The prescription drug trend is an important metric

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1 Generational Impact on Prescription Drug Trend: Part 1 Drug Trends Anna A. Theodorou, RPh, MBA John A. Szychowski, AAS, BS Julie Slezak, MS Steven M. Fox, CPA CVS Caremark The prescription drug trend is an important metric that is affected by drug mix, price, and utilization. The single greatest influence on drug mix and utilization is member age demographics. Because the age of a given population is not something that can be changed to improve the trend, it is important to understand the utilization patterns across age groups. Each generation has an impact on trend because of differing disease prevalences, underlying health, and drug mix. Attitudes toward health, the healthcare industry, and advertising also can affect how and which prescription medications are utilized. The overall drug trend can be broken down by each generation s contribution to the overall trend within our population. There are more people over the age of 83 years than ever before. In addition, by size alone, the most influential peer group of our time is the Baby Boomers, the generation born after World War II through Because older members use more medications, the greater the number of older members, the greater the drug trend will be. Because older members tend to use more prescription drugs than younger members, plans that include a greater concentration of older members generally experience higher levels of drug spending and increases in year-over-year utilization trends. Conversely, a greater number of younger members will result in a lower drug trend. Our population consists of 6 generations. (See the Sidebar for more details.) From the oldest to the youngest, they are as follows: GI generation (born ). Silent generation (born ). Baby Boomer generation (born ). Generation X (born ). Generation Y (born ). Generation Z (born 1991-present). Sidebar. Generations (Birth Years) GI ( ) Assertive and self-reliant Strong civic responsibility Limited access to medications Silent ( ) Willing to compromise, conservative Limited access to medications growing up Physician-centric Baby Boomer ( ) Activist and idealistic More prescription medications available and utilized Individual or patient-centric Generation X ( ) Sophisticated at an early age Early exposure to and use of prescription drugs Individual or patient-centric Generation Y ( ) Usually children of Baby Boomers and people of early Generation X Greater exposure to and use of medications Childhood obesity and chronic disease Generation Z (1991-present) Greater exposure to and use of medications Childhood obesity and chronic disease Source: CVS Caremark Generational Trend Cohort, by GPI-4, YTD December 2008, CVS Caremark Industry Analytics, May VOL. 1, NO. 2 The American Journal of Pharmacy Benefits 111

