Combination Oral Contraceptives. Generation Y’s top class for 2008 was combination oral contraceptives (see

Table 5

). According to IMS Health, oral contraceptives were the 12th most commonly dispensed class of drugs overall in 2008, with approximately 81.6 million prescriptions filled during the year.²¹ In a January 2009 survey of Canadian Generation Y members, 77% of respondents said that birth control pills are not just about contraception and that they want an oral contraceptive that reduces the symptoms they experience around the time of their period.²² Reducing menstrual cramps (66%), having more control over their monthly cycle (61%), and improving the condition of their skin (52%) are at the top of Generation Y wish lists when it comes to their oral contraceptive. This is just another example of how Generation Y wants more control over their lives.²² Key drugs in this class include Yaz, Ocella, and Ortho Tri-Cyclen Lo.

Acne Products. Not surprisingly, acne products appear as a leading class among both Generation Y and Generation Z members, at 3rd and 5th, respectively. The Department of Health and Human Services estimates that 45 million people in the United States have acne vulgaris, with a prevalence of approximately 85% in the population 15 to 24 years of age. The disease is more common and more severe in males than in females.²³

Amphetamines. Amphetamines (eg, Vyvanse and Adderall XR) ranked 5th among Generation Y and 6th among Generation Z; the drugs are used to treat attention-deficit/hyperactivity disorder (ADHD). The adult ADHD market is growing much faster than the pediatric market. In 2008, adult prescriptions, which represented more than 30% of the overall ADHD market, rose 17% compared with an increase of 4% in pediatrics. The growth, in part, reflects an ongoing promotional push to raise awareness of adult ADHD, especially among women who juggle jobs and families.²⁴

Generation Z (Age 17 and Younger)

Generation Z, also known as Generation 9/11, was born between 1991 and present. As expected, they have a very different drug mix than the older generations. They are exposed to cell phones and iPods, and are well versed in computers and the Internet. In multigenerational households, they may be assisting grandparents in navigating through the Medicare Part D Web site to enroll.

Children age 17 years and younger have had the highest exposure to prescription drug advertisements. As a result, they, their parents, and even their grandparents are comfortable with them using prescription medications at an early age. Some DTC advertisements and programs (eg, asthma compliance awareness programs) are specifically designed for this audience.²⁵

The gross PMPM trend for Generation Z is 2.1%, and the days supply utilization trend is −5.7% (

Table 6

). The decrease in utilization trend was impacted by the decrease in leukotriene modulators and the availability of over-the- counter Zyrtec.

Miscellaneous Stimulants. The number 1 therapeutic class for Generation Z is the miscellaneous stimulants class. Key drugs in this class include the branded products Concerta and Focalin XR. Attention-deficit/hyperactivity disorder is one of the most commonly diagnosed psychiatric disorders in children and is prevalent in 4% to 7% of pediatric patients. Symptoms of ADHD may be lifelong. Long-term follow-up studies indicate that ADHD persists into adulthood in 30% to 66% of cases. The use of stimulants in patients with ADHD has always been a concern, despite their status as the mainstay therapy. In February 2006, an FDA panel recommended a “black box” warning for all ADHD stimulants highlighting increased cardiovascular risk.²⁶ The class showed a decreased utilization trend of −0.6% for Generation Z.

Growth Hormones. The 2nd-ranked therapeutic class for Generation Z is growth hormones. Key drugs in this class include Humatrope, Nutropin AQ, and Genotropin. Human growth hormone has been used to help children with growth problems for many years. Its appearance on the top class for Generation Z has more to do with the cost of these biologic drugs (for which no true generic exists) than it does with the prevalence of short stature disorders. Growth hormones were the 7th-ranked class of specialty drugs in our overall Book of Business for 2008, with a gross cost per day of $93.05. Results from the National Cooperative Growth Study published in 2004 cited well-established estimates indicating that the prevalence of children in the United States who have been evaluated by a pediatric endocrinologist and diagnosed with short stature due to growth hormone deficiency was approximately 20,000. The majority of these children were said to be already receiving treatment with growth hormone replacement therapy.²⁷

Leukotriene Modulators. Ranked 3rd for Generation Z are the leukotriene modulators. The key leukotriene modulator is Singulair. Asthma is the most common chronic disorder in childhood, currently affecting an estimated 6.7 million children under age 18 years, 3.8 million of whom had an asthma attack or episode in 2007.²⁸ Singulair was the 20th most heavily DTC-promoted drug in 2008, with more than $77 million spent.12 Singulair’s label was updated 4 times between March 2007 and February 2008 to add postmarketing warnings for tremor, depression, suicide, and anxiety.29 For Generation Z, the gross PMPM trend for leukotriene modulators was −7.7%, and the days supply utilization trend was −12.7%.

DIRECT-TO-CONSUMER ADVERTISING

Direct-to-consumer advertising plays on viewer demographics and is tailored to the desired audience. Since 1997, when the ban on DTC advertising was lifted, many billions of dollars have been spent on promotion of pharmaceuticals to prospective patients. However, pharmaceutical DTC ad spending was down considerably in 2008, falling from $5.33 billion in 2007 to $4.34 billion in 2008, according to The Nielsen Company.12 Among the possible drivers for the lower spending were a decrease in sales growth, fewer blockbuster drugs coming to the market, and the continuing public policy debate regarding advertising restrictions from the pharmaceutical industry.¹²

Although no published estimates were available on how pharmaceutical marketing expenditures break down based on a targeted age band or generation group, certain conclusions can be drawn from the kinds of drugs that were most heavily promoted to consumers and the DTC media on which the most money was spent. Television viewing does increase with age, with individuals in their teens tending to be the early adopters of alternate or nontraditional media.12 Consider the case of Plavix. This platelet aggregation inhibitor is one of the most heavily utilized drugs by the Silent and GI generations; it was also the 2nd most heavily DTC-promoted drug in 2008, with more than $169 million having been spent.¹²

As a result of their upbringing, the media, technology, and myriad other factors, Generation Y’s overall consumer and personal behaviors are substantively different from those of previous generations. In essence, Generation Y has shattered the traditional “prescribe-enforce-consume” model. For as long as there has been a pharmaceutical industry as we know it, physicians have prescribed medications for children, parents enforced the consumption of the prescribed medications, and young people consumed what was prescribed. That model is obsolete with Generation Y, who were raised in an instantaneous, Internet-based, information-on-demand world. Today’s young people are far less likely to comply with prescribed therapy without being both educated and involved. They also are much more distracted, primarily by disruptive technologies, and overwhelmed by consumer advertisers, making capturing their attention that much more difficult.³⁰

CONCLUSION

Understanding the member demographics of a group is critical to understanding their prescription drug utilization patterns. Basic information such as age and sex will tell the educated analyst a great deal about likely conditions and leading therapeutic classes; having a broader understanding of the values and significant events that have come to define a particular group creates a more well-defined picture of the lifestyle choices and decision-making processes associated with a specified population. This, in turn, allows for the development of focused and proactive strategies for more effective delivery of healthcare services.