Healthcare Spending Among Privately Insured Individuals Under Age 65

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1 Healthcare Spending Among Privately Insured Individuals Under Age 65 February 2012

2 Healthcare Spending Among Privately Insured Individuals Under Age 65 February 2012

3 Introduction Healthcare spending and utilization patterns among the privately insured population are not widely understood, or widely available. With limited access to private sector data, health services researchers have relied on the analyses of publicly available data (predominately Medicare) to advance public policy recommendations. 1 To effectively advance healthcare reform, IMS believes a deeper understanding of the privately insured population is critical to successfully address cost growth trends, and ensure appropriate planning for this evolving population. Using comprehensive, proprietary data consisting of more than 10 million privately insured members under age 65, we were able to examine the distinctions between IMS aggregated healthcare use and spending patterns and those commonly cited among health services researchers, including the Agency for Healthcare Research and Quality (AHRQ) and Centers for Medicare and Medicaid Services (CMS). In this report, we highlight the differences, examine healthcare spending patterns among the privately insured under age 65 by considering spending on outpatient, inpatient and pharmacy, and discuss the potential implications. Murray L. Aitken Executive Director IMS Institute for Healthcare Informatics IMS Institute for Healthcare Informatics 11 Waterview Boulevard Parsippany, NJ USA Analysis and support from IMS Payer Solutions gratefully acknowledged in the development of this report IMS Health Incorporated and its affiliates. All reproduction rights, quotations, broadcasting, publications reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without express written consent of IMS Health and the IMS Institute for Healthcare Informatics. FIND OUT MORE If you want to receive more reports from the IMS Institute, or be on our mailing list, please click here.

4 Contents Executive Summary... 1 Total Healthcare Spending All Payers - Privately Insured Outpatient Spending Privately Insured Inpatient Spending Privately Insured Pharmacy Spending Privately Insured Top 1% Member Spending Cohort Profiles Total Healthcare Spending - Spending Profile - RA and MS Spending Profiles Potential Implications End Notes Notes on Sources Appendix About the IMS Institute APPROACH AND METHODOLOGY The LifeLink Health Plan Claims Database, which comprises 6.7 billion medical and pharmacy claims, 79 health plans, and 79.4 million members from 2001 to the present, was used to conduct this study. A more detailed description can be found in the Appendix. These analyses were derived from an analytic subset of the database, covering the time period from January 1, 2009 through December 31, 2010 for only privately insured health plan members under age 65 with continuous enrollment and medical and pharmacy benefit coverage. Cost and use patterns in the overall study population, including 17 chronic conditions, 12 cancers, and 10 auto-immune and other specialty conditions were studied. Costs reported reflect the plan allowed amount (i.e., plan paid amount plus member contribution) for a given service. Members were identified by condition based on Year 1 experience, and their cost and utilization is reported based on Year 2 experience. A more detailed description of conditions studied can be found in the Appendix. Findings in this report may differ from prior analyses of US and Medicare spending due to inherent differences in the health status and age distribution of the privately insured and differences in analytic methods, such as requiring continuous member enrollment and medical and pharmacy benefit coverage during the study time period. Unless otherwise noted in this study, all reference to the privately insured population throughout this report refer to the IMS study population.

