Newly Insured Shift Prescription Trends Substantially

The first full year of enrollment under expanded Medicaid and Health Insurance Exchanges (HIX) had a substantial impact on health care spending in 2014.

The rate of uninsured individuals in the United States dropped by 5.1%, as 15.7 million gained health insurance coverage last year under the Affordable Care Act (ACA) and continued economic recovery, according to an annual medication use report by the IMS Institute for Healthcare Informatics.

Patients in states that expanded Medicaid eligibility had 25.4% more prescriptions filled than in 2013, compared with a 2.8% prescription increase in states that did not expand eligibility.

Total medication spending increased 10.3% to $373.9 billion in 2014, as a record 4.3 billion prescriptions were filled, 2.1% of which were among the newly insured.

“It was a landmark year in the implementation of the [ACA]—and yet, the increase in the number of insured patients under the ACA directly accounted for only $1 billion of the spending growth as patients took some time to ramp up their medicine use,” said Murray Aitken, executive director of the IMS Institute for Healthcare Informatics, in a press release.

Also playing a role was a 1.5% drop in the unemployment rate, as 2.3 million newly employed people gained health insurance through their employers.

Meanwhile, patients with employer-based insurance filled less prescriptions last year, partially as a result of increasing co-pays and deductibles. These high out-of-pocket costs can be reduced by options such as co-pay coupons and vouchers, IMS said.

The overall number of prescriptions filled by patients using a co-pay card reached 8% of all branded prescriptions. Specialty drug classes, such as treatments for multiple sclerosis and rheumatoid arthritis, showed coupon usage at 70% with terms that decreased out-of-pocket spending to levels as low as $5.

IMS noted deductibles have a proven negative effect on patient adherence when out-of-pocket costs rise above $125 per prescription. Adherence has been found to drop at every out-of-pocket level with a deductible, becoming progressively worse after costs exceed $30.

Adherence in patients with standard insurance dropped substantially if out-of-pocket costs exceeded $250. Patients whose coverage shifted to a plan with a deductible had on average 25 fewer days of therapy than those with standard insurance.

While HIX plans are associated with higher consumer out-of-pocket costs, nearly 25% of branded claims through these plans had no co-pay, with only 2% of all claims in HIX rising above $100.

Approximately 10% of all prescriptions filled last year had zero out-of-pocket costs as a result of ACA preventive care provisions, reaching a deductible, or income-based subsidies from exchanges.

The report found 93% of beneficiaries have caps on out-of-pocket costs at less than $6350.

Retail prescriptions increased by 2.4% in 2014, as Medicaid prescriptions grew by 16.8% to account for 70% of the growth in retail prescription demand. IMS said cash payment for prescriptions, which is common for uninsured patients, decreased by 5.5%.

HIX plans filled an estimated 12.6 million total prescriptions last year, while commercially insured patients, including those who purchased coverage on exchanges, filled 8.4 million fewer prescriptions in retail pharmacies in 2014 than in 2013.

Medicaid expansion increased overall enrollment to 15% in 2014. Among those who gained coverage through Medicaid, 14% were previously insured by commercial plans, while 9% paid cash for prescriptions last year.

Nearly a quarter of the prescriptions filled through Medicaid came from the newly enrolled, however, indicating many of these patients had significantly higher disease burdens than existing ones, according to IMS.

The report found 9% of patients who filled Medicaid prescriptions last year, and 24% of patients in HIX plans, may have previously been uninsured in 2013.

Despite a significant number of Americans gaining health insurance, the study found doctor visits last year dropped to 1.2 billion, a 3% decline from 2013.

“Prescription growth has remained relatively stable over the last several years, but office visits have demonstrated greater volatility. Trends in office visits are, in part, linked to prescription trends, and visits can be seen as an influence on future prescription trends,” the authors wrote. “The relationship between office visits and prescription demand is substantially lagged and distorted, perhaps in recent periods by the large group of newly insured patients with substantial disease burdens entering the health system.”