Executive Summary
Specialty medications have piqued the attention of employers because spending on specialty medications has been increasing. In 2012, specialty medications accounted for 24 percent of total drug spending in the commercial market, but by 2016 specialty medications accounted for 36 percent. By 2020, specialty medications are expected to account for nearly one-half of total drug spending in the commercial market. Managing specialty medications is considered one of the most effective tactics when it comes to controlling health care costs.
In this Issue Brief, the Employee Benefit Research Institute (EBRI) examines the impact of plan type on use of specialty medications. This paper also focuses on the impact that use of specialty medications both among workers and their dependents has on worker productivity. The analysis was conducted on nearly 100,000 unique individuals with rheumatoid arthritis (RA), Crohn's disease, ulcerative colitis, psoriasis, and multiple sclerosis (MS) using data from the Truven Health Analytics MarketScan® Research Commercial Claims and Encounters Database.
Use of specialty medications among individuals with multiple sclerosis (MS): ?
- Among individuals with MS, there was no difference in the likelihood of filling a prescription for a specialty medication by type of health plan. However, among individuals with MS that had filled a specialty medication prescription, individuals with preferred provider organization / point of service (PPO/POS) and health reimbursement arrangement (HRA) plans used more specialty medications than those with health maintenance organization / exclusive provider organization (HMO/EPO) plans. There was no difference between those with health savings account (HSA)-eligible health plans and those with HMO/PPO coverage.
Use of specialty medications among individuals with rheumatoid arthritis (RA), Crohn's disease, ulcerative colitis, and psoriasis: ?
- Plan type had no impact on whether any specialty medications were used, with one exception. Among individuals with RA, those with an HRA were less likely than those in HMO/EPO plans to use any specialty medications. Among individuals that had filled specialty medication prescriptions, we found mixed effects on the number of fills. For the most part, there were no differences in the number of fills by plan type. However, among individuals with RA, those in HRA plans filled fewer specialty medications than those in HMO/EPO plans. Among individuals with Crohn’s disease, those in PPO/POS plans used more specialty medications than those in HMO/EPO plans.
Use of Specialty Medications and Worker Productivity ?
Any Use: We found few instances where productivity was affected by use of specialty medications. We did not find any relationship between any use of specialty medication and any use of sick or vacation leave, or number of days absent. We also did not find that any use of specialty medications affected whether a worker took short-term disability. However, we did find that any use of specialty medications reduced the number of days on short-term disability for workers with Crohn’s disease by 37.6 days and for workers with psoriasis by 42.6 days. ?
Number of Medications: Regarding the impact of the number of specialty medications fills on productivity, we did not find an impact on the likelihood of taking any days off or on the likelihood of being on short-term disability. There was evidence that a higher number of specialty medication fills increased the number of absentee days for individuals with Crohn’s disease and psoriasis. However, the magnitude of these effects was quite small, increasing absenteeism by 0.53 days for those with Crohn’s disease and by 0.25 days for those with psoriasis. There was also evidence that a higher number of specialty medication fills increased the length of short-term disability for individuals with MS by 5.6 days. ?
Dependent Use: We also examined the impact of use of specialty medications on worker productivity by examining whether worker productivity was affected by use of specialty medications among dependents. We tested this by examining the impact of spousal use of specialty medications for married workers. We found nearly no evidence that any use of specialty medications reduced worker absenteeism with one exception—among spouses using specialty medications for ulcerative colitis, workers were absent from work 6.5 fewer days. With respect to the number of specialty medications filled among those who had filled at least one prescription, we found mixed results. There was no impact on worker absenteeism among spouses with Crohn’s disease, psoriasis or MS. Higher use of specialty medications reduced absenteeism among workers with spouses treated for ulcerative colitis, but it increased absenteeism among workers with spouses treated for RA.
Figure 14
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Figure 17
Average Spending on Prescription Drugs, by Disease and Plan Type, 2013
Average Number of Days Absent, by Disease and Use of Specialty Medications, 2013
Figure 10
Select Demographic Means, by Plan Type, 2013
Spending by Drug Type, 2012-2016, Projected to 2020
Estimated Impact of Employees Use of Specialty Medications on Short-Term Disability Days
Linear Fixed Effects Model Estimates of Plan Type Impact on Condition-Specific Specialty Drug Use
Figure 4
HSA-Eligible
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Paul Fronstin is director of the Health Education and Research Program at the Employee Benefit Research Institute
The Relationship Between Health Plan Type, Use of
HSA-Eligible
20 80 .0 D % isease Dependent Variable
HMO/EPO PPO/POS Health Plan Statistical
76%
Prescription Drugs (Generic Names) Included in Analyses
Care 42, H no. MO/E 11 P(O Nov pla en msb . er 2005): 1130-9.
