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Shumaker K, Maczuga S, Kirby J. Assessment of Overpayment for Topical Dermatological Drugs—Clawbacks. JAMA Dermatol. 2019;155(11):1315–1317. doi:10.1001/jamadermatol.2019.3078
Since 2011, pharmaceutical costs have increased exponentially, outpacing inflation.1 Recent research has shown an increasing frequency of prescription drug overpayments, or “clawbacks,” where an insured patient’s copayment exceeds the insurer’s cost for the drug. To date, clawbacks have been quantified for the most commonly used oral drugs across all medical disciplines, but clawbacks have not been assessed for topical drugs. The objective of this study was to investigate the prevalence and cost of clawbacks for topical prescription drugs.
We conducted a retrospective cohort study of the MarketScan Commercial Claims and Encounters database, a claims database for privately insured individuals. This study identified 61 topical medications using 11-digit national drug codes from January 1, 2012, to December 31, 2016. Included drug claims were required to be 1 of 61 common dermatologic medications during the 5-year study period and have complete data. Claims were excluded if the ingredient cost or copay was less than or equal to $0. Cost from the patient perspective was represented by the copay. The insurer’s cost of the drug was taken as the sum of the ingredient cost and dispensing fee. The ingredient cost was determined by the average wholesale market value for the drug. A clawback occurrence, and the clawback amount, were defined when the copay cost exceeded insurer’s cost by $2 or more. The total cost of overpayments was calculated by multiplying the mean cost of the overpayment by the frequency of claims with an overpayment. Descriptive statistics were conducted to identify frequencies, percentages, means, and standard deviations of overpayments in prescription drugs using SAS statistical software (version 9.4; SAS Institute, Inc). Costs were adjusted for inflation to 2016 dollars.2 Data analysis was performed in March 2019. This study was reviewed and approved by the Penn State institutional review board, and written informed consent was waived owing to deidentification of all data used.
Overall, 0.06% of topical prescription claims had an overpayment, with an average of $15.07 per claim. The estimated total cost of overpayments for the included topical prescription drugs during the 5-year study was $2 633 701.36. The mean (SD) overpayment per drug claim was higher for brand name drugs compared with generic drugs ($21.02 [49.04] vs $9.11 [26.35]). Assessed as a proportion, the percentage of topical prescriptions with overpayment was greater for branded than generic drugs (0.065% [2 625/4 023 540] vs 0.058% [11 378/19 683 568], respectively). Among the 10 most frequently prescribed topical medications (Table), triamcinolone was the most frequently prescribed, but had a low rate of overpayment (0.08%). The medications with the highest proportion of overpayments include 3 topical corticosteroids, 2 medications associated with acne treatment, and 2 topical antifungals. When grouped by medication type, topical retinoids had the highest mean overpayment per claim, and the overpayment was higher for branded vs generic ($63.79 vs $23.22, respectively), (Figure).
To our knowledge, this is the first assessment of overpayments for topical prescription medications. Findings from this study indicate that the prevalence of overpayments was lower for generic drugs. Percentages are small, but contributed an estimated $2.6 million in excess cost over the 5-year study period. This study is limited to privately insured patients so it may not be generalizable. Differences by insurance plan or type (eg, high deductible) were not possible with this data set.
Elevating out-of-pocket expenditures for patients will hinder the opportunity to provide affordable quality care to patients. In recent months state and federal policies have been enacted to ban gag clauses on pharmacists and in commercial insurance contracts.3-5 Gag clauses prevented pharmacists from proactively informing patients if it is more cost-effective to purchase their prescription out-of-pocket. Many Americans struggle to afford their out-of-pocket medical expenses, educating patients and clinicians about clawbacks has the potential to increase adherence and lower costs for prescriptions.
Corresponding Author: Joslyn Kirby, MD, MS, MEd, Department of Dermatology, Penn State Health Milton S. Hershey Medical Center, 500 University Dr, Hershey, PA 17033 (firstname.lastname@example.org).
Accepted for Publication: August 9, 2019.
Published Online: October 9, 2019. doi:10.1001/jamadermatol.2019.3078
Author Contributions: Dr Kirby 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.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Shumaker, Maczuga.
Critical revision of the manuscript for important intellectual content: Kirby, Shumaker.
Statistical analysis: Shumaker, Maczuga.
Administrative, technical, or material support: Kirby, Shumaker.
Study supervision: Kirby.
Conflict of Interest Disclosures: None reported.
Meeting Presentation: This research was presented as a poster at the Society for Investigative Dermatology conference; May 11, 2019; Chicago, Illinois.