Squares represent out-of-pocket spending (the sum of copays, deductibles, and coinsurance); circles represent copayments; diamonds represent deductible payments; and triangles represent coinsurance. All spending estimates are inflated to 2014 US dollars using the US Bureau of Labor Statistics Consumer Price Index calculator.4 Data were retrieved from the 2007-2014 Truven MarketScan Commercial Claims and Encounters database (http://truvenhealth.com/portals/0/assets/PH_11238_0612_TEMP_MarketScan_WP_FINAL.pdf).
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Chua K, Conti RM. Out-of-Pocket Spending Among Commercially Insured Patients for Epinephrine Autoinjectors Between 2007 and 2014. JAMA Intern Med. 2017;177(5):736–739. doi:10.1001/jamainternmed.2017.0252
In 2007, Mylan obtained the right to EpiPen, the most widely used epinephrine auto-injector for serious allergic reactions.1,2 Since then, Mylan has increased the list price for EpiPen from $94 to $609.2 In part due to patient outcry over rising out-of-pocket spending, Mylan released a $300 generic EpiPen in December 2016.3
Whether generic EpiPen decreases out-of-pocket spending depends largely on insurers’ benefit design. To date, the generosity of EpiPen coverage has not been well characterized. We assessed EpiPen out-of-pocket spending between January 2007 and December 2014 among the commercially insured, a population that accounts for 70% of annual EpiPen prescriptions.1
We analyzed the Truven MarketScan Commercial Claims and Encounters database for 2007 through 2014 (http://truvenhealth.com/portals/0/assets/PH_11238_0612_TEMP_MarketScan_WP_FINAL.pdf). MarketScan contains data from individuals ages 0 to 64 years who receive private insurance from over 100 employers in all 50 states. We limited the sample to enrollees continuously insured during the year. This study was deemed exempt by the University of Chicago institutional review board.
We used national drug codes to identify EpiPen prescription fills (including both EpiPen and EpiPen Jr). To assess EpiPen use, we calculated the annual rate of EpiPen prescription fills per EpiPen patient (patients with ≥1 fill during the year). For each EpiPen patient, we added copays, coinsurance, and deductible payments to calculate annual EpiPen out-of-pocket spending. We calculated the percentage of EpiPen patients with at least $100 and $250 in annual EpiPen out-of-pocket spending, and the percentage of annual EpiPen total spending (out-of-pocket spending plus insurer reimbursement) attributable to out-of-pocket spending. We inflated spending to 2014 US dollars using the Consumer Price Index.4
Across the study period, the sample included 191.2 million enrollees, of which 51.7% were female and 27.8% were children ages 0 to 18 years.
Between January 2007 and December 2014, the annual rate of EpiPen prescription fills per EpiPen patient increased from 1.18 to 1.20 (+1.6%) (Table). During the same period, annual EpiPen out-of-pocket spending per EpiPen patient increased from $33.8 to $75.5 (+123.6%). Levels of EpiPen out-of-pocket spending per EpiPen patient were higher for children than adults in all years, and deductible payments accounted for an increasing proportion of EpiPen out-of-pocket spending over time (Figure).
The percentage of EpiPen patients with at least $100 and $250 in annual EpiPen out-of-pocket spending increased from 3.9% to 18.0% (+365.6%) and from 0.1% to 7.4% (+5631.7%), respectively. Annual EpiPen total spending per EpiPen patient increased from $123.9 to $468.7 (+278.4%); the percentage of this spending paid out-of-pocket decreased from 27.3% to 16.1% (−40.9%).
Among commercially insured patients who use EpiPen, annual EpiPen out-of-pocket spending more than doubled between 2007 and 2014. Simultaneously, the annual rate of EpiPen prescription fills barely increased, suggesting that the increased financial burden on patients was not driven by higher use. Though insurers covered a higher share of total EpiPen spending over time, patients were still only partially protected against the dramatic rise in EpiPen prices. Therefore, our results suggest that while the aggressive pricing by Mylan was a main driver of increased EpiPen out-of-pocket spending, coverage policies also played a role.
With the recent release of generic EpiPen and competitors, the price of epinephrine autoinjectors will likely decrease over time. The impact of these price decreases on patient out-of-pocket spending will vary depending on insurance benefit design. For patients subject to price-sensitive cost-sharing mechanisms such as deductibles or coinsurance, out-of-pocket spending could decrease substantially; for patients subject to copayments, out-of-pocket spending may be less impacted.
Our study is limited by is its reliance on a convenience sample of commercial claims. Our findings highlight the need for patients, physicians, and policymakers to advocate for both fair pricing by pharmaceutical manufacturers and adequate insurance coverage of life-saving medications.5
Corresponding Author: Rena M. Conti, PhD, Section of Pediatric Hematology/Oncology, Department of Pediatrics, University of Chicago, 5841 S Maryland Ave, Wyler C432, MC 5080, Chicago, IL 60637 (firstname.lastname@example.org).
Published Online: March 27, 2017. doi:10.1001/jamainternmed.2017.0252
Author Contributions: Drs Chua and Conti 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: All authors.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: All authors.
Obtained funding: Conti.
Conflict of Interest Disclosures: Dr Conti serves on the National Academy of Sciences, Engineering, and Medicine Committee “Ensuring Patient Access to Affordable Drug Therapies.” No other conflicts are reported.
Funding/Support: Dr Conti received funds from The Commonwealth Fund to support her efforts on this study.
Role of the Funder/Sponsor: The funder/sponsor 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.
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