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Total (n=96,691) (n=12,231) (n=70,329) HRA (n=9,859) (n=4,272) Significance
72%
Specialty Medications, and Worker Productivity
HSA-Eligible Statistical
1 TA rad ny it ion Sp al Me ecia dlic ty at D ion ru s g No Spe Spci ealty cia lM ty e dD icr at uion g s Statistical
Figure 9, Spending, by Disease, 2013 ................................ Coefficient- Predicted................................ Probability- Conditional Nu ................................ mber of Conditional Numb............. er of 14
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"Imp act of Medication Adherence on Absenteeism and Short-Term Disability for Five Chronic Diseases." Journal of
assistance from the Institute’s research and editorial staffs. Any views expressed in this report are those of the
Rheumatoid Arthritis 68%
10.1 HMO/EPO PPO/POS HRA Health Plan Significance
Total
70% Independent Variable Any Specialty Drug Fills Any Specialty Drug Fills Specialty Drug Fills Specialty Drug Fills
Roe Use of Spec buck, M. C ialty hrist M oped heic r, a J. tiSa onm s a ant nh da W Do oug rker herProd ty 67% , Rob uce ti rv t it Ka ye stner, and Laur Fia ll sM. Miller. "Incre Fa ilsed ls Use Of P Signirfe icsc anrc ip etion
Disease Sample Sizes
We als 10.0 o examined whether use of specialty medications affected worker productivity. We found few instances where
Biologic DMARDs (other mechanism of action) 7.5 Biologic DMARDs (other mechanism of action)
Use of Specialty Medications and Worker Productivity
Paul Fronstin, Ph.D., Employee Benefit Research Institute; and M. Christopher Roebuck, Ph.D.,
m d us H w Oc e ow it or e d c h a d up uc ee tv lik tn o aible etr e H t ion , rly S ea s a A a b tit- o l a n th out e tb ligib he nd e e t hr on c se E le ond n e v e p d he ir - la is it q o a a io ns ua nm lt bns h ili rcte t a p e y unde nt n b la r s of or n al M e spe c rlose us te st hose d nt e udy ic d t $4 ine o to .w b ,0 Me e it e 54 68 it h R ing he d , ic OOP no. A ra d sh tis a ion nd a 7 (Jul ift , bc s w le om MS the d e ya p r a c nd/or 20 a e rost r ee g 12 d w r oup of ) om w : so ill t it he 79 e e h $3,08 d n, a 2 lin -t805. h w h c a thil hr ta 3 a te r e he e e only m tyg o e ong aw ne rone eor r a a tklr ho l ca - efo e ra se s or ur d te y tw g h tor g it a a e h a k ie rting e s: t n HRA he mc a e m o n lo r . ttito The c , os of $ c2,19 hoo tte im arv oid se e e 5 r off f a s ag , m e no o ra ng om n g-e
authors a DMnd ARDsh s: bould iolog icnot s be ascribed to the $9,2 3 offic 0 ers, t$r9 us ,83t5ees, or ot $9he ,19r 1 sponsor $s of 9,047EBRI, E$m 8,p 55loy 9 ee Bene fit Research
Rheumatoid Arthritis 64%
5.6*
2 Rheumatoid Arthritis
July 23, 2018 • No. 454 5.1
Figure 10, Average Out-of-Pocket (OOP) Spending, by Disease and Plan Type, 2013 .......................................... 15
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productivity wa ab s a ataff ce ep ctted by use of specialty medications. abatacept
Total OOP spending $1,972 $1,298 $1,925 $2,651 $3,192 ***
b a tRx r w hose a lt iolog or nge eEco r kn . s fr a ic w t iv nomics it do h a e is H m M e he D a O M 38 P se /a A P Elt P R .3 O/P -O h ca D m ,s LLC a : od nm OS, or n ify ong e -b serv ing ia ond l otg ho ia icc $1 snt se es ir ,421 . he w Bit y uh C m a 20 m ar16 tong ohn’ ic, d25 rs tugs hose $304 d p 2.4 ris e efe r (c D a w e se MA nt it h a tRD of o n HMO/ 46 e s $311 ) m .3 a , p aloy nd mE eong b 41% P riolog s O w (tit Fi ho $303 ic h 10 gse u DrMA ew – 49 1 itRD 0 h RA 9 w ). sA . $306 or m . CrThe or on k ee ftr g ic s a ost a MS vnd eerp raoid 61 a g $297 te ie s (e. p a nt e grs e c g e w for ., n it 7t .h a 0 p indiv of r *** en d e nis m H idu SA pone loy a-lse , r w s ith
Institute-Education and Research Fund (EBRI-ERF), or their staffs. N 59%either EBRI nor EBRI-ERF lobbies or takes
The analysis of worker productivity includes both days absent and on short-term disability. One limitation of using days
? Any Use: We found few instances where productivity was affected by use of specialty medications. We did
Crohn's Disease 706 29.9 31.0
OOP spending on prescriptions $663 $560 $617 $843 $1,346 ***
60% PPO/POS 42%
Charlson, M. E a., lem P. tuP zu om map bei, K. L. Ales, and C. 0.R. 003MacKenzie. n "A at aN lie zw um Me ab thod of Class 0.1if 40 ying Prognostic C 7om .1 orbidity in
Pur Gpo ends ere of this Paper
Corticosteroids $105 $122 $103 $104 $88 ***
3
w p e Cligib r rit e ohn’ h 500 or dnis les 0.0 olone he dis ae lt m a h p , se o dre la e is xa n, w low m or 60 ek e t ha e rp rt e s off son ha rce ne nt et)rhe e a of d r e ot OOP e us it he he er d r spe c ond t ao nnding rH e itd RA iouc ns - e w or b a inf e s d H cla a SA ue u ms-m e et ligib o a Ctr p ion, ohn’ re lesc p a s rnd la ipti dn (Fi isa on era ese g d rur r out ug is e iof s 3) ne , t.c e ly om Use n p prpre a e of sc r sent erC d ibe D w H a d it P m h 46 p c s is ong on ce om xpe ce hrildr ic tc a etn nt e etd n, ly a t m o w wong he it cont h re H a inu s RA e
positions on specific policy proposals. EBRI invites comment on this research.
