Cost-Motivated Treatment Changes in Commercial Claims: Implications for Non-Medical Switching

Health benefits designs in both private and public health insurance programs include mechanisms to control the costs of care, resulting in many health care choices being made with a focus on financial concerns that could outweigh clinical factors. This can particularly be true for interventions involving prescription drugs and biologics. In some cases, choice of prescription therapy may be driven by patient cost sharing and affordability controls. In others, plan benefit design may result in “non-medical switching” between prescription therapies. Whether by conscious design or inadvertent result, patients with significant chronic disease whose condition has been stabilized on a particular drug regimen can lose access to continued coverage for their therapy, forcing physicians to switch the patient’s prescription to an alternative drug.

Whatever the mechanism by which non-medical switching is induced, it raises significant clinical issues for patients who find themselves being switched from a therapy known to be working toward a therapy of presently unknown efficacy. The immediate consequence of cost-motivated treatment changes is the potential for treatment failure. In the intermediate and longer term, the consequences of remediating that treatment failure may be substantial, potentially offsetting some or all of the immediate “savings” that accrue because of the switch in therapies.

In a prior study for the Institute for Patient Access (IfPA), The Moran Company investigated whether the effect of non-

medical switching on Medicare spending could be demonstrated by analyses of Medicare claims data. In that study, we found that switching between Part B drugs occurred at different levels in patients being treated for various conditions. We further found that for rheumatoid arthritis patients, total non-drug Medicare Part B spending increased materially for patients with one or more switches to less expensive medications.

IfPA asked us to extend our prior analysis of switching issues in Medicare by examining these issues in commercial claims data. Using a sample of Truven’s MarketScan® Commercial Claims and Encounters and Medicare Supplemental database for chronic conditions of interest, we analyzed the prevalence of switching for various populations and examined the drug and nondrug costs of studied patient populations before and after identified switching events. Since it is not possible to track patients across plans, our claims come from patients who maintained consistent coverage for at least three of the five years in claims data. Thus, our analysis probably understates the level of switching in the populations being studied.

As we present in the paper that follows, we again found evidence to support our hypothesis that cost-motivated treatment changes can lead to higher costs for patients with various conditions, in this case for patients with Crohn’s disease, osteoarthritis, multiple sclerosis, rheumatoid arthritis, and psoriasis.

Read the Study


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