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Pharmacy Use and Costs in Employer-Provided Health Plans Insights for TRICARE Benefit Design from the Private Sector Geoffrey Joyce Jesse D. Malkin Jennifer Pace Approved for public release; distribution unlimited Prepared for the Office of the Secretary of Defense The RAND Corporation is a nonprofit research organization providing objective analysis and effective solutions that address the challenges facing the public and private sectors around the world. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. R ® is a registered trademark. © Copyright 2005 RAND Corporation All rights reserved. No part of this book may be reproduced in any form by any electronic or mechanical means (including photocopying, recording, or information storage and retrieval) without permission in writing from RAND. Published 2005 by the RAND Corporation 1776 Main Street, P.O. Box 2138, Santa Monica, CA 90407-2138 1200 South Hayes Street, Arlington, VA 22202-5050 201 North Craig Street, Suite 202, Pittsburgh, PA 15213-1516 RAND URL: http://www.rand.org/ To order RAND documents or to obtain additional information, contact Distribution Services: Telephone: (310) 451-7002; Fax: (310) 451-6915; Email: order@rand.org Library of Congress Cataloging-in-Publication Data Joyce, Geoffrey. Pharmacy use and costs in employer-provided health plans : insights for TRICARE benefit design from the private sector / Geoffrey Joyce, Jesse D. Malkin, Jennifer Pace. p. cm. Includes bibliographical references. “MG-154.” ISBN 0-8330-3549-5 (pbk. : alk. paper) 1. Pharmacy, Military—United States. 2. Insurance, Pharmaceutical services— United States. 3. United States—Armed Forces—Medical care. 4. Veterans—Medical care—United States—Periodicals. 5. Retired military personnel—Medical care— United States. 6. Military dependents—Medical care—United States. 7. Drugs— Prices—United States. I. Malkin, Jesse D., 1969- II. Pace, Jennifer. III. Title. UH423.J68 2004 368.38'24—dc22 2004001289 The research described in this report was sponsored by the Office of the Secretary of Defense (OSD). The research was conducted jointly by the Center for Military Health Policy Research, a RAND Health program, and the Forces and Resources Policy Center, a RAND National Defense Research Institute (NDRI) program. NDRI is a federally funded research and development center supported by the OSD, the Joint Staff, the unified commands, and the defense agencies under Contract DASW01-C-01-0004. iii Preface Section 701 of the National Defense Authorization Act for Fiscal Year 2000 requires the Secretary of Defense to establish an effective, effi- cient, and integrated pharmacy benefits program. As part of a pro- gram redesign effort, which will result in the establishment of a Uni- form Formulary, the Department of Defense (DoD) is considering moving from a two-tiered copayment system to a three-tiered copay- ment system. To assist the DoD in assessing the potential implica- tions of this policy change, the RAND Corporation used an existing data resource from the civilian sector to examine how beneficiaries with private drug coverage responded to similar changes in pharmacy benefits. The findings from this analysis can inform the DoD of the potential costs and benefits of adopting the proposed Uniform For- mulary (UF). This report covers research that was conducted from March through July 2003 on one of two phases of a research project on the proposed UF. A second report, scheduled for publication in 2004, will describe TRICARE Senior Pharmacy utilization during Fiscal Year 2002 and will examine determinants of the dispensing location, which influences pharmacy costs. The study findings reported here should be of interest to TRICARE Management Activity personnel and others with an interest in pharmacy benefit design. This work was sponsored by the Assistant Secretary of Defense for Health Affairs. The project was carried out jointly by RAND Health’s Center for Military Health Policy Research and the Forces and Resources Policy Center of the National Defense Research Insti- iv Pharmacy Use and Costs in Employer-Provided Health Plans tute. The latter is a federally funded research and development center sponsored by the Office of the Secretary of Defense, the Joint Staff, the unified commands and the defense agencies. Questions regarding this report should be directed to the princi- pal investigators, Geoffrey Joyce (gjoyce@rand.org) and Jesse Malkin (malkin@rand.org). Susan Everingham (susane@rand.org) is the di- rector of RAND’s Forces and Resources Policy Center and C. Ross Anthony (rossa@rand.org) is director of the RAND Center for Mili- tary Health Policy Research. v The RAND Corporation Quality Assurance Process Peer review is an integral part of all RAND research projects. Prior to publication, this document, as with all documents in the RAND monograph series, was subject to a quality assurance process to ensure that the research meets several standards, including the following: The problem is well formulated; the research approach is well de- signed and well executed; the data and assumptions are sound; the findings are useful and advance knowledge; the implications and rec- ommendations follow logically from the findings and are explained thoroughly; the documentation is accurate, understandable, cogent, and temperate in tone; the research demonstrates understanding of related previous studies; and the research is relevant, objective, inde- pendent, and balanced. Peer review is conducted by research profes- sionals who were not members of the project team. RAND routinely reviews and refines its quality assurance pro- cess and also conducts periodic external and internal reviews of the quality of its body of work. For additional details regarding the RAND quality assurance process, visit http://www.rand.org/ standards/. vii Contents Preface iii Figures ix Tables xi Summary xiii Acknowledgments xxi Acronyms xxiii CHAPTER ONE Introduction 1 CHAPTER TWO Background 3 The TRICARE Senior Pharmacy Program 4 The DoD Formulary System 6 Prices Paid by DoD for Outpatient Pharmacy Items 8 Pharmacy Costs and Use in the Private Sector 9 Summary 10 CHAPTER THREE Data Sources and Methods 13 Data Sources 13 Study Sample 14 Data Cleaning 16 Dependent and Explanatory Variables 16 Dependent Variables 16 Explanatory Variables 17 viii Pharmacy Use and Costs in Employer-Provided Health Plans Statistical Techniques 19 Model Specifications 21 Class-Level Analyses 22 Drug-Level Analyses 23 CHAPTER FOUR Analysis Results 25 Descriptive Statistics 25 How Does Civilian Population Pharmacy Use Compare with Use by TRICARE Non–Active-Duty Beneficiaries? 