5 Executive summary In 2010, 184 million Americans were enrolled in a private health insurance plan and collectively were responsible for $822 billion in healthcare expenditures. By 2020, enrollment is expected to be 198 million and expenditures will reach $1.4 trillion. This commercially insured segment of the healthcare system and in particular the under 65 year segment will remain the dominant part of the payment system even as the impact of implementation of the Affordable Care Act transforms the healthcare landscape. A deep understanding of the characteristics, dynamics and drivers of utilization and cost within the commercially insured under 65 segment is particularly important as we stand on the threshold of substantial increases in spending and dependence by enrollees in such programs. TOTAL HEALTHCARE SPENDING LEVELS For the total sample of more than 10.6 million privately insured health plan members analyzed in this report, average healthcare spending in 2010 was $3,840, or $320 per member per month. However the 5% highest cost members accounted for 50.6% of the total cost, and over 25% of the total cost was for just 1% of the members. Conversely, just 3% of total cost was incurred by the 50% of members with the least annual spending. This reinforces the importance of understanding the profile, behavior and interventions that can be optimally applied to the relatively small number of members who have a substantial impact on overall healthcare costs. Overall spending levels of the privately insured under 65 population are mostly focused on outpatient and pharmacy services, representing 59% and 21% of total spending, respectively. Inpatient services represent the remaining 20% of spending. This distribution of costs differs significantly from that reported by the Medical Expenditure Panel Survey (MEPS) for all payers and for the Medicare 65 and over population. In particular, Medicare 65 and over population spending on inpatient services represents 43% of total spending, while outpatient and pharmacy services represent 39% and 18%, respectively. The differences in spending distribution between the privately insured under 65 population and the Medicare 65 and over population are substantial and highlight the need for correspondingly differentiated analysis, understanding, and actions aimed at bending the overall US healthcare cost curve. Among health plan members, spending is highly disproportionate to prevalence rates. Over one-third of members have one or more chronic conditions and account for over two-thirds of total spending for all members. Members with cancer amount to only 1.5% of all health plan members and account for almost 8% of total spending. Other members with auto-immune or other specialty conditions represent 1.7% of all members, and consume 7% of total spending. OUTPATIENT SPENDING Outpatient services represent the largest share of total spending, averaging $2,251 per member per year, or $188 per member per month. Professional and facility visits account for 74% of overall spending, with emergency room visits a further 10%. Outpatient medical drug therapy, including office, facility and home-based injections and infusions, were 5% of all outpatient spending, or $9 per member per month on average. However, outpatient drug therapy for oncology, auto-immune and other specialty condition populations studied were significantly higher, and amount to 19% and 18%, respectively. continued on next page... 1

6 Executive summary INPATIENT SPENDING Spending per inpatient admission was $14,248 on average, and accounts for 20% of overall spending per member. Facility costs account for 84% of the total inpatient spending, with the balance being professional costs. Members with chronic conditions had 63% of all hospital admissions, and averaged $15,566 per admit. These costs include average 4.5 days of stay, and 219 professional visits per 1,000 members. Oncology patients had the highest average cost per admission, at $20,074 but admissions only totaled 2.8 admissions per 1,000 members compared to 29.3 admissions per 1,000 members for chronic conditions. PHARMACY SPENDING Average pharmacy spending including outpatient drug claims for both specialty and non-specialty medicines amounts to 21% of total healthcare spending for the privately insured under age 65 population. For every 1,000 members, 11,950 prescriptions were filled in 2010, of which 78% were for those members with chronic illnesses. Members with oncology and those with auto-immune or other specialty conditions filled only 4% and 5% of the total number of prescriptions. Specialty drugs represent about 1% of the total of pharmacy prescriptions but 17% of total pharmacy spending. Relative to total healthcare spending including inpatient costs, outpatient medical costs and non-specialty pharmacy costs specialty drug therapy and outpatient medical drug therapy are particularly high for members with auto-immune or other specialty conditions and represent 33% of their total healthcare spending. By comparison, these drugs represent 17% of spending for oncology patients, and just 6% for those members with chronic conditions. TOP 1% SPENDING COHORT Consistent with patterns across the healthcare system, privately insured under 65 health plan members who are among the top 1% in annual spending are vastly disproportionate users of healthcare resources. They average almost $100,000 in annual spending per member. Within the top 1% cohort, our analysis shows that 77% of the members had at least one chronic condition, 16% had one or more cancers, and 13% suffered from auto-immune or other specialty conditions (some members had more than one of these condition groupings). The oncology patients had the highest average spending, of $118,000 per year....continued from previous page The distribution of spending among the 1% cohort is similar to that of the Medicare 65 and over population, with 45% of spending being for inpatient services, 45% for outpatient services, and 10% for pharmacy benefits. Average spending for the top 1% of members with specific chronic conditions is between five- and tenfold the average spending for all members with the same conditions. For example, members with diabetes average $11,858 in annual spending, while those suffering from diabetes who are in the top 1% cohort average $102,465 in annual spending. Similarly, those with chronic renal failure on average spend $33,801 per year, but those within the top 1% cohort spend over $150,000 annually. Efforts to address healthcare spending levels and ensure optimal care for patients require detailed understanding from timely and robust information. This analysis is intended to focus attention on the patient segments, care settings, and treatment options that can best bring improved health outcomes at lowest cost to those in need. Understanding the privately insured under 65 populations and addressing their health needs efficiently will bring significant benefits to the entire healthcare system. 2

