医疗保险中保险公司和药房福利管理人员拥有的药房的使用和指导。

IF 9.5 Q1 HEALTH CARE SCIENCES & SERVICES JAMA Health Forum Pub Date : 2025-01-03 DOI:10.1001/jamahealthforum.2024.4874
Pragya Kakani, Swayami Navangul, Christie Lee Luo, Kayla N Tormohlen, Genevieve P Kanter, Mary Beth Landrum, Nancy L Keating, Amelia M Bond
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引用次数: 0

摘要

重要性:由综合保险公司和药品福利管理公司(PBMs)或保险公司-PBMs所拥有的药店的流行受到越来越多的监管关注。然而,人们对这些药店在医疗保险中的作用知之甚少,其中药房网络保护可能会影响市场动态。目的:评估保险公司-药品福利管理自营药店的流行程度,以及保险公司-药品福利管理引导患者到他们在医疗保险中拥有的药店的程度。设计、设置和参与者:本横断面研究使用了医疗保险D部分处方填写的索赔数据,随机抽取20%的美国受益人样本,从2021年1月1日至12月31日登记。数据分析时间为2024年3月至11月。暴露:处方填充。主要结果和措施:主要结果是按药房类型(专业和非专业)和药物类别划分的保险公司- pbm拥有的药房所占的支出份额。对于索赔量排名前100位的专业和非专业分子,4家主要保险公司-药品福利管理公司(信诺、CVS、Humana和联合健康集团)确定了2个数量:指数公司旗下药房填写的保险公司索赔份额,以及指数公司旗下药房填写的其他公司保险公司索赔份额。评估这些数量之间的差异,以评估保险公司-药品福利管理公司引导患者到自己的药店的程度。结果:在10例 455 患者中,726例(女性54.8%;平均[SD]年龄71.8[10.7]岁),34.1%的所有药房和37.1%的专业药房支出发生在信诺、CVS、Humana或联合健康集团的药房。在特殊分子中,市场份额因药物类别而异(抗病毒药物:18.5%;抗精神病药:29.5%;癌症:32.5%;改善疾病的抗风湿药物占41.1%;多发性硬化:64.8%;肺动脉高压和特发性肺纤维化:89.7%)。在分子-公司组合中,保险公司拥有的药品福利管理药房的索赔比例分别比没有指导专业和非专业类别的预期高19.8 (95% CI, 18.0-21.6)和13.9 (95% CI, 13.1-14.7)个百分点。结论和相关性:这项横断面研究发现,保险公司- pbm公司代表了医疗保险D部分市场的重要组成部分,特别是对于某些药物类别,并且保险公司- pbm公司将患者引导到他们自己的药房,尽管在医疗保险中有某些药房网络保护。这些发现强调需要了解保险公司- pbm和药房整合对医疗保险患者药物获取和成本的影响。
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Use of and Steering to Pharmacies Owned by Insurers and Pharmacy Benefit Managers in Medicare.

Importance: The prevalence of pharmacies owned by integrated insurers and pharmacy benefit managers (PBMs), or insurer-PBMs, is of growing regulatory concern. However, little is known about the role of these pharmacies in Medicare, in which pharmacy network protections may influence market dynamics.

Objective: To evaluate the prevalence of insurer-PBM-owned pharmacies and the extent to which insurer-PBMs steer patients to pharmacies they own in Medicare.

Design, setting, and participants: This cross-sectional study used Medicare Part D claims data on prescription fills for a 20% random sample of US beneficiaries enrolled from January 1 through December 31, 2021. Data were analyzed from March to November 2024.

Exposures: Prescription fills.

Main outcomes and measures: The main outcome was the share of spending filled by insurer-PBM-owned pharmacies overall, by pharmacy type (specialty and nonspecialty), and by drug class. For the top 100 specialty and nonspecialty molecules by claim volume, 2 quantities were identified for 4 major insurer-PBMs (Cigna, CVS, Humana, and UnitedHealth Group): share of the index firm's insurer claims filled by its owned pharmacies and share of other firms' insurer claims filled by the index firm's owned pharmacies. Differences between these quantities were assessed to evaluate the degree to which insurer-PBMs steered patients to their own pharmacies.

Results: Among 10 455 726 patients (54.8% women; mean [SD] age, 71.8 [10.7] years), 34.1% of all pharmacy and 37.1% of specialty pharmacy spending occurred through Cigna, CVS, Humana, or UnitedHealth Group pharmacies. Among specialty molecules, market shares varied by drug class (antivirals: 18.5%; antipsychotics: 29.5%; cancer: 32.5%; disease-modifying antirheumatic drugs: 41.1%; multiple sclerosis: 64.8%; pulmonary arterial hypertension and idiopathic pulmonary fibrosis: 89.7%). Across molecule-firm combinations, a 19.8 (95% CI, 18.0-21.6)-percentage point and 13.9 (95% CI, 13.1-14.7)-percentage point greater share of claims were filled at insurer-PBM-owned pharmacies than would be expected without steering for specialty and nonspecialty categories, respectively.

Conclusions and relevance: This cross-sectional study found that insurer-PBM firms represented an important portion of the Medicare Part D market, especially for certain drug classes, and that insurer-PBM firms steered patients to their own pharmacies, despite certain pharmacy network protections in Medicare. These findings underscore the need to understand the impacts of insurer-PBM and pharmacy integration on medication access and costs for Medicare patients.

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期刊介绍: JAMA Health Forum is an international, peer-reviewed, online, open access journal that addresses health policy and strategies affecting medicine, health, and health care. The journal publishes original research, evidence-based reports, and opinion about national and global health policy. It covers innovative approaches to health care delivery and health care economics, access, quality, safety, equity, and reform. In addition to publishing articles, JAMA Health Forum also features commentary from health policy leaders on the JAMA Forum. It covers news briefs on major reports released by government agencies, foundations, health policy think tanks, and other policy-focused organizations. JAMA Health Forum is a member of the JAMA Network, which is a consortium of peer-reviewed, general medical and specialty publications. The journal presents curated health policy content from across the JAMA Network, including journals such as JAMA and JAMA Internal Medicine.
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