absent is that the data field (as received from the data provider) includes both sick leave and vacation time. As
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HRA -0.0158** 40% -0.2948* 6.7
There are some limitations to the data and research methods used for our analysis. Fixed effects regression modeling
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The pur M p aose le of this paper is to examine the 37% impact of pla 37% n type on us37% e of specialty 37% medications for 41% individuals *** with
e D t the o nr MA e olle xpa ot RD he end ss, 40 p r. c , To ond thoug slie ow tions rch th ednt is us e ear am ua e se ong is lly p e rd v og P o ide P rnot O/P enc ss e ion, a OS p tha pe e D tnr a MA t rhe olle unt RD g e il so rs a sow and rm te h r et45 one he at e p p e is in t rim r cin t e he ant ry he us a pir m h e a ong 30 of rm ssu . aH c The c MO/ olog h pC la E ic ha P n aO s m l t rls r eon e nr a ayt olle m C bom e ee nt sl sor ow fo (b Fir idit ing g RA ur ye d ,I o C nde 11 w rohn' ) n. x is g ( AFr s si onst d m e isne ila eia n, rrs ae lly , in
Cro Hh SA n'-s e D lig is ie ba le s e health plan 42%
0.001 -0.021 7.0
repor Ptse od ri a in Figur sis e 16, we -2.9 found few instances where prod 1uc ,46t3 ivity was affect3 e 1d .1 by use of specia 28lt .3 y medication** s. We did
Leads To num Low beerr H of ea dla th C ys a ab re sent Use . A W nd e a Cls ost o s D did enot spit fin e Id n c th re aa t sed any D us rug e of Spspe ending cialt." y m He ea dlt ich Af ation fas a irs ff 30 ec, ted no. w 1 (J heta he nu r aar yw 2 or 01 ke 1) r :
helps safeguard against obtaining biased estimates due to confounding. However, the technique is inefficient in that it
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DMARDs: biologics $10,757 $11,714 $10,693 $10,613 $9,562 **
w Bhe ac n d k50 gr e% pe o nde und nts are on specialty medications if those medications reduce the need for the employee to take time off
Sug Cr g oes h Tn o'ta s ted D l iO se O ci a P s e statio pendinn g: Paul Fronstin and M. $2C ,1h 4r 9istophe$ r1 R ,3oe 43 buck. “ $The 2,079 Relations $2,9h 8ip 3 Betwe $e 3,n He 503 alth P *** lan Type, Use
See Figure 9.13 in https://www.kff.org/report-section/ehbs-2017-section-9-prescription-drug-benefits/.
rheum Fig a Fur t eoid ma e 1 la e 2, rth Arviteis ra (gReA N ), um Crohn' ber of s dD isaeyas A se, bu 63% sen lcetr, ab tiy v e D c isolit ea 63% se is, a pnd soria Use sis , of 63% and Spe m cia ult ltiple y Me 63% sd clic ea rosis tions, 201 (MS) 59% . 3 P ......................... lan type is *** used a 16 s
2018) u p the a lcte t e m ra r.id n t iv -e e 0.3 m ce olit -rto ge - is, p 0.39 d for sor rindiv aia nge sisidu , . a Hnd a ow ls m e wvult it eh riple , pitso a sc rvia ele si ra rso g , si eRA s s. T 1. , u 3 ra l c a de m ir tio a otng na ivel D t c hose olit MAiRD sw , a it s nd h RA (su Ccr, h a ohn’ sus m gs ge de st is tho ing eat s re teha . xa Httighe e the ) dy riff OOP ae rr e fr m o cuc ost mh b s m iolog on oreic lik ely
Multiple Sclerosis 521 30.7 28.5
not find significant relationships between any use of specialty medication, and any days absent or conditional number
91-99. took short-term disability. However, we did find that any use of specialty medications reduced the number of
-10.0
Congressional Budget Office. Offsetting Effects of Prescription Drug Use on Medicare’s Spending for Medical Services.
requires w Hit M hin O/E- Pp Oerson variation over time. Wirteh f relatively small sa 40% mple sizes (particrula ef rly in the productivity analyses),
OD OM Pr A sip R tu e Dx n si: d m n in o a g n b o -b ni o plr o egsic cr siptions $108$582 $99$482 ustekinum$110 ab $538 $97 $794 $113 $1,057 6.7 ***
fromof wSp ork e c to ialt ca y rMe e for dic tahe tions ir d, ea pnd ende Wnt or. ke Arlt P er rod natuiv ct eily vit , yspou .” EB sa RI l ti Iss mue e m Bight rief , bno. e ne 453 ede (dE t m o paloy ccom ee p Ba eny ne fit or Re trasea nsp ror ch I t p ns attiit eut nte s ,
48%
a In 2015 proxy ,fo $3 r high 24.6 b cos illion w t shar aing s s, pa es t nt he on p out erc peant tie ant ge pof resc indiv ripti idua on ls dr in hig ugs in t h-he de dUnit uctible ed St he aa te ltsh p , ac la cns ou nt (Hing DHP fo sr) 10 ha s inc percreent as o ef d
t p D o rMA eha sc S RD v r oip e u s, w rtc c ion d o e- : m E hic mp or rugs h b loidit c yom ew eie e p Bs r e re is n t ha e e ef xpe in ne t Rtw e hose rs ie e er nc a rspe ce w hd Iit n ca h th ia sm tilt tong u ye t e d ot r e ug H she tS ima A r c l-c a e tond ss e ligib se bs of iatle sio e d ns he te on cl . n aThe lt ad h p a mi ss d la n ifi is in se t tr rd e ibu a nr ta ivc o t e c ion o lle o er n e d rs o ing f th lb lme et ce o a n us tst a a hn e m ed ir of p c le lm at ihe e ms bcyha high d ty anis p tae .m d of eof d he uc aa c tlt ible tion (e h p . la Nn ot ith d only e oe r s
5
Th of dae ys a R d ba Psen P ye O s on /lat P t Oe Sxc shei opo rtt -n in one tes rmh d ip c isaase bili . B tN yae for mt e we lw y, or a -k 0ny .e 0e 1 r 2 s w spe nit H ch C ialte y rohn’ da rug lt s d us h is 39% e e Pl a for se a RA byn 37 w T a.6 d s ay ss ap y 0o .3 s a ce 9ia 71 nd t, *edUs for w itw h 2.5 e ork of erfe s w w 7 e it .1 rh cp ond sorit ia iona sis b l y
Percent of OOP spending on prescriptions 32% 42% 30% 32% 32% ***
C ong See rFi ess gur ioena Co 9.l B r6 ticin udg os te http re oit d s sOffi ://w ce w,w 20 .kff 12 .o.rg /report-s $488 ection/ehbs- $518 2017-section$510 -9-prescription $378 -drug-benefits $311 / ***
we may not ha se vce u ksu inff um icaie bnt variation to exploit (i.e., patients might not be varying specialty drug use over time). Also,
to reFi S cte g aiv tur is ee t ispe c1 al3, sc ig iA a nv lt ife y ir c a a dn g rc ug e e N oinj fum de ifb c fe teion rr e n of s. ceD s a iny me s on ans Sho by a rt n-yTe filrlm s u s D in is ga K brili ustk ya , l b W ya D lliis s e eq au se alia tynd -of-Use pop u of latSp ione sc ria an ltky t e Me st d de ic na ottions ed a, s
July 40 %23, 2018).