7 Total Healthcare Spending All Payers HIGHLIGHTS Private insurance will remain the largest segment (57%) of the covered population through Insurance exchanges are projected to include 12.5% of the privately insured by Private insurance expenditures will remain the largest share of insurance spending (41%) through

8 TOTAL HEALTHCARE SPENDING ALL PAYERS Enrollment in private insurance will reach 197.8Mn by 2020 Insurance Enrollment in the US(Mn) Mn individuals, 63% of insured population Mn individuals, 58% of insured population Mn individuals, 57% of insured population In 2010, 63.4%, million, of insured individuals in the US were enrolled in private health insurance, while 16.1%, 46.8 million, and 18.5%, 53.7 million, of insured individuals were enrolled in Medicare and Medicaid, respectively. By 2016, private insurance enrollment is projected to increase by 6%, from million to 195 million people. Health insurance exchange plans will represent 18.8 million people, 9.6%, of all private enrollment. By 2020, private health insurance enrollees are projected to remain the largest proportion of the overall insured population, at 57.3%, with Medicare and Medicaid accounting for 18.1%, 62.3 million, and 24.2%, 83.5 million individuals, respectively Uninsured Exchanges Other Private Employer CHIP Medicaid Medicare Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group 4 Dec 2010 Chart notes Medicare volume includes individuals under age 65. Medicare enrollees who purchase supplemental private insurance are represented in both Medicare and private insurance categories. 11 4

9 TOTAL HEALTHCARE SPENDING ALL PAYERS Spending on private insurance will exceed $1.4 trillion in 2020 Healthcare Expenditures in the US($Bn) $822Bn, 44.5% of insurance expenditures , $1,141Bn, 42.6% of insurance expenditures , $1,402Bn, 41.1% of insurance expenditures Private health insurance spending in 2010 was $822.3Bn, or 44.5% of total insurance expenditures. Medicare and Medicaid expenditures were 28.4%, $525Bn, and 21.7%, $400.7Bn, respectively. By 2016, private health insurance expenditures are projected to exceed $1 trillion, increasing by 38.8%, to $1,141Bn. In 2020, private health insurance expenditures will reach nearly $1.5 trillion and represent 41.1%, the largest proportion of insurance spending for healthcare in the US. Medicare and Medicaid will represent 27.7%, $922Bn, and 26.7%, $908.1Bn, respectively, of total healthcare spending on insurance Exchanges Other Private Employer CHIP Medicaid Medicare Source: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group 4, Dec 2010 Chart notes Medicare volume includes individuals under age 65. Medicare enrollees who purchase supplemental private insurance are represented in both Medicare and private insurance categories. 11 5

10 Total Healthcare Spending Privately Insured HIGHLIGHTS Healthcare spending was highly concentrated, with 1% of the population driving over 25% of all spending. Spending among the privately insured under age 65 population was outpatient driven, in contrast to Medicare. Treatment pattern differences across conditions were noteworthy, in that they were: Outpatient driven among members with chronic conditions or cancers. Pharmacy driven for members with auto-immune or other specialty conditions. Members with chronic conditions, cancers or conditions treated with specialty medicines represented a disproportionate share of spending. 6

11 TOTAL HEALTHCARE SPENDING PRIVATELY INSURED Spending was highly concentrated Distribution of Spending in the Privately Insured 96.9% 85.4% 80.7% 74.3% 65.2% 50.6% 25.6% 3.1% A sample of more than 10 million privately insured health plan members, from the IMS LifeLink database, showed that over 25% of all spending was for just 1% of the total number of health plan members. More than 50% of the total spending was for only 5% of all health plan members. Slightly more than 3% of expenditures went to treat the bottom 50% of all members, who had average annual spending of less than $874 per member. Spending distribution nearly mirrored the overall US population, where AHRQ also reports that 3% of spending was driven by the bottom 50%, while 22% of spending was driven by the top 1%. 3 Top 1% Top 5% Top 10% Top 15% Top 20% Top 25% Top 50% Bottom 50% (>=$44,957) (>=$14,947) (>=$8,582) (>=$5,773) (>=$4,169) (>=$3,130) (>=$874) (<$874) PERCENT OF HEALTH PLAN MEMBERS, RANKED BY HEALTHCARE SPENDING ($) Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Chart notes Spending distribution reflects spending for all health plan members, including members with no service use and no spending in the analysis year. 7