26 How Do Pharmacy Costs and Use Differ by Type of Drug Benefit? 28 Multivariate Analyses 31 Aggregate Analyses 31 Class-Level Analyses 35 Drug-Level Analyses 36 Summary 38 CHAPTER FIVE Conclusions and Policy Implications 41 Generalizability 41 Study Limitations 44 Policy Implications 46 Summary 48 APPENDICES A. Relationship Between Pharmacy Costs and Age 51 B. Results of Multivariate Regressions: Aggregate Analyses 55 C. Results of Multivariate Regressions: Classs-Level Analyses 69 Bibliography 77 [...]... (acting in the interest of their patients) an incentive to prescribe lower-tier, less-costly options To assist the DoD in assessing the potential implications of this policy change, RAND used an existing data resource to examine how beneficiaries with private drug xiii xiv Pharmacy Use and Costs in Employer-Provided Health Plans coverage responded to similar changes in pharmacy benefits The findings from. .. Included in Multivariate Models of Pharmacy Costs and Use 19 Framework of Difference -in- Differences Methodology 19 Model Specifications 22 Mean Copayments by Plan Type, 1999 and 2000 26 Pharmacy Use Among 4 5- to 64-Year-Olds in TRICARE and Private- Sector Plans 27 Average Pharmacy Spending and Use per Member, per Year, 1999 28 Average Pharmacy Costs and Use by Plan Type and. .. not included in outpatient pharmacy databases 3 4 Pharmacy Use and Costs in Employer-Provided Health Plans growth in pharmacy spending within DoD in the late 1990s was similar to that in the United States as a whole Since FY 2000–FY 2001 however, military pharmacy spending has grown much more rapidly than has pharmacy spending by the nation as a whole (see Table 2.1) The acceleration in DoD pharmacy costs. .. drugs and mail-order 10 Pharmacy Use and Costs in Employer-Provided Health Plans pharmacies (Thomas et al., 2002) Another study of private plans found that tiered copayments were associated with a 6- to 13percentage-point increase in the market share of preferred brands (Rector et al., 2003) Although the rise of multi-tier cost sharing has been the most dramatic change in pharmacy benefit design in recent... Pharmacy Use and Costs in Employer-Provided Health Plans • Beneficiary expenditures grew more rapidly in three-tier plans, both new and fixed, than in fixed two-tier plans Copayment outlays by enrollees increased $7 per member per year during the first year in fixed two-tier plans, $27 per member per year in fixed three-tier plans, and $38 per member per year in new three-tier plans, although the differences... Costs in Employer-Provided Health Plans management and benefit consulting services to employers, health plans, pharmaceutical manufacturers, and others The aim of the study was to enable DoD to predict how moving from a two-tier pharmacy benefit structure to a three-tier structure would affect medication use and costs in aggregate (for all medications), for selected high-cost therapeutic drug classes, and. .. presented in this report, can inform the DoD of the potential costs and benefits of adopting the proposed Uniform Formulary Approach To predict the effects on cost and utilization of changing the current two-tiered DoD formulary to a three-tiered one, we performed a quantitative analysis of pharmacy claims from a group of privatesector health plans that instituted a similar change in coverage The purpose... copayment for name-brand drugs than for generics However, the majority of employer-sponsored pharmacy benefit plans now include at least three copayment levels These plans typically reserve the first tier for generics, the middle tier for preferred (on-formulary) brands, and the third tier for non-preferred (offformulary) brands A small but growing number of plans now include a fourth tier for “lifestyle”... (six plans that remained two-tier and seven that had become three-tier plans before the start of our analysis period) We included only two- and three-tier plans because they correspond to the current Summary xv TRICARE drug benefit structure and the proposed copayment structure under the Uniform Formulary, respectively Our analysis assessed the effects of the benefit design (two-tier versus three-tier)... resembles that of the private- sector civilian plans we analyzed, the cost savings will be substantial A 15-percentage-point reduction in the rate of growth in DoD spending, for example, would generate savings of nearly $200 million in the TRICARE Senior Pharmacy (TSRx) program in the first year However, many factors affect the applica- Summary xvii bility of these results to the TRICARE program; these factors . to ensure high standards for research quality and objectivity. Pharmacy Use and Costs in Employer-Provided Health Plans Insights for TRICARE Benefit Design from the Private Sector Geoffrey. Geoffrey. Pharmacy use and costs in employer-provided health plans : insights for TRICARE benefit design from the private sector / Geoffrey Joyce, Jesse D. Malkin, Jennifer Pace. p. cm. Includes bibliographical. responded to similar changes in pharmacy benefits. The findings from this analysis can inform the DoD of the potential costs and benefits of adopting the proposed Uniform For- mulary (UF). This report