national he HR aA lth expenditures (NHE) (Martin, et al. 2017). Annua40% l growth in prescription drug spending averaged 4.4
Roe dram buc atik cU , allly Ma cer ain t r tik v eC he Co ., l iRob la tisst e dre t cJ. adK ea. eOur stne st r, udy is a and Juli -0n im .0 a 0 3S. pD ro oug vem he ernt ty . ov "Iem r p pa rior ct of studie Meds for ication 0a .0 5n 8 Aum dhe breernc of e ron easo He ns 6a .8. lth Se First, rvpic rio es r
d not ant id i - ta A he tp um gp ey e ( o y spe ae rr ane trnd o s)cvra m orsi y or s f b ey aOOP cctond or , (ita the int on. i- pTNF e Only rce)nt or 14 spe o -16 the nd 4 3 p r.)e 3 OOP . rc Se ent e on Fi of g pur trh e 4e e 2 sc .9 4 sa r ip for m tions p a le c w om waa 4 s e p s 3 r .5 highe e nr he olle nsrd iv b e in a e c lis a 4u t 3C .0 sof D e H d gP r eug ne in 201 rfil icls d 4 3, w r inc 1ug .5ur na hic rem d h is ju ees ar a *** ly nd st in b the e the low ir
days absent (p=0.09). In MS, each additional specialty drug fill was associated with 0.28 more days absent.
42.6 days.
Ulcerative Colitis
tocilizumab 41%
aSp ll pae tiec ntial s hadt ty he M ir ree spe d ci tic vea cond tio itions ns a,s of an thed fi W rst yo ear r k (of e the r Pr threo e) d of u the c ptainv el d ity ata set. This represented a
fo -20.0 llowH sS : A *-* e* li g pi< b0 le. 0 h1 e; a* lth * p pl< a0 n.05; * p<0.10. -0.020 38% 0.267 7.0
T o ta l O 2013 OP sp ................................ ending 12 ................................ $1,962 Figur $1,2 e 74 3................................ $1,900 $2,66................................ 2 $3,162 ***............. 16
6
p steudie rcent s us beetd w e de an 2009 ta most ly and fro 2m 01 20 5, hig 00-20 he09 r t, ha wn th hen fe e 3.8 p wer e indiv rcent idua avls er a wgeer ea nn in HDHP ual grow s atnd h r a cost te in spe sharing nding for on spep cria ofe ltyss ional
y t t Uti he he ea liz r r18 a a w pt e e ion in put re eric c lik ecnt e Me la ly sna si d in ic fitcc ion a ur a id. trion ae "l a d Me s v b e e e d m rfor ia cp g ae loy e l C .the e a d rThere e indiv in , Ma this idua rd c o h 2018 stnot udy. l re a a c p : he p 2e 66 d a r- hi 2 ts or o 73 b.e he any r d d eiff duc erteible nce.s in t he samples when examined by health
See Figure 9.6 in https://www.kff.org/report-section/ehbs-2017-section-9-prescription-drug-benefits/
Darkow <, 18 Theodore, J. Ross Maclean, Geoffre 6% y F. Joyce, D7% ana Goldman, 6% and Darius N 6% . Lakdawalla9% . "Coverage *** and Use
? NuD m Mber ARDs: o bf iolM oged ics ications: Regarding $4,6 0t 5he impa$ c4 t, 5of 38 the num $4b ,6e 6r 7 of specia $4l ,7 ty 31 medicat$io 3,ns 559 fills on p roductivity,
Ulcerative Colitis
tofacitinib 36%
OOP spending on prescriptions $583 $463 $538 $795 $1,095 ***
W mixt e e u Cxa ro ep m of yin rig inc edh ide tt In he nt im form ap nd acp a t rti of eo vs a np le :ousa nt Thi ca l use s r ses; ep or of and t spe is vca c op ria ylt y ing ryight m de ee d gd ic r eb a ey ts of ion the s for d E ism e a p m se loy arr seve eie ed B w e rit ne or y, k fit w e rhic Re s. sea h c The ould r cfin h I d ns not ings a ti tb ue te r e c ( ont E pB re rRI olle sent ). d Iet . d m in ay be
9 1
Percentage of Employers Offering HSA-Eligible Health Plan/HRA,
serv ice30 s, a % nd lower than the 5.2 percent rate for hospital services. While only at 10 percent of NHE, prescription drugs
m Pa eul Fro dications Hns M O w t /in, a EPs g O Ph.D. enerally , E lomplo w as cye ome p Ben ared te o rf eit ftod 33% Res ay. e a Se rch I cond, ns 17% neta itut rly e all p ; arnd ior sM. tudie C refs hris focus top edhe on r R crooebuck, ss-sectiona Pl h.D.,
plan enrollment. 6.8
of Cancer Ther DMAa Rp Die s: n s in t on-bio he log iTr cs eatment of Chro $107 nic Myeloid $122 Leukemia." $104 American Jour $118 nal of Mana $86 ged Care 18 , no. 11
18w -2e 5 P ed rcid ent not of O fin OP d sp e ann im ding o pna p crte son crip t tihe on slik5% elihood 36% of tak 6% ing 46% any days off o 5% 34% r on the 36% 6% likelihood of 38% b 6% eing on *** shor t-term
32%
ustekinumab
7
Fi Sim gur ila Fi er g ly 1 ur 8 , e . w W 1 e4, ed id found Line not a rinde ne Fixe arx sp ld y E nff o ec ee ia cv tlt ide s Mod y d nc rug ee l tha us Est t e i, a m t ny he at e us re s of for e of e P la ut sp n T ili ec ze ia yrp lt s inc e y Im mlude epdaic ct a d t on ion botC s h e ond rexis diuc tion tin ed g - Sp w and or eckifi ne ec r w a Sp b us se ec ent ir as. lt ee y is Dm rug . There Use .... wa 17 s
used without permission but citation of the source is required.
