For the second year in a row, the pandemic has resulted in fewer plan members making claims for prescription drugs—yet the average eligible amounts per insured and per claim continue to increase year after year, pandemic notwithstanding.
“The growing mix of higher-cost specialty drugs as well as more widespread utilization of drugs for diabetes and mental health are propelling costs upward,” noted Shawn O’Brien, Principal, Data Enablement and HBM Product, TELUS Health, who presented the Data Trends and National Benchmarks Retrospective 2021 at TELUS Health’s annual conference on May 10.
As well, the lower number of insureds making claims in 2020 and 2021 is likely a temporary reprieve. “Delayed diagnoses and treatments for serious conditions such as cancer will likely have an impact,” said O’Brien. “Clearing the backlog may lead to increased claimants in 2022 and beyond. And studies have begun to show that patients are presenting with more advanced disease.”
This year’s presentation included new data and analysis on high-cost claimants, whose annual total eligible amount for all submitted claims exceeded $10,000. These high-cost claimants, who represent just 2% of all claimants, accounted for 40% of the total eligible amount for TELUS Health’s book of business. This share is up from 33% five years ago.
“Even more compelling is the fact that 0.03% of claimants accounted for close to 6% of the total eligible amount by the end of 2021. These claimants are taking ultra high-cost drugs (>$100K) for very rare diseases, which can cost hundreds of thousands of dollars annually,” said O’Brien.
He added that one in five of these ultra-high-cost claimants were below $10,000 in 2020. “In just one year, likely as a result of the progression of disease, the eligible amounts for their treatments increased more than 10-fold.”
While the medications themselves are the main driver of the high costs, “comorbidities are also a factor,” noted O’Brien. “High-cost and ultra-high-cost claimants live with an average of six health conditions.”
On the cost-savings front, the potential for biosimilar biologics is promising based on evidence so far from B.C. Private drug plans in that province saw biosimilar drugs’ share of the eligible amount for biologics (for which biosimilars are available) soar from 7% in January 2019 to 65% by the end of 2021. In contrast, the comparable share for biosimilars in the rest of Canada is 12%.
In terms of savings from biosimilars in B.C., by the end of 2021 the relative eligible amount per claimant for a biologic was 66% of what it was in January 2019. Meanwhile, the relative eligible amount per claimant in the rest of Canada increased by 10% during that same time period.
Additional points of interest include:
- The average monthly eligible amount per claim increased by 8.9% in 2021.
- Specialty drugs’ share of the eligible amount reached 34% in 2021 for 1.4% of claimants. TELUS Health forecasts specialty drugs could represent almost half of the average eligible amount per certificate by 2026.
- The top five therapeutic areas based on eligible amount continue to be rheumatoid arthritis, diabetes, skin disorders, depression and asthma. Depression overtook asthma to assume fourth position, and diabetes appears to be closing the gap on rheumatoid arthritis, which has long held the number-one position.
- For the top categories by number of claimants, drugs to treat depression climbed from fifth to third position for claimants aged 20 to 59.
- Eighty-eight per cent of certificate holders had plans with both mandatory and regular generic substitution policies, unchanged from 2020 (88%).
- Twenty-two per cent of certificate holders had plans with an annual maximum, compared to 18% in 2017. The annual maximum amount is most often between $2,500 and $5,000.