2 n Theodorou Szychowski Slezak Fox This 2-part article provides an overview of the generational impact on trend among the utilizing members in CVS Caremark s reportable database. Part 1 focuses on important therapeutic classes for all generations. METHODS This was a retrospective study of million prescription claims in a computerized database. The study population was 25.9 million members across a multitude of funded benefit prescription plans administered by CVS Caremark. The plan sponsors included Medicaid, national and local employers, health plans, managed care organizations, insurance companies, unions, and government agencies located throughout the United States with prescription claims for all months between January 1, 2007, and December 31, The generational trend was categorized by age bands: 83 and older, 63 to 82 years, 44 to 62 years, 30 to 43 years, 18 to 29 years, and 17 years and younger. The utilization trend was based on average days supply and gross cost (which includes both plan sponsor and member contributions), and is reported on a per member per month (PMPM) basis. Medicare Part D plans were excluded. Note that the trend includes member contribution (gross trend) and specialty drugs. The plan sponsors had average eligibility changes limited to within ±15% period over period. OVERALL GENERATIONAL TRENDS The calendar year 2008 gross PMPM overall trend, excluding Medicare, was 3.7% and the utilization trend was 0.6% (Table 1). The lowest trend was 2.1% in Generation Z, which represented 26% of the members. Not surprisingly, the highest trend was 14.9% in the GI generation, which includes members age 83 years and older. It is interesting to note that the GI generation had the fewest available medications in their youth and have a high opinion of their physicians and other healthcare providers. Though the overall gross PMPM trend was high at 6% in the 18- to 29-year-olds, Generation Y represented only 14% of the membership and 6% of the cost. The Baby Boomers overall gross trend was 3.1%; this group represented 30% of the trend cohort membership. The study did not include Medicare Part D participants; however, the highest utilization trend was 13.7% in the GI generation, which represented 2% of the membership. The Silent generation comprised 9% of the members in the analysis and had a utilization trend of 2.1% and a gross PMPM trend of 4.7%. More than 45% of the overall gross cost in 2008 was for Baby Boomers medications. The Silent generation was responsible for 24% of the overall gross cost in The gross cost and trend of each generation are affected by the type and quantity of prescription medications utilized. Younger members use fewer chronic medications (eg, statins) and more acute medications (eg, antibiotics). IMPORTANT THERAPEUTIC CLASSES FOR ALL GENERATIONS The top 10 therapeutic classes by gross cost represented more than 32% of the overall spending in The Baby Boomer generation shared many of the same top classes with both Generation X and the Silent generation. Table 2 shows the top therapeutic classes for each of the 6 generations. The most common top 25 therapeutic classes in all generations included proton pump inhibitors, miscellaneous anticonvulsants, sympathomimetics, antidepressants (selective serotonin reuptake inhibitors [SSRIs]), and insulin. All of these classes are common to all generations top 25 class by cost list. Table Drug Trends by Generation Generation (Age Band) Gross PMPM Trend, % Utilization Trend PMPM Days Supply, % Members, % Gross Cost, % GI (83+ y) Silent (63-82 y) Baby Boomer (44-62 y) Generation X (30-43 y) Generation Y (18-29 y) Generation Z (<17 y) All generations PMPM indicates per member per month. Source: CVS Caremark Generational Trend Cohort, by GPI-4, YTD December 2008, CVS Caremark Industry Analytics, May The American Journal of Pharmacy Benefits Summer

3 Generational Impact Table 2. Top Therapeutic Class Rankings by Generation and Gross Cost, 2008 Drug Class All Generations GI Silent Rank Baby Boomer Gen X Gen Y Gen Z Proton pump inhibitors Statins Anticonvulsants, miscellaneous Sympathomimetics Antihypertensive combinations Selective serotonin reuptake inhibitors Serotonin-norepinephrine reuptake inhibitors Insulin Opioid agonists Multiple sclerosis agents Source: CVS Caremark Generational Trend Cohort, by GPI-4, YTD December 2008, CVS Caremark Industry Analytics, May n Proton Pump Inhibitors Proton pump inhibitors were the top-ranked class for the GI generation, Baby Boomers, and Generation X; they were ranked 2nd for the Silent generation and 14th for Generation Z. This class includes Nexium, Prevacid, generic Protonix (pantoprazole), and generic Prilosec (omeprazole). It is interesting to note that the older generations would remember a precursor drug, Tagamet, introduced in 1976 as the first blockbuster ($1 billion in sales) innovative drug. (The Figure, which depicts pharmaceutical industry milestones, provides additional historical context.) 1,2 Generations Y and Z would know H2 blockers such as Zantac and Pepcid as over-the-counter options for heartburn. n Miscellaneous Anticonvulsants The miscellaneous anticonvulsant category was ranked 2nd for Generation X and Generation Y. The market for antiepilepsy drugs is small relative to that of other chronic treatment therapeutic categories. 3 Utilization growth is directly related to the breadth of indications for which many of these products are approved and the extent to which off-label prescribing affects this particular class. Lyrica, for example, is approved for adjunctive use in patients with partial seizures. It also is approved for postherpetic neuralgia, neuropathic pain associated with diabetic peripheral neuropathy, and fibromyalgia (the first drug to be approved for this indication). 4 A 2006 study found that although 21% of overall medication use is off-label, gabapentin (Pfizer s Neurontin and generics) had the highest proportion of off-label prescriptions for a single product (83%); the off-label prescribing rate for the entire class was 46%. 5 The class was ranked 4th among Baby Boomers and 13th among the Silent generation. n Sympathomimetics Sympathomimetics were ranked among the top 10 classes for all generations. These drugs (eg, Advair, Symbicort) are used by about 6 million asthma patients whose symptoms are not well controlled by other drugs, including inhaled corticosteroids. Two other drugs, Serevent Diskus and Foradil, don t contain an inhaled corticosteroid. n Selective Serotonin Reuptake Inhibitors The SSRI class of antidepressants (eg, Prozac and Zoloft, along with their generics) were ranked among the top 25 classes by all generations, with the highest utilization by Generation X and Generation Y. Results published in July 2008 from a study partially funded by AstraZeneca showed that antidepressants that block the action of the serotonin reuptake mechanism appear to raise the risk of upper gastrointestinal bleeding. The increased risk of bleeding was further augmented by the use of nonsteroidal anti-inflammatory drugs or antiplatelet drugs. 6 This risk may be one reason why these antidepressants were not as commonly used by the Silent and GI generations. n Insulin Insulin was ranked 10th among Baby Boomers and the Silent generation and was ranked 15th and 11th for Generation X and Generation Y, respectively. The class continues to be a contributor to gross trend. A 2007 study by the American Diabetes Association estimated that VOL. 1, NO. 2 The American Journal of Pharmacy Benefits 113