10 by Firm Size, 2010 –2016, With Pro11 jections Through 2019
W Sinn ee , FiAga ur ron Pe P O 7. N /P 2 ., Oin SN a http ncy s :L // . w Kw ea wt.ing, kff.oa rg nd /reS pto art cie -s 0 e .B 0c 1. tion/ 7Dus ee hb tzin s-2017 a. "Fa -scet 19% c or tion s A -7 ssoc -emia pt loy ede e W -c it 0o h Ty .0 s8t3 -sha rosi ring ne/ .K inase I6nhi .9 bitor Initiation
For each disease, Figure 12 presents the average number of days absent and Figure 13 presents the average number
Figure 13
E d ac a cc on ta ount .ome -30.0 e Our Pd sto ric A for ri ast s iudy u stn he a ly thir si se sd s la long rgeitst u d sh ina arl d e of ataN a Hnd E, fix follow ed eing ffecho ts spit mod al se els.rv icOur es ( 32 study pera ce lsn o t), fo a cu nd ses pron ofetss he ion im ap l se acr t vtic he at s ( u26 se of
RxEconomics Cortico, s LLC teroids $179 $156 $191 $147 $136
(November 2012): S272-S278.
disability. There w 28% as evidence that a higher number of specialty medication fills increased the number of
26-35 12% 11% 12% 12% 12%
vedolizumab
HRA 18%
0.010 Figure 16 -0.242 6.6
one exc 10 ep 0% tion: among spouses using specialty medications for ulcerative colitis, employees were absent from work 6.5
and Adhere To nc tae l O A Om P song pend iMe ng dicare Beneficiaries Wi $1t ,4 h C 91 hronic $936 Myeloid Leuk $1,e 45m 1 ia." Jour $2,na 046l of Clin$ ic 2a ,4l O 78 ncolog*** y 34, no. 36
of days on short-term disability by specialty drug use status (in 2013). Statistically significant differences in days absent
24%
percent). Psoriasis
specialty medications – by both workers and their dependents -- has on worker productivity, which we believe has not
8 20%Average Number of Days on Short-Term Disability, by Disease and Use of Specialty
ab HS sent A-elie gie b led h a ey as fo lth plr a nindividuals with Cr 0ohn’ .000 s disease and p 17% soriasis. However0 , .1 t7 he 9 magnitude of t 7he .0 se effects was
UnivFi R arep g ia ur to e e r a t a 1nd 5, vP b ar iv il ea a drbil ic iatte it ed y aN :n um Thi alyses b s r ere p w of or eSp rte is e c c ond aia vlt ail uc ya D b te r le d ug on wFi itth d lls he A ifIm fe nton reernc g ne P eta in m a tie t w nte w s w aw ns .e it h M b te rst i.or ul ed t giple us in Sc g le the rosis Kr, us Ck ond al-W itiona allis e l oq n A ualit ny y -Use of- ,
There See Fia 3gr 6ur e -4 e a 5 7. nu B 8 m io in lb o e http gr ic of DM s:lim / A /R w Ds itw a w t (a ions .nktff i-T . o r Ne rg F) la /re tep do trt o 25% -s ty ep ction/ e of e he hbas F lt - 26% i2017 h p gur la Be i-n a os l5 e oc gs w tion ic DM e-ll 24% 7 A . -R e For Ds m p ( a loy ins ntie t -T a eN n -c F) co 25% es, t-w sha e a ring re / una . 27% ble to control *** for the
OOP spending on prescriptions $582 $429 $531 $856 $1,235 ***
Employees
fewer days. When it came to the number of specialty medications filled among those who had filled at least one
(December 2016): 4323-4328.
D em ey eo, r ge R. d Ps A o in t r., ia D sM D w isA . o RC D of . s: C b the ihe olor gfiv k icin, a se dind seaM. sesA. . IC n R iol. A "a A $nd 9d ,8a 7p 1 ptsor ing iaasi C s, a $l1i0 nic ,1 ny 2a 8 l spe Com cia olt r $b 9 y,idit 9d 24rug y Inde usex for $w 10a ,0s a 7 5 Uss se oc wiit ath I $ e7d ,8 C 1w D 4it -9 h 2 -CM -3 mo A *** dm re ini dsa tr ya st iv of e
Linear Fixed Effects Model Estimates of Employees Specialty Drug Use Impact
been examined in the past. 87%
Percent of OOP spending on prescriptions 40% 50% 38% 43% 43% ***
90 q% uite small, increasing ab -sen 37.6**teeism by 0.53 days for those with Crohn’s disease and by 0.25 days for those
c phoic opula e -40.0 tset of ions r a a an v d b k a a y ila lt ie P m b st la ule m n Ty m ahe b eta p ho lt eh d ................................ p (la Krns us Se . kW all e ea c nd d t o DW not em al lis k onow gr 19 ................................ a5 p if a 2) hi.c p M N la ee n e a xt a d, a n nr lw is m ,olle e u b e m y st e aD b im ha is ................................ ad e t e a ad s c e lin hoi , 2 ec a 0e r1 fi of 3xe ot dhe eff r ehe c................................ t am lth p odela lsns of , n spe or cd ia o ltw y e d. r 17 ug
Medications, 2013
46-55 36% 35% 36% 36% 32% ***
10-499 500+ 5,000+
prescription, HMOw /Ee P Ofound mixed results. There wra es f no impact on w38% orker absenteeism ra em f ong spouses wit6h C .2 rohn’s
9
Growth in prescription drug spending in 2015 was faster than that of any other health care service, primarily due to
absenteeism D. MSho ARDsr : tn-otn e-r bm iol od gis icsability days werA e $131 highe T r A by a$131 bG outL four A d Na$131 yC s am Eong spe $133 cialty drug $129 users in ulce rative colitis;
DataThi bases." s st Muludy w ti p Jour le Scln a es c a rol o sio sf C nduc linitc ea dl Epid throug em h th iolog e y E B 45 RI , no. Cen6 (Ju ter for ne R 19 esea 92r)c : h o 613 n -H 9.e alth Benefits Innovation, with the funding
In one prior study, only 30 of the over 24,000 individuals in the sample were in an HDHP (Palmer, et al. 2012). In contrast,
10% with psoriasis. There was also evidence that a higher number of spe 80% cialty medication fills increased the length
use as a fun PPO c/tP c io O ern o Stolif p zum la an ty b pep go e l, and a vector of covariates incc luding erto 38% liz ua m g ae b; pree gg oion l (Northeast, Midwest, South, and West);
know what other health plans might have bee 0.n a 004 vo a Ril n ha e b uP m le r a o tha od id du tc he tir Cvi e ro b h tn e y 'e s n choic Ulc e e. ra W ti0 v e .e 0 3 d 7o not know to wM 6ha .3 ut lt id pe leg ree
-42.6***
56-64 16% 15% 17% 15% 14% ***
disease, psoriasis or MS. Higher use of specialty medications reduced absenteeism among workers with spouses
Total OOP spending $2,261 $1,421 $2,195 $3,083 $4,068 ***
new medicine Cors ti;c og sr te ow roid th in s prices for existing b $54 rand-name $48 drugs; highe $56 r spending on $54generic dr $37 ugs; and a*** decline in the
15 percent of our sample is in HDHPs.
