Report on drug use and expenditure in the United States (2): cost of self paid medical expenses of patients in the United States

In the first part (report on drug use and expenditure in the United States (middle): the driving force of drug expenditure and growth in the United States), we mainly see that the total amount of drug expenditure in the United States has continued to grow in the past decade Due to preferential measures such as drug price discounts, the growth of net drug expenditure has been slow Patent drugs drive the growth of medical expenses in the United States, while loe saves medical expenses Next, let's look at the change trend of the cost of self paid medicine in the United States, how much medicine each patient needs to pay each year, whether the cost of self paid is related to drug compliance, and whether the preferential measures of drugs reduce the cost of self paid medicine American patients need to pay part of their own medical expenses According to different medical insurance, each type of medical insurance has different characteristics So before we study American medical self financing, let's look at three major types of medical insurance in the United States: Private health insurance (commercial): company or individual insurance, purchased at their own expense Medicare provided by the federal government: commonly known as "red and blue card", the insurance provided by the federal government for retirees (65 years old) or kidney washers In this insurance, the following main discussion is about Medicare Part D, namely the federal government's welfare insurance for the purchase of prescription drugs Medicaid provided by the state government: the federal government will pay the state government to provide medical assistance insurance for the elderly and the disabled with low income, commonly known as white card, most of which have no monthly fee and self payment In the following figure, patients are divided into three categories according to the three main types of medical insurance What are the characteristics of each type of patients' self payment amount of prescription drugs in 2018 and what is the proportion structure of self payment of prescription drugs 1 Overall, of all payment types, 8.8% of patients in the United States paid more than $500 for prescription drugs in 2018, and 1.8% paid more than $1500 for prescription drugs More than half of patients pay less than $50 a year 2 Specifically, Medicaid has the lowest level of self expense, with 90% of patients paying no more than $50 for prescription drugs in a year 3 Secondly, it is in commercial insurance, which is the most popular type of insurance More than half of the patients in commercial insurance pay less than $50 per year, while only 8% pay more than $500, while 1.4% pay more than $1500 The annual deductible of commercial insurance is about $1000 Obviously, most patients are within the deductible Besides, there are some Medicare coupons that can promote the increase of self payment If there is no preferential measures, more commercial insurance patients will not reach the deductible 4 The highest level of Medicare coverage is provided by the federal government for retirees (65 years old) In Medicare Part D (prescription drug insurance), 19.8% of patients pay more than $500 for their own expenses, and 4.7% of patients pay more than $1500 for their annual expenses The average deductible amount of Medicare Part D is 185 US dollars per year The maximum deductible amount in 2018 is 405 US dollars After the deductible amount exceeds the self payment amount, it is 25% of the cost sharing That is to say, you still have to pay a lower proportion of the prescription drug fee, and you can't use coupons Therefore, patients with Medicare Part D have to bear higher costs, which will bring significant obstacles to improve patient compliance The cost, efficacy and side effects of prescription drugs will change the possibility of automatic continuation of prescriptions and affect the compliance of patients In the figure below, we see the relationship between the increase of out of pocket expenses and prescription abandonment from the perspective of patients' own expenses 1 Once the out of pocket cost of patients reaches $50, the abandonment rate of prescriptions for commercial insurance and Medicare patients will rise steadily from 30% When the out of pocket expenses exceed $250, the prescription abandonment rate is as high as about 80% 2 In the case of self expense of $50, the abandonment rates of commercial insurance and Medicare are 31.2% and 27.6% respectively, and the abandonment rates of commercial insurance are slightly higher However, when patients pay more than $75, Medicare's prescription abandonment rate exceeds that of commercial insurance 3 Whether it's commercial insurance or Medicare, the main reason for prescription abandonment is the increase of patients' cost at their own expense Of course, there are many other factors, such as pharmacies, feeling that drugs are not effective or disease awareness, which can affect the abandonment rate of prescriptions In the figure below, we look at the trend of patients' out of pocket expenses for prescription drugs and some preferential measures from the scope of commercial insurance: 1 The total out of pocket expenses for commercial insurance increased from $56 billion in 2014 to $61 billion in 2018, an increase of 9% in five years As mentioned earlier, the cost of generic prescriptions in the United States has declined, as has the cost of some patients 2 With the increase in out of pocket expenses, coupons used by commercial insurance patients reached a record high of $13 billion in 2018, more than double the $6 billion coupons used in 2014 The deductible cost of US $13 billion accounted for 17.6% of patients' out of pocket expenses in 2018, and the offset amount of these preferential measures helped to reduce patients' out of pocket expenses 3 In some commercial insurance claims plans, patients are not allowed or restricted to use coupons, that is, coupons cannot be included in the deductible However, such plans are relatively few and have little impact on the overall statistics In the figure below, we look at the changes of five drug prices from 2014 to 2018 Before that, we first understand the relevant drug price system in the United States: (1) Wholesale acquisition cost (WAC) of brand drugs, which is equivalent to the retail price or catalog price recommended by pharmaceutical manufacturers (2) The average price of branded drugs in drugstores, excluding discounts and other preferential measures, is lower than WAC (3) If the patient's out of pocket cost exceeds the deductible or reaches the upper limit of the insurance, the patient's out of pocket cost will be greatly reduced If the coupon is reused, the out of pocket cost is lower (4) Average price of generic drugstores (5) Cost of generic patients at their own expense (6) Total out of pocket costs including branded drugs and generic drugs 1 In the five years since 2014, the brand drug WAC has increased from $364.92 to $657.08 However, the final out of pocket expenses of these brand drugs are almost the same, all of which are around $30 in five years 2 In 2014, the average pharmacy price of branded drugs ($258.91) was nearly $106 lower than that of WAC ($364.92) The final out of pocket cost of branded patients ($29.98) was $336 lower than WAC ($364.92) In 2018, the difference between WAC and drugstore price increased to $229, and the difference between WAC and patient's final expense increased to $626 It can be seen that although the price of brand drugs in the catalogue and the average price of drugstores have increased, the cost of patients' burden has not increased 3 The average price of generic pharmacy and the cost of patients' self payment are relatively stable Over the five years, generic drugstore prices rose slightly to $19.10 from $18.50 in 2014, while the final cost of generic patient out of pocket fell from $6.74 in 2014 to $6.18 in 2018 The drop in generic costs indicates increased competition in this area and may provide more patients with access opportunities 4 As more than 90% of prescription drugs are generic drugs, the cost of self financing of generic drug patients has decreased, so the overall level of self financing, including brand and generic drugs, has also declined From $10.28 in 2014 to $9.05 in 2018 (Note: the following average costs only reflect patients who have been prescribed, not those who have not been treated or who have given up.)