4 n Theodorou Szychowski Slezak Fox approximately 17.5 million Americans have been diagnosed with diabetes, and that the number of people diagnosed with diabetes is growing by roughly 1 million per year. This study estimated that $27 billion is spent on care directly to treat diabetes. 7 Results from a recent study conducted by epidemiologists from the National Institutes of Health and the Centers for Disease Control and Prevention showed that nearly 13% of adults age 20 years or older have diabetes, but that 40% of them have not been diagnosed. Researchers noted that diabetes is especially common in the elderly; nearly one third of those age 65 and older have the disease. An additional 30% of adults have prediabetes, a condition marked by elevated blood sugar that is not yet in the Figure. Time Line of Industry Milestones 1906: The FDA was created. 1938: Food, Drug & Cosmetic Act broadened the FDA s authority, instituted safety regulations. The first CVS/pharmacy opened its doors in PCS Health Systems was founded in 1969, creating the PBM industry. 1997: Ban on DTC drug advertising lifted in the US. 2006: Federal Medicare Part D Rx drug benefit went into effect on January 1. GI Generation Silent Generation Baby Boomer Generation Generation X Generation Y Generation Z Aspirin became available without a prescription in Insulin was introduced in Before insulin, diabetes was generally fatal within a few years of its diagnosis. Synthetic cortisone was invented in Tetracycline was invented in Enovid the first oral contraceptive was introduced in 1960; 1.2 million American women were using the pill just 2 years after Enovid s launch. Tagamet the first effective H2 blocker was introduced in It revolutionized the treatment of duodenal/stomach ulcers and other gastrointestinal disorders. First blockbuster ($1-billion sales) drug. Prozac the first SSRI to be approved was introduced in It revolutionized the treatment of depression and other mental disorders. Zyrtec a second-generation prescription antihistamine was approved for over-the-counter sale in late DTC indicates direct-to-consumer; FDA, US Food and Drug Administration; PBM, pharmacy benefit management; SSRI, selective serotonin reuptake inhibitor. Source: References 1 and The American Journal of Pharmacy Benefits Summer