whersu ea ps in mu port of lt tiple he follow scleros ing is or spe gacniz ialtayt ions drug : A ut on iliza Ht eion w witt, a Bslue re la Cr te oss d t o Blue ap pShie roxild maA tss ely o csi ia xt ion, feweIrC d UB ay As on , JPMor shor gta-n teC rm ha se,
80%
Figure H R 1 A6, Linear Fixed Effects Model Est -i 0m .00a 6tes of Employee 37% s Specialty Drug Use -0.23 1 Impact on Produc 6.0 tivity ............ 18
of shor eta t- ntee rr cm ep tdisability for individuals with M AS rthb ry it is 5.6 d etana ey D rs. c ise e pa tse Colitis Psoriasis Sclerosis
indiv relatio idua nship ls wtit o h th polic e ydhold iseae ses r (self, exam spouse ined in t , or he c hil pad p/e ard c ult hoos dee p espe nde cnt ific ) 73% ; j ob Cha s b rlson C ased om on o the rb idit ava yila Inde ble xhe (C aha lth cov rlson, ere atg e al. . We 198 7)
Disease OOP spending on prescriptions $856 $613 $772 Dependen $t 1 ,V 19a 9riable $2,253 ***
-50.0 72% 72%
t D re oshi ate, dJa for lpa M uulc l tiA p., e ler a Ti Sctla i ev rny o es ia c soli n Hu, tis, b Put engxia it inc ng reaLse i, d A m ab ysent R. Peeetis titm , Xiny among an Y w u, oraknd ers w Mait ris h sa spouse Blums t . "rSp eae tc eia d lt for y Tier RA.- Level Cost
HSA-eligible health plan 38%
number of expensive blockbuster drugs whose 0.00p 7atents expired (Martin, et al. 2017 -) 0. .0 3There 6 was also s6t.r 2ong growth in
d Da isat ba ilit y.
Kaiser Permanente, Mercer, Pfizer and PhRMA.
(n=32,982) (n=14,899) (n=13,799) (n=25,701) (n=13,223)
Specialty medications have piqued the attention of employers because spending on specialty medications has been
10 ? De Pe p ren ce go nt ld io m en f u Om O t U a P b sp see: nd iW nge o na pls reo s ce rixa ptio m nsined the 41% impact of 50% us gole im of umspe ab c38% ialty medica41% tions on wor 52% ker prod Cou nc d *** tiitv iit oy n aby l
Use of any Number of Use of any Number of Use of any Number o A f ny Sp Us e ec o if a aln ty y Drug N umbN er o o fSpeciUs al et o yf a D nr yug NS ut mb at eir o stfical
(Deyo, C 0%herkin and Ciol 1992) (Quan, et al. 2005); and indicators for the presence of seven comorbidities (diabetes,
also do not know if individuals with the diseases examined in the paper pick a health plan because a specific physician
See stud Mulie tipsl er e Scv le ie ro w sie sd in Doshi, et a l (2016B).
DMARDs: biologics $32,834 $31,469 $33,104 $33,104 $31,693 **
SharE ing mpl70 a ond y %eeBiologic Agent Use in the Medic 56% are Part D Ini 57% tial Coverage 57% Period Among 56% Beneficiarie 50% s With Rheum ***atoid
new speciaslt pey c ialt m y d eru dic g at spions ecialty d . rug specialty drug specialty drug specialty drug specialty drug specialty drug specialty drug specialty drug specialty drug
Figure 17, Estimated Impact of Employees Use of Specialty Medications on Short-Term Disability Days ............... 19
S G o eu n rd ce e: rEmployee Benefit Research Institute estimates based on administrative enrollment and claims data.
