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Many PPACA exchange plan enrollees use HIV drugs

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The people who sign up for exchange plans have been 59 percent more likely to use specialty drugs than other insured Americans and much more likely to use HIV drugs.

Express Scripts, a pharmacy benefits manager, has shed light on the health status of the enrollees in the Patient Protection and Affordable Care Act (PPACA) qualified health plans (QHPs) in a report based on its own utilization management data.

Julie Huppert, an Express Scripts analyst, found that 50 percent of the QHP enrollees it tracked used their prescription benefits between January and July, compared with 55 percent of all insured people the company tracks.

About 57 percent of the exchange QHP enrollees who filled specialty drug prescriptions bought HIV drugs. In a comparable commercial plan, just 20 percent of all health plan specialty drug users bought HIV prescriptions. Because the QHP enrollees were 59 percent more likely to fill a specialty drug prescription, and the QHP specialty drug users were three times more likely to use HIV drugs, the likelihood that any given QHP enrollee would fill an HIV drug prescription was about 4.5 times the likelihood that a member of all of the plans Express Scripts tracks would fill a specialty drug prescription.

About 3 percent of the QHP enrollees who filled specialty drug prescriptions used Hepatitis C drugs. QHP enrollees were about twice as likely to fill Hepatitis prescriptions as all people with health coverage.

The QHP enrollees were about as likely to fill specialty drug prescriptions for drugs for transplants, cancer, multiple sclerosis and coagulation problems. They were less likely to fill prescriptions for fertility drugs and growth deficiency drugs.

The insurers that sell QHPs noted before the 2014 open enrollment period started that they assumed the early enrollees would be much sicker than the commercially insured population and priced accordingly. The insurers have released little information about QHP claims experience.

Stephen Zaharuk, an analyst at Moody’s, suggested in a recent commentary that QHP enrollees make up a fairly small percentage of enrollment at the big health insurers and that the effects of any QHP underwriting problems on the insurers’ overall performance is likely to be small.


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