12 TOTAL HEALTHCARE SPENDING PRIVATELY INSURED Spending increased with age in the under 65 population Average Annual Spending Per Member By Age and Gender ($) $3,893 $6,297 $5,601 Health plan members between the ages of 45 and 64 expended, on average, $5,900 annually on healthcare services, or nearly twice that of their counterparts between the ages of 20 and 44, and four times that of members in the youngest age group - 0 to 9 years of age. Average annual spending for women less than 65 years of age was higher, at $4,278 per year, versus $3,373 for men under 65, predominately due to higher rates of healthcare utilization overall. This was especially true for women aged 20 to 44. $1,308 $1,580 $1,784 $1,779 $2,188 F M F M F M F M Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Chart notes Estimates of annual spending are averages based on spending of all health plan members, including members with no service use and no spending in the analysis year. 8

13 TOTAL HEALTHCARE SPENDING PRIVATELY INSURED Spending continued to increase in the Medicare population Annual Program Payments Per Member ($) $14,527 $10,953 $6,550 As with privately insured under age 65 individuals, spending for Medicare enrollees increased with age, with average annual spending per enrollee higher than for the IMS privately insured population. On average, Medicare spending was $10,109 per member across the age 65 and older age groups. For low-cost Medicare members, the prevalence of minor age-related illnesses, such as cataracts was higher. High-cost Medicare beneficiaries had higher prevalence of chronic conditions, including hypertension, chest pain and coronary artery disease years years 85 years or over Source: Centers for Medicare & Medicaid Services, Office of Information Services, 2010 Chart notes Graph represents data from See Appendix for the definition of Medicare program payments. 9

14 TOTAL HEALTHCARE SPENDING PRIVATELY INSURED Spending increases differed as males and females aged Average Annual Spending Per Member ($) F M F M F M F M Pharmacy $172 $242 $331 $415 $670 $454 $1,400 $1,267 Outpatient $941 $1,117 $1,166 $1,086 $2,311 $1,345 $3,725 $3,003 Inpatient $195 $221 $287 $278 $912 $389 $1,173 $1,330 Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Males, from birth to age nine, had higher annual healthcare spending, on average, at $1,580, than females, at $1,308. The average annual per member spending for females, ages 20 to 44 was $3,893, 78% higher than same-aged males at $2,188. This difference might, in part, be due to maternity and other reproductive healthcare services. Higher per member spending by gender, in the study population, reflected increased utilization of services. 7 Similarly, the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH) also reported higher use of health services among females than males in the US population. 8 Chart notes See Appendix: Cost and Use by Age and Gender for detailed age-gender spending profiles. 10

15 TOTAL HEALTHCARE SPENDING PRIVATELY INSURED Spending was outpatient driven, in contrast to Medicare Distribution of Spending by Payer Type 21% 22% 18% 39% 47% 59% Among the IMS privately insured study population, the proportion of spending for inpatient and pharmacy services was about the same, at 20.4% and 20.9%, respectively. The proportion of Medicare age 65+ spending on inpatient care was 43%, more than double the IMS population, while spending for outpatient services, 39%, and pharmacy, 18%, were much lower than the IMS population. Inpatient spending remained a higher proportion of overall spend. 43% 20% 31% IMS Privately Insured Under Age 65 Inpatient MEPS All Payers Outpatient MEPS Medicare 65 and Over Pharmacy Source: IMS LifeLink Health Plan Claims Database, Dec 2010; Medical Expenditure Panel Survey 2, 2009 Chart notes MEPS represents data from See Notes on Sources for details. IMS place of service definitions differ slightly from MEPS definitions. See Appendix for detail. 11