This study made 2012 use of the 20 13 Truven H20 ea 14lth Analy20 tic 15 s MarketSc 2016 an® Com 20m 17p ercial Cla 20im 18ps and Enc 2019p ounters D 20 a20p tabases
63%
increasing exa H . M Im n 20 O/in EPing O12 , wspe hetc he ialt r y w m ore kd eic r a ptrio od ns uc a tiv ccirtou ey f nt wa es d afor ffe c 2t4 p ed e bryc 73% e us nte of C of otn spe ot da itl d c iF o ia in lrlt lu s ayg l m spe e re dfnding A icn ay tion D a in t s a ys Fo he m iln long s com N d u m e m p eb e rSc e nde iig ra n o l m if fnt i D ca s aa n r . y k cW s e ete ,
Disease infliximab Sample iS nifl ze ix simab 7.4
W c isong hil in t e ehe st ov iv e pe rla ahe me n ll use ’d s ne a icr ati t o f ntof a sw ilu or spe filr lk se ,. c, c o high ia ndiltitoy n alm blood e me dic dic a ati ptr oio e nsns ssur film lse , c a , oy nd db y itisl e on ipid alexpe me em dc ictia ati ed , on a sto stfil h im lm s, cpa oa n/c dc itith o n w ral oni ork me ce ob dr 61% i cati p st r ood n rsuc ut fil civ lt si ,e c v oit p ny dulm i, tiom nalona edme icra dy it c ati io dis on a ne s ad se, filhe ls, c rd oe ne dnc ip tiore ne al ss mion, ay
DMARDs: non-biologics $593 $588 $598 $586 $530
Arthritis." Arthritis Care & Research 68, no. 11 (November 2016): 1624-1630.
Notes:
Spouse 59% 33% 32% 59% 33% 33% 36% ***
11
PPO/POS on use o0 n. u 00 se 9 Figure 7 74% on use 0.5932*o * n * use 7.9 on use
Male 23% 47% 49% 50% 23%
(copyright © Truven Health Analytics, all rights reserved) for 2013-2015. Using the full Commercial Claims and
but Th bre y e20 stud 16 ispe eN s oe n cxi -B a ailt mine oy lo m gid ce DM d lon ica A gR tiions t Ds ud (ina n o anc l -s c do p ae unt ta ci.a e l tTw d y) for o o 36 f tho pe se rc s etu ntd. ie NB o sy n fo -B 20 c ious 20 loe g, d icspe o DM n c A cia R aDs nc lty e ( n m r o(e n (-s d Dark ic pea ctio ion aw lty ,s a )et ra el. e2012) xpect e ad nd t o (Go acld cou ma nt n ,for
Rheut ma est toi ed d A this rth rb iti ys examining the impact of spousA al use ny8 D ,4 a 8 of y 7s spec N ia ult m y bm ee r d oic 5 f .D a 1t aions ys fo Sr h o m ra t-rT re ierd 6 m . 0 w ork oe nr s S. hW ore t- T found erm
60%
and schizopCo hrre tinia coste /bip roidola s r disorder). Capitalizin $71g on the p $63 anel nature $73 of the analyt $67 ical dataset (i $80 .e., three y *early
be a better measure. Count measures of prescription drug utilization do not account for drug switching, concomitant
HMO=health maintenance organization; EPO=exclusive provider organization; PPO= preferred provider organization;
SpecFi iag ltur y e m H R 18 e Ad, icL aine tion ar s a Firxe e d d iff Eff er eecnt ts Mod frome tl Es radtit im ion ata el o s of utp Sp atous iente s Sp pr73% esc ercip iatlt ion y D d rug rugs. Use They Imp a acrte on high Pr-od cost uc tm ive itd yic ............... ations used 19
0.007 0.3768* 7.7
Child/Other R h D eu e mato pen idd A e rth nt ritis Crohn's Dise 10% ase 12% Ulcerative Colitis 10% Psorias 11% is 13% Multiple Sclerosis ***
Jena, et al. F2010) emale) and one Ave for ca us ge ed P or n eR sA c r(iKa ptr ia oc n a -D Mand rug 77% ic U , s ee t ,a b l. y 2010) Dis 53% e . a Dat se a a n wd a sP 51% us lae nd T fro yp m e,2005 250% 01a 3nd earlier 77% in two of the
Encounters Data 51% base, outpatient and inpatient claims were searched for individuals diagnosed with one or more of the
nearCr lyo one hn' N s- o D ha te iSo s slf of : e a uu a rce: s ra en Express to ot fia nl d Scri rug pts, spe Drug nding Trend Re in t port, he 2 0c 1om 2-20m 17e , an rcd ia El mm 4 p,lo 1 ay 5r a ee 5 k ue r Benefit t o. thMa iog Rese na lucg o arch ing se Inspe 7 stitute .1cia (EBRI) lty m pro ed jec ic tio at nions s 6.7 is considered one of
Ultimately ne , a prla lyn ty no p ee v ide manc y e no tth a m t aatny ter us sim e p of ly spe becca ia us lty e m indi A eb dv se ic idua a nttion ls s r wit eh hig ducA eh b dse -w cos n or ttk e cond r abit sent ions a Disa eeb is rie lm i tm y w oit re h o likne eD ly ie sa txc o be r ile p it a ty ion ch — their
In PO dS e =p po ein nt d oe f n set r v V ica e; ri H a Rb Al=e health reimbursement arrangement; HSA=health savings account.
Doshi, JapH la SA A -e., ligP ibe lengxia healthng planLi, Vrushabh P. La -0d .0 a 2g 6e, Amy R. Pettit 70% , and Erin A. Taylor 0.3 . 6" 9Impact of Cost Sha 7.7 ring on
ob use serv , and ations or t im foirng ea . cMe h p de ic ra so tio n) n a , fix dhe edr e enc ffee c tm s e ea stsiur ma ets a es rw e e rout re g ine ene lyr a us te ed d v in he ia wit ahin lth se -surb vjic ee cs r t ve asea riatio rcn in h (Ca ar ll v ls, ae rt ia a bl. le20 s. 12),
to treat chronic conditions 48% that are often rare, such as aut 48% oimmune diseases and multiple sclerosis (MS), which have a
studies ((Goldman, Jena, et al. 2010) and (Karaca-Mandic, et al. 2010)), and from 2009 and earlier in the Darkow, et al.
based on data from Express Scripts.
