US Insurer Spending on Ivermectin Prescriptions for COVID-19 | Health Care Economics, Insurance, Payment | JAMA | JAMA Network
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Table 1.  Characteristics of Oral Ivermectin Prescriptions for COVID-19, December 1, 2020, Through March 31, 2021, PharMetrics Plus for Academics
Characteristics of Oral Ivermectin Prescriptions for COVID-19, December 1, 2020, Through March 31, 2021, PharMetrics Plus for Academics
Table 2.  Estimated Insurer Reimbursement per Ivermectin Prescription for COVID-19, December 1, 2020, Through March 31, 2021
Estimated Insurer Reimbursement per Ivermectin Prescription for COVID-19, December 1, 2020, Through March 31, 2021
1.
López-Medina  E, López  P, Hurtado  IC,  et al.  Effect of ivermectin on time to resolution of symptoms among adults with mild COVID-19: a randomized clinical trial.   JAMA. 2021;325(14):1426-1435. doi:10.1001/jama.2021.3071PubMedGoogle ScholarCrossref
2.
Centers for Disease Control and Prevention. Rapid increase in ivermectin prescriptions and reports of severe illness associated with use of products containing ivermectin to prevent or treat COVID-19. Published August 26, 2021. Accessed October 1, 2021. https://emergency.cdc.gov/han/2021/han00449.asp
3.
IQVIA Institute for Human Data Science.  The Use of Medicines in the US. IQVIA Institute; 2021.
4.
Chernew  ME, Rosen  AB, Fendrick  AM.  Value-based insurance design.   Health Aff (Millwood). 2007;26(2):w195-w203. doi:10.1377/hlthaff.26.2.w195PubMedGoogle Scholar
5.
Schwartz  AL, Landon  BE, Elshaug  AG, Chernew  ME, McWilliams  JM.  Measuring low-value care in Medicare.   JAMA Intern Med. 2014;174(7):1067-1076. doi:10.1001/jamainternmed.2014.1541PubMedGoogle ScholarCrossref
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    2 Comments for this article
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    The Reason Insurers Cover Unproven Medication
    Thomas Hilton, PhD | Retired, NIH
    While it seems irrational to pay for medication that is ineffective, the cost in the case of ivermectin is below annual premium rates - i.e., still profitable. Given the drug's political baggage, failing to pay claim risks permanently alienating both current and potential clients. Had the cost been much higher, claims might have been rejected, just as we have seen reticence to cover the cost of aducanumab, which is also of comparablt dubious effectiveness but costs the price of a new car.
    CONFLICT OF INTEREST: None Reported
    Business case for prior-authorization
    David Anderson, MSPPM | Duke University Department of Population Health Sciences
    The business case for any single insurer to institute a prior authorizatoin requirement or other prescription limitations for ivermectin, and other fad drugs for COVID, is not as straightforward as the authors seem to imply with the sentence " Findings suggest that insurers heavily subsidized the costs of ivermectin prescriptions for COVID-19, even though economic theory holds that insurers should not cover ineffective care." The authors estimate a $129,000,000 excess cost for ivermectin in a single year for Medicare Advantage and privately insured patients. Using KFF 2019 coverage estimates, this is between 56% to 61% of the population depending on how the ACA marketplace coverage is counted. At 56% of the population, the per member per month (PMPM) cost is less than $0.06 PMPM. There are real costs to set up and administer holds. Large insurers may be able to amortize the costs over sufficient number of denied claims to justify the hurdle costs.

    There are two other factors that may be related to the continued payment of claims for an ineffective treatment. First, if insurers assume that ivermectin prescriptions will resemble the trajectory of hydroxychloroquine where there was a significant spike and then a rapid fade as new evidence on ineffectiveness was presented (1), the PMPM of plausible savings would decrease. Secondly, COVID has become heavily polarized and politicized including the prescription of ineffective folk cures (2). Insurers may be motivated to minimize media attention on a matter that has no material effect on premiums.

