PAUL, Minn., April 23, 2018 /PRNewswire/ — Two new studies by pharmacy benefit manager Prime Therapeutics LLC (Prime), using real-world integrated medical and pharmacy data, show members with multiple sclerosis (MS) had 8.3 times higher annual total health care expense than members without MS. More than 80 percent of the excess cost was due to disease-modifying drug (DMD) therapy. Prime researchers will present the studies at the Academy of Managed Care Pharmacy’s (AMCP) Managed Care & Specialty Pharmacy 30th Annual Meeting April 23-26 in Boston.
MS is a chronic, autoimmune disease of the central nervous system that results in accumulation of neurologic damage over a course of decades. DMD therapy is commonly used to treat MS. While DMDs are expensive, at about $80,000 per year, improving adherence can lead to a significant drop in moderate to severe clinical relapses and have moderate savings on medical costs.
For both studies, Prime researchers evaluated commercially insured members who were continuously enrolled from October 2013 to September 2017 and younger than 65 years old. Of the approximately 4 million members who met the study’s criteria, 8,356 had claims indicating an MS diagnosis.
In the first study, Prime analyzed total pharmacy and medical claims data from the most recent 12 months for members with MS and a matched group of members who did not have MS. Researchers set out to determine the percentage of MS members treated with a DMD and the percentage adherent to a DMD during those 12 months. Adherence was defined as those patients who showed 80 percent or greater proportion of days covered (PDC) with a DMD.
The per patient per year (PPPY) total pharmacy and medical claims cost for MS members with a DMD claim was $84,712, of which $68,544 (80.9 percent) was for DMDs. Whereas the PPPY total claims cost for all MS members – with or without DMD utilization – was $63,200, of which $45,231 (71.6 percent) was for DMDs and $17,884 (28.4 percent) was for all other medical and pharmacy claims. This real-world data shows the $63,200 average annual total health care cost for MS members was 8.3 times higher than the matched group without MS for whom their PPPY average total claims cost was $7,642.
Compared with those without MS, MS members had a $10,301 PPPY excess medical expense that was not for DMDs. Some of the largest individual expense categories identified include MRIs, non-DMD specialty drugs, hospital inpatient stays, and office visits.
Researchers designed the second study to determine if there was an association between MS DMD adherence and relapses.
The study analyzed 4,753 members who had a claim for an FDA-approved DMD from October 2013 to September 2014. In the subsequent three years, 2,859 (60.2 percent) were adherent and 1,894 (39.8 percent) were not adherent to DMD therapy. The adherence measure allowed for switching DMDs during the three-year period.
Moderate to severe relapses occurred in 991 members and averaged $8,866 per patient.
The 991 members with claims evidence of a relapse consisted of 520 (18.2 percent) of the 2,859 adherent members compared with 471 (24.9 percent) of the 1,894 of the non-adherent members. Three years of DMD adherence was associated with a statistically significant (seven percentage point) lower incidence of members with claims indicating a moderate to severe clinical relapse. This finding implies that, on average, improving adherence to DMD therapy for 15 non-adherent MS members for three years would be expected to prevent one member from having a moderate to severe relapse. Given this, a DMD cost of $3 million to obtain adherence in 15 members for a period of three years would be expected to avoid $9,000 in medical costs from avoidance of moderate to severe relapses for one MS patient – an investment of $333 to save only $1 in direct medical costs.
“This real-world study shows that DMD adherence was associated with a significant decrease in relapses, which is a major goal of therapy,” said Kevin Bowen, M.D., principal health outcomes researcher at Prime. “These findings provide us with a better understanding of the value of improving DMD adherence and the magnitude of offsetting direct medical cost. Multiple studies attempting to assess the total value of DMD therapy have concluded use of MS DMDs greatly exceeds conventional thresholds for cost-effectiveness without large reductions in the prices of these drugs. This study only measured direct costs for relatively short periods of time. The value of treating more MS members with DMDs or improving adherence needs to be assessed from a societal perspective and over decades.”
These real-world findings quantify the quality of care and treatment gaps associated with DMD adherence, as well as confirm the majority of MS care costs are from pharmaceuticals. Understanding these factors will be used to negotiate value based contracts and develop pharmacist care service offerings.
About Prime Therapeutics
Prime Therapeutics LLC (Prime) helps people get the medicine they need to feel better and live well. Prime manages pharmacy benefits for health plans, employers, and government programs including Medicare and Medicaid. The company processes claims and offers clinical services for people with complex medical conditions. Prime serves more than 27 million people. It is collectively owned by 18 Blue Cross and Blue Shield Plans, subsidiaries or affiliates of those plans. For more information, visit www.primetherapeutics.com or follow @Prime_PBM on Twitter.