HMO=health maintenance organization; EPO=exclusive provider organization; PPO= preferred provider organization;
50%
Tabl Ulce e ro atif veC Co olnt itisents 4,353 8.6 H 4S .7 A-Eligible **
follow the most ing SS o ta e u crond ff ti cs ee ti : c c E a a t it mp ziv l ions a site lg o h n y it io e fa : ie p cc a r Bt ir n e ic n he c n e es w e o fum ift d Rhe ie fa f se t e n it oid ra ern ch c e c a Is nom r isn t tih m tu e re te it s t ais n eso s ti ( aR ma c cro A ote s nt )s, s p r b C lollin a ar n sohn' e ty d g p oe n he s u as dd imi n ais glt n e K h is ra au tr zc se s a aa k ti t a, r h vle e iu W o elc c p a nost r le r liio s n r le a e ls. me qtu i v a ne lt ity ac n -oli o df c -lp t ais o ims p, up ld asor a tita on .isa rsi ansk, te asnd t den m oul tedt iple as fo lsc low le s: rosis (MS).
out of poc am ke ong t m a spouse ximums us reging ardspe lessc ia of lttyhe m ire d he ica alt tion h ps for lan e ul nrcollm erate iv nt e. cG olit old is, w man, ork Joy ers ce w , eerte aal. b( sent 2006 fr)om found wortkh 6. at 5 fe usew of er
Specia Rh lte yu D ma rug toiUti d A liz rth atrion itisand Outcomes: A Review of the Evidence and Future Directions." American Journal of
Conseq Figur uee nt 19 ly, , tLim ine ea -inv r Fiaxe ria dn E t ff cha ectrs Mod acterist el Es ics, b tim ot ah o tes of bser Me ved dic (a et.g ion Adhe ., gende re r)nc ae nd on unob Woserv rker ePdr od (euc .g., tivait y p, ot Peant tie ia nt l s With
(Fronstin, Sepulveda and Roebuck 2013). We generated the proportion of days covered for individuals with MS by
(2012) study, when fewer individuals were in HDHPs and cost-sharing for specialty medications was generally low as
prevalencP eO r Sa =p te oi nof t ofa sb erou vicet; H 0.1 RA=p hee ar lth ce rnt eim in t burshe eme n Unit t arre an d g eSt ma entt; e s H. S A = Sp hee alc thia slt avy in m gs e acd cioc ua nt t.ions usually require special handling and/or
Notes: *** p<0.01, ** p<0.05, *p<0.10
N *o *te * p s: <* 0* .0 *1 p ; < *0 *. 0 p1 <,0 * .* 0 5 p; < * 0 . p 0< 50 , .* 1p 0< .0.10 HMO/EPO PPO/POS Health Plan Statistical
Ch Pso ar rilA a so s gie n s (Co yemo ars)rbidity Index 0.7 46.38 0, .6 279 38.3 0.7 3.241.1 0.6 42.63.20.6 44.9 ***
PatientB s w ack eg re ro cc und ylc alss os ................................ ip fied orin e as having the illne ................................ ss if 39% associated prim cha l................................ orry o q o uri nseconda e ry diagnosi ................................ s codes were recor................. ded at least 5
days. With respect to the number of specialty medications filled among those who had filled at least one
specialty A n m ye sd pic ea cita io lty ns d w ru eg r e f illa lsrgely insensitive to cost sh -a 0r .0 ing 05among indiv -2.idua 455*ls with RA a 0nd .018 MS, with pric 10 e. 0 e7 la 7sticities
Ma comp na a g re e d d D C to M a A rto e R D dMult 22 sa =y d, i se no. iple ase- m 3 (Ma Sc odle ifyriosis nrg c h 20 an ti ................................ rh16 eum )a : ti18 c dr8 u- g197. s. ........................................................................................... 20
c confounde ustom cod r)ing wetrhe e edlim rug in-a spe ted c. ifi c A d siangle ys' su -yp ep ar ly d for um e m ay c h p (for r e20 sc14 rip)t ion d also reug ntefil re l-- d inc the luding mod eal to c ll pha ont rmra ol cyfor and unde merd ly ic ing al secular
storage, Ma os t delhe s iny cl ua dr ee o th oft ere co n inj variae tec st , e bu d t , arinf 36% e sus uppe rd es, seor d f o inh r bra ev le ity d.. They can be covered by the pharmacy benefit, the medical
40% Total (n=96,691) (n=12,231) (n=70,329) HRA (n=9,859) (n=4,272) Significance
I n this Mu lIti ss pue le S c B lr eie rofs,i sthe Employee B enefit Research Institut 3e ,3 9 (1 EBRI) examines t 5.3 he impact of pla1 n ty 1.2 pe on use of **specialty
<18 5% 10% 6% 7% 1%
doxycycline cyclosporine
Rheumatoid Arthritis 34% 32% 34% 33% 31% ***
once in inp pSrta e ati sc tsie tirn cip at lt sion, or ign itfw icw aic n ee c ef in ound of dout iffe rm p ea nixe c te ie sd nt in r me e set su antlt sings o s ac. roThe ss p n d lr ae n iff ty w pe a ers u e sno nt ing d K im ra ut sp e ka a slc . W tC aon a llindid s e w qor ua alk t ity e e -rI o nt fa -p be osen r pna ulatti te io ona e nis s rm al C n ka lte a m sss t ong dific eno a spouse te tio d an o s fof D ls w lowis sit : eha ses
of -0.07Co for n dMS itioa nnd al n-u 0.21 mbe for r o fRA sp. e cI in o altyt he dru r g w for illd ss, if cost 0 .0 sh 02 aring double-d 0, .1us 99e of specialt0 y. 0 m 02 edications w-ould 2.90 0fall by 7
32%
HMO=health maintenance organization; EPO=exclusive provider organization; PPO= preferred provider organization;
trends in outcomes. Finally, given the high proportion of zeros in the specialty drug use variable, we specified two
insurance adjudicated claims. We subsequently re-estimated the multivariate models of worker productivity, and
plan, Soor ur cb eot : Eh. mp loyee Benefit Research Institute estimates based on administrative enrollment and claims data.
12 Purpose of this Paper ................................................................................................................................... 8
Rheumatoid Arthritis
m edications **1 *8 . p -Thi 2 <0 5.01 s p ; **a pp