16 TOTAL HEALTHCARE SPENDING PRIVATELY INSURED Share of spending was disproportionate for certain conditions Proportion of Spending by Health Services Channel Condition Set All Members Chronic Conditions Oncology Auto-Immune/Other Specialty 10,657,042 3,862, , ,393 Members (N) 100.0% 36.2% 1.5% 1.7% $PMPM $320 $216 $25 $22 $PMPM (%) 100.0% 67.5% 7.9% 7.0% Spending was highly disproportionate to prevalence rates among health plan members with chronic conditions, cancer, auto-immune or other specialty diseases. When the prevalence of these various conditions was compared to total spending for members affected by these specific diseases, their impact was immediately evident and dramatic. More than one-third of all members, 36%, were shown to have at least one chronic condition, and comprised approximately two-thirds, 67.5%, of spending for all members. Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Chart notes $PMPM is a population-based measure that reflects the proportion of all plan spending attributable to overall members or member sub-populations. Estimates for subgroups will be relatively low, even when spending for each member in the subgroup is high, because the denominator is the overall population. 12

17 TOTAL HEALTHCARE SPENDING PRIVATELY INSURED Treatment pattern differences across conditions were noteworthy Distribution of Spending by Treatment Setting ($) 21% 24% 3% 3% 12% 56% 52% 53% 20% 21% 21% All Members ($320 PMPM N=10,657,042) Chronic Conditions ($216 PMPM N=3,862,984) 14% Oncology ($25 PMPM N=162,767) 39% 8% 37% 16% Auto-Immune / Other Specialty ($22 PMPM N=183,393) Inpatient Outpatient Medical Outpatient Medical Rx Pharmacy Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Treatment patterns were outpatient driven among members with chronic or oncology conditions, and pharmacy driven for members with auto-immune and other specialty conditions. For members with chronic conditions, 55% of all spending was for outpatient services, of which 3% was for medical drug therapy. Outpatient services comprised 65% of all spending for members being treated for cancer, with 12% of all spending for medical drug therapy. Inpatient spending represented a smaller share of all spending for members with auto-immune and other specialty conditions, while outpatient spending was 45% and medical drug therapy 8% of all spending. Pharmacy spending was 39% of all spending for members with autoimmune and other specialty conditions. Chart notes Outpatient Medical Rx includes injected or infused drug therapy administered in a facility, office, or home health setting. $PMPM is spending per member per month. 13

18 Outpatient Spending Professional and facility visits accounted for 74% of outpatient spending overall. Emergency room visits were 10% of outpatient spending overall. Medical drug therapy provided in the office, facility or home was 5% of outpatient spending overall, but represented 18-19% of spending for members with specialty conditions. 14

19 OUTPATIENT SPENDING PRIVATELY INSURED Most outpatient spending was on professional and facility services Distribution of Outpatient Spending $PMPM Home Health Medical, $5, 3% Professional Medical, $74, 39% Laboratory/Pathology, $7, 4% Radiology, $8, 4% Medical Rx, $9, 5% Emergency Room, $18, 10% Home Health $1 Facility $2 Emergency room visits, at $18 per member per month, was 10% of all outpatient spending. Home health medical services represented 3% of all outpatient spending, followed by radiology and laboratory/ pathology at 4% each. Outpatient medical drug therapy, including office, facility and home-based injections and infusions, were 5% of all outpatient spending, or $9 per member per month. Facility Medical, $65, 35% Professional $6 Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Chart notes Medical Rx includes drugs administered in an outpatient facility, office or home health setting, under the medical benefit, identified by HCPCS or revenue codes. Spending may be understated for this category since not all health plans capture outpatient service usage at this level of detail. $PMPM is spending per member per month. 15

20 OUTPATIENT SPENDING PRIVATELY INSURED Medical drug therapy use resulted in different spending profiles Distribution of Outpatient Spending $PMPM 1% 3% 39% 35% 5% 4% 4% 10% All Members ($188 Outpatient PMPM N=10,657,042) 1% 3% 38% 36% 5% 4% 5% 8% Chronic Conditions ($120 Outpatient PMPM N=3,862,984) 1% 2% 23% 44% 19% 2% 6% 3% Oncology ($16 Outpatient PMPM N=162,767) 1% 4% 30% 34% 18% 3% 4% 6% Auto-Immune / Other Specialty ($10 Outpatient PMPM N=183,393) Emergency Room Radiology Laboratory/Pathology Medical Rx Facility Medical Professional Medical Home Health Medical Other Source: IMS LifeLink Health Plan Claims Database, Dec 2010 In oncology, auto-immune and other specialty condition populations studied, higher use of medical drug therapy resulted in outpatient spending profiles that differed from the overall or chronic patient populations. Medical drug therapy represented 19% of all outpatient spending for members with various types of cancer, and 18% for members with auto-immune and other specialty conditions, compared to all members and members with chronic conditions at 5% each. Professional and facility spending represented the largest share of outpatient spending for members overall, and for members with chronic conditions. Gary Gatyas 11/15/2011 Should we add a - Y axis on the right to show dollars? Chart notes $PMPM is spending per member per month. 16

