Cambia Health Solutions, Portland, Oregon.
Prime Therapeutics, Eagan, Minnesota.
J Manag Care Spec Pharm. 2020 Jun;26(6):766-774. doi: 10.18553/jmcp.2020.19411. Epub 2020 Mar 10.
Pharmacy benefit can be purchased as part of an integrated medical and pharmacy health package-a carve-in model-or purchased separately and administered by an external pharmacy benefit manager-a carve-out model. Limited peer-reviewed information is available assessing differences in use and medical costs among carve-in versus carve-out populations.
To compare total medical costs per member per year (PMPY) and utilization between commercially self-insured members receiving carve-in to those receiving carve-out pharmacy benefits overall and by 7 chronic condition subgroups.
This study used deidentified data of members continuously enrolled in Cambia Health Solutions self-insured Blue plans without benefit changes from 2017 through 2018. Cambia covers 1.6 million members in Oregon, Washington, Idaho, and Utah. The medical cost PMPY comparison was performed using multivariable general linear regression with gamma distribution adjusting for age, gender, state, insured group size, case or disease management enrollment, 7 chronic diseases, risk score (illness severity proxy), and plan paid to total paid ratio (benefit richness proxy). Medical event objectives were assessed using multivariable logistic regression comparing odds of hospitalization and emergency department (ED) visit adjusting for the same covariates. Sensitivity analyses repeated the medical cost PMPY comparison excluding high-cost members, greater than $250,000 annually. Chronic condition subgroup analyses were performed using the same methods separately for members having asthma, coronary artery disease, chronic obstructive pulmonary disease, heart failure, diabetes mellitus, depression, and rheumatoid arthritis.
There were 205,835 carve-in and 125,555 carve-out members meeting study criteria. Average age (SD) was 34.2 years (18.6) and risk score (SD) 1.1 (2.3) for carve-in versus 35.2 years (19.3) and 1.1 (2.4), respectively, for carve-out. Members with carve-in benefits had lower medical costs after adjustment (4%, < 0.001), translating into an average $148 lower medical cost PMPY ($3,749 carve-out vs. $3,601 carve-in annualized). After adjustment, the carve-in group had an estimated 15% ( < 0.001) lower hospitalization odds and 7% ( < 0.001) lower ED visit odds. Of 7 chronic conditions, significantly lower costs (12%-17% lower), odds of hospitalization (22%-36% lower), and odds of ED visit (16%-20% lower) were found among members with carve-in benefits for 5 conditions (all < 0.05).
These findings suggest that integrated, carve-in pharmacy and medical benefits are associated with lower medical costs, fewer hospitalizations, and fewer ED visits. This study focused on associations, and defining causation was not in scope. Possible reasons for these findings include plan access to both medical and pharmacy data and data-informed care management and coordination. Future research should include investigation of integrated data use and its effect across the spectrum of integrated health plan offerings, provider partnerships, and analytic strategies, as well as inclusion of analyzing pharmacy costs to encompass total cost of care.
This study received no external funding. The study was jointly conducted by employees of Cambia Health Solutions and Prime Therapeutics, a pharmacy benefit manager servicing Cambia Health Solutions. Smith, Lam, Lockwood, and Pegus are employees of Cambia Health Solutions. Qiu and Gleason are employees of Prime Therapeutics.
药品福利可以作为医疗和药品健康套餐的一部分购买——这是一种切块模型，或者单独购买，并由外部药品福利经理管理——这是一种切块模型。有限的同行评议信息可用于评估切块与切块人群在使用和医疗成本方面的差异。
比较接受切块式与切块式药品福利的商业自我保险会员的年度每人医疗总成本（PMPY）和使用情况，以及按 7 种慢性病亚组进行比较。
本研究使用 Cambia Health Solutions 自我保险的 Blue 计划中连续参保成员的匿名数据，从 2017 年到 2018 年期间没有福利变化。Cambia 覆盖了俄勒冈州、华盛顿州、爱达荷州和犹他州的 160 万会员。使用具有伽马分布的多变量广义线性回归，根据年龄、性别、州、参保人数、病例或疾病管理登记、7 种慢性病、风险评分（疾病严重程度代理）和计划支付与总支付比率（福利丰富度代理）进行 PMPY 比较的医疗成本。使用多变量逻辑回归比较住院和急诊（ED）就诊的几率，调整了相同的协变量，以评估医疗事件的目标。敏感性分析排除了每年花费超过 25 万美元的高成本成员，重复了 PMPY 比较的医疗成本。使用相同的方法分别对患有哮喘、冠状动脉疾病、慢性阻塞性肺疾病、心力衰竭、糖尿病、抑郁症和类风湿关节炎的成员进行慢性病亚组分析。
共有 205835 名接受切块式和 125555 名接受切块式福利的成员符合研究标准。平均年龄（标准差）为 34.2 岁（18.6）和风险评分（标准差）为 1.1（2.3），分别为接受切块式和接受切块式的 35.2 岁（19.3）和 1.1（2.4）。接受切块式福利的成员在调整后医疗成本较低（4%，<0.001），平均每年医疗成本 PMPY 降低 148 美元（3749 美元的切块式与 3601 美元的切块式年化）。调整后，切块式组的住院几率估计降低了 15%（<0.001），ED 就诊几率降低了 7%（<0.001）。在 7 种慢性病中，在接受切块式福利的成员中，有 5 种慢性病（所有<0.05）的成本显著降低（12%-17%），住院几率降低（22%-36%），ED 就诊几率降低（16%-20%）。
这些发现表明，综合的、切块式的药品和医疗福利与较低的医疗成本、较少的住院和较少的 ED 就诊有关。本研究侧重于关联，并未确定因果关系。这些发现的可能原因包括计划对医疗和药品数据的访问以及基于数据的护理管理和协调。未来的研究应该包括调查综合数据的使用及其对综合健康计划产品、医疗服务提供商合作关系和分析策略的影响，以及包括分析药品成本以涵盖总成本的护理。
本研究没有外部资金支持。该研究由 Cambia Health Solutions 和 Prime Therapeutics 的员工共同进行，Prime Therapeutics 是为 Cambia Health Solutions 提供服务的药房福利经理。Smith、Lam、Lockwood 和 Pegus 是 Cambia Health Solutions 的员工。Qiu 和 Gleason 是 Prime Therapeutics 的员工。