    References

    1. Bull-Otterson L, Gray EB, Budnitz DS, et al. Hydroxychloroquine and Chloroquine Prescribing Patterns by Provider Specialty Following Initial Reports of Potential Benefit for COVID-19 Treatment - United States, January-June 2020. MMWR Morb Mortal Wkly Rep 2020;69(35):1210-1215. Published 2020 Sep 4. doi:10.15585/mmwr.mm6935a4

    2. Harrigan, J.J., Hubbard, R.A., Thomas, S. et al. Association Between US Administration Endorsement of Hydroxychloroquine for COVID-19 and Outpatient Prescribing. J Gen Intern Med 35;2826–2828 (2020). https://doi.org/10.1007/s11606-020-05938-4.

    CONFLICT OF INTEREST: None Reported
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    Research Letter
    January 13, 2022

    US Insurer Spending on Ivermectin Prescriptions for COVID-19

    Author Affiliations
    • 1Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, Ann Arbor
    • 2Department of Markets, Public Policy, and Law, Questrom School of Business, Boston University, Boston, Massachusetts
    • 3Division of General Medicine, University of Michigan Medical School, Ann Arbor
    JAMA. 2022;327(6):584-587. doi:10.1001/jama.2021.24352

    Ivermectin dispensing surged in the US in December 2020, even though evidence suggests ivermectin is ineffective for COVID-19.1,2 Studies have not assessed the degree to which insurers cover the costs of ivermectin prescriptions for COVID-19 or estimated wasteful US insurer spending on these prescriptions. We addressed these gaps by using national claims data from December 1, 2020, through March 31, 2021.

    Methods

    We conducted a cross-sectional analysis of the IQVIA PharMetrics Plus for Academics database. During the study period, the database included a convenience sample of 5 million patients with private insurance and 1.2 million with Medicare Advantage across the US. Compared with all US patients with private and Medicare Advantage insurance, the database contains a higher proportion of patients residing in the Midwest and a lower proportion of patients residing in the South. Because data were deidentified, the institutional review board of the University of Michigan Medical School exempted analyses from review.

    We identified oral ivermectin prescriptions dispensed during the study period, excluding those for patients who lacked continuous enrollment or had a diagnosis code for a parasitic infection (B65.XXX-B89.XXX) during the 7 days before dispensing. We assumed the remaining prescriptions were for COVID-19. This approach maximized sensitivity because it captured prescriptions written during visits in which COVID-19 was not coded and during visits not billed to insurance.

    For each payer type, we calculated mean insurer reimbursement, out-of-pocket spending (deductibles plus coinsurance and co-payments), and total spending (insurer reimbursement plus out-of-pocket spending) per prescription. To assess the degree to which insurers covered prescription costs, we divided aggregate insurer reimbursement across prescriptions by aggregate total spending.

    To assess the potential magnitude of US insurer spending on ivermectin prescriptions for COVID-19, we estimated private and Medicare plan spending on these prescriptions during the week of August 13, 2021, the most recent week for which dispensing data were available.2 We assumed that all 88 000 ivermectin prescriptions dispensed that week were for COVID-19 except 3600, the average US weekly dispensing total in the 12 months before the pandemic2; that 52% (43 888) and 28% (23 632) of the remaining 84 400 prescriptions were paid by private and Medicare plans, mirroring the overall distribution of payer type for US prescriptions3; and that our estimates of insurer reimbursement per prescription generalized to all private and Medicare plans. We multiplied by 52 to estimate annual spending. Analyses used SAS version 9.4.

    Results

    Of 5939 ivermectin prescriptions, 348 (5.9%) were excluded. Of the remaining 5591 prescriptions, 4700 (84.1%) were for privately insured patients. Mean patient age was 51.8 years (SD, 15.7 years) (Table 1).

