Managing Cost of Care and Health Care Utilization in Patients Using Immunoglobulin Agents

In a Pharmacy Times® Continuing Education Supplement, Leslie J. Vaughan, BS, RPH, examined cost and health care utilization in patients using immunoglobulin agents.

The introduction of human immunoglobulin (Ig) therapies 40 years ago reduced the risk of often life-threatening infections for individuals with immune-related conditions known as primary immunodeficiencies (PIs). Since then, the use of Ig has expanded to numerous other conditions. However, even though less than 1% of covered lives under Medicare or commercial insurers require Ig, it is in the top 5 drug categories in terms of annual spending.

A 2017 report from the Jeffrey Modell Foundation that used the IMS database containing medical and pharmaceutical claims for more than 60 million patients from 90 US health plans found that annual treatment costs for patients with PIs declined from $111,053 per patient before diagnosis to $25,271 per patient after diagnosis, even before Ig treatment.

The cost of Ig is directly related to the type of delivery method used and the site of care. Ig represents the fourth highest drug spending for Medicare Advantage plans, with an average per member per month of $2.82 in 2016 and an average cost per claim of $3282, representing 6% of overall Medicare Advantage prescription drug spending that year. The number of Medicare Advantage beneficiaries using Ig, although higher than the commercial population, is still less than 1% (0.97 per 1000).

Numerous studies attest to the efficacy and cost savings of shifting Ig to the home setting, as well as shifting patients from intravenous Ig (IVIG) to subcutaneous Ig (SCIG), since these treatment options may be more expensive than IVIG on a per-gram basis. The Jeffrey Modell Foundation has estimated that 38% of US patients with PIs received IVIG in a clinic setting in 2015 and 30% received IVIG in the home setting, whereas 28% of patients received SCIG. This represents a significantly higher decline in hospital outpatient delivery between 2014 and 2015 (35% to 26%) in the managed care Medicare environment.

There is a movement to shift patients from IVIG to SCIG given numerous studies demonstrating clinical equivalence between the 2 with lower overall costs and improved patient satisfaction with SCIG administration. SCIG drugs may be more expensive per gram and that is important to take into consideration. When additional costs are factored in, including administration fees and site-of-care fees, several studies found lower overall costs.

Payers have numerous options to ensure Ig is used appropriately for the right patient in the right setting. These include formulary management, site-of-care programs; education for providers and patients on the possibility of switching from IVIG to SCIG; preauthorization policies that restrict the use of Ig to certain specialties for specific indications; implementation of evidence-based coverage criteria; and shifting coverage from the medical to the pharmacy benefit. It is important that these factors are all weighed appropriately so that the best treatment can be used on a per-patient basis.

To take the full continuing education activity, visit the Pharmacy Times® website.