Everyone is curious about what health utilization and spending by the exchange enrollees will look like and how that will compare to pricing. We have gotten some answers to that question just watching insurer behavior, as some low-priced plans have dropped out for 2015 and others have raised prices significantly. The fastest information is generally from drug use, which is captured electronically in real-time for virtually 100% of prescriptions. Express Scripts recently issued a follow-on report describing the drug use of exchange enrollees in its data base. (ES Report) Nearly 50% of enrollees in an exchange plan used their pharmacy benefit, compared to 55% in other private plans. They had a generic drug use rate of 87%, which is higher than the 82% rate for other privately-insured persons. In general, exchange members are covered by plans with relatively high cost-sharing, which provides an incentive for selecting cost-effective compounds. Those persons who signed up late in the open enrollment period tended to be younger, poorer and use less medications than the exchange population overall. They were also healthier, with lower rates of common chronic diseases. Exchange enrollees were using a lot of specialty drugs, probably the effect of adverse selection, whereby persons with more serious illnesses were more likely to get insurance to cover the costs of treating those diseases. Specialty drugs, which are very expensive, were 59% more likely to be taken by exchange members than the traditional insured population. Almost 60% of all prescriptions filled by this group were for HIV. This suggests that managing specialty drug costs may be particularly important for insurers offering exchange plans. And the general trend of higher drug use in these categories not only suggests higher overall drug spending, but there is usually significant other health spending associated with these diseases. If exchange enrollment continues to lag and be a small percent of the uninsured, or, as is possible, if some of the healthier exchange enrollees decide to drop out, it is likely that premiums for exchange plans will begin to increase rapidly.