5 Generational Impact diabetes range. Prediabetes, which causes no symptoms, substantially raises the risk of a heart attack or stroke and of developing type 2 diabetes. Type 2 diabetes accounts for up to 95% of all diabetes cases and virtually all cases of undiagnosed diabetes. The study also found that diabetes is rare in persons age 12 to 19 years, but about 16% of these have prediabetes. 8 IMPACT OF ECONOMY ON THE GENERATIONS The 2008 gross drug trend by generations was influenced by member age demographics, drug mix, and change in the economy in the last half of All generations were affected by the economic downturn; however, joblessness was far higher among younger people than for those later in their careers. For workers under age 29 years, the unemployment rate jumped to more than 11% in December 2008, compared with less than 9% in the same period in 2007, according to Labor Department figures. That is far worse than the overall rate of 7.2%, up from 4.9% in the prior year. The loss of jobs or inability to get employment for Generation Y workers (age years) was far worse, approaching 20%. For workers in their 30s and older, the rate was still under 7% and generally declined as workers got older. 9 At the other end of the spectrum, older workers were not staying on the job longer as the economy worsened. The Social Security Administration (SSA) reported a major surge in early retirement claims. Since the current federal fiscal year began October 1, 2008, claims have been running 25% ahead of last year, compared with the 15% increase that had been projected as the post World War II generation reached eligibility for early retirement, according to the SSA. The SSA and other analysts believe that due to immediate financial pressures many of the additional retirees were probably laid-off workers who claimed Social Security benefits early, despite the fact that these benefits would be reduced. 10 For insured workers contemplating early retirement, the choices in health insurance coverage after retirement may be limited. If they retire before they are eligible for Medicare at age 65, they can purchase an individual health insurance policy. But if they do so, they might encounter problems such as prohibitive costs for individual health insurance, especially if premiums are based on the retiree s age and health status. Early retirees may no longer have a funded prescription benefit and have to rely on discount or cash card discount programs. 11 Trends for 2009 will certainly be impacted by the state of the economy. PRESCRIPTION DRUG TRENDS: PART 2 Part 2 of the article will include therapeutic class detail by generation, including a comparison of 2007 and 2008 class ranking, and the PMPM gross and utilization trends for the top 10 therapeutic classes. Author Affiliations: From the Division of Analytics & Outcomes (AAT), CVS Caremark, Scottsdale, AZ; and the Division of Analytics & Outcomes (JAS, JS, SMF), Northbrook, IL. Address correspondence to: Anna A. Theodorou, RPh, MBA, Director, Industry Analytics, CVS Caremark, 9501 E Shea Blvd, Scottsdale, AZ anna.theodorou@caremark.com. REFERENCES 1. Daemmrich A, Bowden ME. A rising drug industry. The top pharmaceuticals that changed the world [special issue]. Chemical & Engineering News. June 20, 2005;83(25). coverstory/83/8325/index.html. Accessed June 3, Bellis M. 20th Century - the technology, science, and inventions. Accessed May 30, Cowen and Company, LLC. Epilepsy. In: Therapeutic Categories Outlook. New York, NY: Cowen & Co LLC; October 2007: McManus B. Pfizer s Lyrica is first drug approved for fibromyalgia. The Pink Sheet Daily. June 21, 2007;19(120, No. 008). 5. Off-label use study prompts disagreement on both problem and solution. The Pink Sheet. May 22, 2006;68(No. 21). 6. Moon MA. SSRIs, SNRIs linked to upper GI bleeding. Health News Daily. July 8, 2008;20(131). 7. American Diabetes Association. Economic costs of diabetes in the US in 2007 [published correction appears in Diabetes Care. 2008;31(6):1271]. Diabetes Care. 2008;31(3): Cowie CC, Rust KF, Ford ES, et al. Full accounting of diabetes and pre-diabetes in the US population in and Diabetes Care. 2009;32(2): Tahmincioglu E. Under 30? Looking for a job? You re not alone. MSNBC.com. January 16, id/ /. Accessed May 22, Dorning M. Early retirement claims increase dramatically. The Los Angeles Times. May 24, nationworld/nation/la-na-retirement may24,0, story. Accessed June 3, Karoly LA, Rogowski J. Effects of Access to Post-Retirement Health Insurance on Retirement Behavior and Insurance Coverage. Research Highlights RAND Health RB Accessed June 3, VOL. 1, NO. 2 The American Journal of Pharmacy Benefits 115

The year 2009 has been one of economic uncertainty,

Recent Trends in Utilization of Antianxiety Medication Drug Trends Anna A. Theodorou, RPh, MBA; Kelly M. Johnson, MBA; Julie Slezak, MS; and John A. Szychowski, BS The year 2009 has been one of economic