[PHP25] Impact Of US Health Exchanges (Hix) On The Pharmaceutical Industry

[PHP25] Impact Of US Health Exchanges (Hix) On The Pharmaceutical Industry

2016 Value in Health

Young, K. E. | Soussi, I. | Kornfeld, A. | Toumi, M. | Volume: 19, Issue: 7, Pages: A443,

OBJECTIVES: This study intends to provide an overview of the new US insurance health exchanges and its impact on the pharmaceutical industry. METHODS: A literature review was conducted from the Centers of Medicare and Medicaid Services website, Managed Care Organisation websites, Pubmed, and available grey literature. RESULTS: In the US, health insurance marketplaces, also called health exchanges (HIX), are organizations set up to facilitate the provision and purchase of government-regulated and standardized health care plans in each state in accordance to the Patient Protection and Affordable Care Act (ACA). All HIX were certified and operational since January 1, 2014 and has ushered approximately 280 formularies by over 330 insurers, both public and private. Open enrolment for 2016 coverage period ended with about 12.7 million individuals and is projected to grow to 29 million by 2019. Enrolees are not as healthy as expected. Moroever, 91% of current enrolees chose lower cost options bronze and silver plans rather than platinum and gold which have higher cost-sharing for prescription drugs, and more than 8 in 10 individuals qualified for financial assistance. Data reflects a price-sensitive cohort and lower cost medication choices and utilisation. Insurers will continuously track enrolment and utilization patterns and modify breadth and depth of pharmaceutical coverage in their plans. CONCLUSIONS: Health exchanges are still in flux but will continue to grow and become a significant component of managed care, pharma’s most influential sales channel. It will create opportunities for pharma as it will cover previously uninsured population. However, with the competition and transparency of the framework, and the cost-sensitivity of both the insured and payer, greater cost control, pricing negotiations, rebates, and cost-sharing requirements are expected. Pharma needs to monitor how the health plans evolve and what payers need as the enrolment numbers grow and new drug utilization patterns emerge.

https://www.doi.org/10.1016/j.jval.2016.09.563