21 Inpatient Spending Facility-based services were 84% of inpatient spending, while professional services were 16%. Members with chronic conditions had 63% of all inpatient admissions. Inpatient services spending among members with chronic conditions or cancers was about 20% of their total spending, similar to that of the overall membership. Inpatient services were only 16% of all spending among members with auto-immune or other specialty conditions. Members with cancer had the highest spending per admission, at $20,074, which was nearly $6,000 higher than the average spending per admission across all members. 17

22 INPATIENT SPENDING PRIVATELY INSURED 84% of inpatient spending was for facility-based care Inpatient Spending Distribution and Service Use Professional 16% Measure Inpatient $PMPM Allowed Amount ($) Per Admit Average Length of Stay (ALOS) Cost Per Admit ($)/Rate $65 $14, Spending per inpatient admission was, on average, $14,248. Each inpatient admission lasted 4.2 days, on average, with 46.4 admissions per 1,000 members per year. Inpatient spending included professional visits, with 310 visits per 1,000 members per year. Admits Per 1,000 Days Per 1,000 Professional Visits Per 1, Facility 84% Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Chart notes $PMPM is spending per member per month. 18

23 INPATIENT SPENDING PRIVATELY INSURED Inpatient was a lower share of spending for specialty conditions Distribution of Total Spending $PMPM All Members $65 $254 All Chronic Conditions $44 $171 Inpatient spending was 16%, or $4 per member per month, of all spending for members with auto-immune and other specialty conditions. Spending on inpatient services, for members with chronic conditions and members with cancers, more closely resembled the proportion spent for inpatient services in the overall population. All Oncology $5 $20 All Auto- Immune/Other Specialty $4 $19 0% 20% 40% 60% 80% 100% Inpatient Outpatient & Pharmacy Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Chart notes $PMPM is spending per member per month. 19

24 INPATIENT SPENDING PRIVATELY INSURED Members with chronic conditions had 63% of all inpatient admissions Description Inpatient $PMPM Cost Per Admit($) Admits Per 1,000 Average Length of Stay (ALOS) Days Per 1,000 Professional Visits Per 1,000 All Members $65.33 $14, Chronic Conditions $44.49 $15, Oncology $5.33 $20, Auto-Immune /Other Specialty $3.59 $16, Members with chronic conditions had the largest share of inpatient facility admits at 29 admissions per thousand; they also had the largest share of professional visits, logging 219 visits per 1,000 members. Oncology patients had the highest average spending per admission, at $20,074, which was nearly $6,000 higher than the average spending per admission across all members. Oncology patients also had a longer average length of stay compared to the overall member population and members with a chronic condition, making cancer admissions the most expensive. Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Chart notes $PMPM is spending per member per month. 20

25 Pharmacy Spending Members with chronic conditions filled more than 75% of all prescriptions. Specialty medicines provided by a pharmacy were a very small share of all prescriptions, but 17% of all pharmacy spending. Spending on specialty medicines provided by a pharmacy, or administered in the facility, office, or home, when combined, accounted for: 6% of all spending across all members. 33% of all spending for members with auto-immune or other specialty conditions. 17% of all spending for members with cancer. 21

26 PHARMACY SPENDING PRIVATELY INSURED Specialty pharmacy was 1% of utilization, yet 17% of spending Specialty vs. Non-Specialty Rx Spend and Usage $ ,950 1% 17% Overall, 11,950 prescriptions per 1,000 members were filled annually, with 174 prescriptions per 1,000 members for specialty medications, the majority of which were branded. At $11.31 per member per month, specialty prescriptions were 17% of pharmacy spending. 99% 83% $PMPM Non -Specialty Source: IMS LifeLink Health Plan Claims Database, Dec 2010 Specialty Scripts/1,000 Chart notes Figures reflect outpatient drug claims typically processed by a pharmacy benefit manager utilizing NDC codes. See Appendix for detail. $PMPM is spending per member per month. 22

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