    Among ivermectin prescriptions, mean (SD) out-of-pocket spending was $22.48 ($24.78) for privately insured patients and $13.78 ($26.24) for Medicare Advantage patients; mean insurer reimbursement was $35.75 ($50.63) and $39.13 ($40.18), respectively; and mean total spending was $58.23 ($51.47) and $52.91 ($42.47), respectively. Aggregate total spending was $273 681.00 for privately insured patients and $47 142.81 for Medicare Advantage patients, of which insurer reimbursement represented 61.4% and 74.0%, respectively (Table 2).

    In the week of August 13, 2021, private and Medicare plans paid an estimated $1 568 996.00 (43 888 × $35.75) and $924 720.16 (23 632 × $39.13) for ivermectin prescriptions for COVID-19. The weekly total of $2 493 716.16 extrapolated to $129 673 240.30 annually.

    Discussion

    Findings suggest that insurers heavily subsidized the costs of ivermectin prescriptions for COVID-19, even though economic theory holds that insurers should not cover ineffective care.4 Wasteful insurer spending on these prescriptions, estimated at $2.5 million in the week of August 13, 2021, would extrapolate to $129.7 million annually. For perspective, this total exceeds estimated annual Medicare spending on unnecessary imaging for low back pain, a low-value service that has received extensive attention.5 The true amount of waste is even higher because estimates did not include Medicaid spending. Moreover, by reducing barriers to a drug that some individuals use as a substitute for COVID-19 vaccination or other evidence-based care, insurance coverage could increase spending for COVID-19 complications.

    Limitations of this study include unclear generalizability to all private and Medicare plans. Despite this, findings suggest insurers could prevent substantial waste by restricting ivermectin coverage; for example, by requiring prior authorization. Although these restrictions might impede ivermectin use for non–COVID-19 indications, low prepandemic levels of dispensing suggest this use is infrequent.2 Consequently, the restrictions could reduce wasteful spending, and the number of patients who would experience barriers to evidence-based treatment for ivermectin would be small.

    Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Associate Editor.
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    Article Information

    Corresponding Author: Kao-Ping Chua, MD, PhD, Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School, 300 N Ingalls St, SPC 5456, Room 6E18, Ann Arbor, MI 48109-5456 (chuak@med.umich.edu).

    Accepted for Publication: December 20, 2021.

    Published Online: January 13, 2022. doi:10.1001/jama.2021.24352

    Author Contributions: Dr Chua had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Chua, Conti.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Chua.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Chua, Conti.

    Supervision: Conti.

    Conflict of Interest Disclosures: Dr Chua reported receiving personal fees from the Benter Foundation outside the submitted work. No other disclosures were reported.

    Funding/Support: Funding for purchasing the data was partially provided by the Susan B. Meister Child Health Evaluation and Research Center, University of Michigan Medical School. Dr Chua’s work is supported by a career development award from the National Institute on Drug Abuse (grant 1K08DA048110-01).

    Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    References
    1.
    López-Medina  E, López  P, Hurtado  IC,  et al.  Effect of ivermectin on time to resolution of symptoms among adults with mild COVID-19: a randomized clinical trial.   JAMA. 2021;325(14):1426-1435. doi:10.1001/jama.2021.3071PubMedGoogle ScholarCrossref
    2.
    Centers for Disease Control and Prevention. Rapid increase in ivermectin prescriptions and reports of severe illness associated with use of products containing ivermectin to prevent or treat COVID-19. Published August 26, 2021. Accessed October 1, 2021. https://emergency.cdc.gov/han/2021/han00449.asp
    3.
    IQVIA Institute for Human Data Science.  The Use of Medicines in the US. IQVIA Institute; 2021.
    4.
    Chernew  ME, Rosen  AB, Fendrick  AM.  Value-based insurance design.   Health Aff (Millwood). 2007;26(2):w195-w203. doi:10.1377/hlthaff.26.2.w195PubMedGoogle Scholar
    5.
    Schwartz  AL, Landon  BE, Elshaug  AG, Chernew  ME, McWilliams  JM.  Measuring low-value care in Medicare.   JAMA Intern Med. 2014;174(7):1067-1076. doi:10.1001/jamainternmed.2014.1541PubMedGoogle ScholarCrossref
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