Nguyen Jennifer L, Do Duy, Swart Elizabeth C, Lee Tiffany, Peasah Samuel K, Patel Urvashi, Good Chester B
UPMC Health Plan, Center for Value-Based Pharmacy Initiatives, Pittsburgh, PA.
Evernorth Research Institute, St. Louis, MO.
Med Care. 2025 Jan 1;63(1):1-8. doi: 10.1097/MLR.0000000000002045. Epub 2024 Aug 30.
This study sought to identify: (1) the demographic and clinical characteristics of very high-cost users (defined as patients with pharmaceutical expenditures that were equal to or greater than the 99th percentile), (2) whether or not these characteristics changed over time, (3) sociodemographic and clinical correlates of being very high-cost users, (4) the average pharmaceutical costs of very-high cost users, and (5) the therapeutic classes and medications that contributed to these high costs.
There are growing public concerns about rising drug costs, in part due to increased availability, greater effectiveness, and market considerations. There is a concentrated portion of patients that accounts for a disproportionately large portion of pharmaceutical expenditures.
A large serial cross-sectional study was conducted with De-identified, member-level pharmacy claims (n = 65,739,791) from a large, national pharmacy benefits manager from January 1, 2018 to December 31, 2022. The main outcome and measures were 2018-2022 pharmaceutical expenditures; amounts were adjusted for inflation to reflect 2022-dollar values.
Across the study period, the odds of being classified as a very high-cost user were 1.31 times as high for those 45-64 years old compared with those 18-44 years old (reference category); the odds were 1.42 times as high for males compared with females; 1.13 times as high before those identifying as non-Hispanic Black compared with non-Hispanic white; 1.11 times as high for those enrolled in a health care exchange plan compared with a commercial plan. In addition, very high-cost users lived in areas with higher social needs. Human immunodeficiency virus, inflammatory conditions, multiple sclerosis, and cancer accounted for the largest share of costs among this group.
This study identified the unique characteristics of very high-cost pharmaceutical users and identified the top conditions and prescription drugs that drove high pharmaceutical expenditures among this population. These findings are essential to understanding rising pharmaceutical costs in the United States and can help identify the issues and solutions of specific cost drivers within our health care policies.
本研究旨在确定：（1）超高成本使用者（定义为药品支出等于或高于第99百分位数的患者）的人口统计学和临床特征；（2）这些特征是否随时间变化；（3）成为超高成本使用者的社会人口统计学和临床相关因素；（4）超高成本使用者的平均药品成本；以及（5）导致这些高成本的治疗类别和药物。
公众对药品成本上升的担忧日益增加，部分原因是药品可及性提高、疗效增强以及市场因素。有一部分患者集中占据了药品支出中不成比例的很大一部分。
对一家大型全国性药房福利管理机构在2018年1月1日至2022年12月31日期间的去识别化会员级药房报销数据（n = 65,739,791）进行了一项大型系列横断面研究。主要结局和指标为2018 - 2022年的药品支出；金额经通胀调整以反映2022年美元价值。
在整个研究期间，45 - 64岁人群被归类为超高成本使用者的几率是18 - 44岁人群（参照类别）的1.31倍；男性被归类为超高成本使用者的几率是女性的1.42倍；自我认定为非西班牙裔黑人的人群被归类为超高成本使用者的几率是非西班牙裔白人的1.13倍；参加医疗保健交换计划的人群被归类为超高成本使用者的几率是参加商业计划人群的1.11倍。此外，超高成本使用者生活在社会需求较高的地区。人类免疫缺陷病毒、炎症性疾病、多发性硬化症和癌症在该群体的成本中占比最大。
本研究确定了超高成本药品使用者的独特特征，并确定了导致该人群药品支出高昂的主要疾病和处方药。这些发现对于理解美国药品成本上升至关重要，并且有助于在我们的医疗保健政策中识别特定成本驱动因素的问题及解决方案。
