About that Express-Scripts data

I just want to highlight and raise some data caveats about the Express Scripts data set concerning pharmacy/prescription costs for Exchange patients.  There are some interesting nuggets in the data.

Population inferences:

Our early analysis reveals that, in January and February, use of specialty medications was greater among Exchange enrollees versus patients enrolled in a commercial health plan. Approximately 1.1% of total prescriptions in Exchange plans were for specialty medications, compared to 0.75% in commercial health plans, a 47% difference.


More than six in every 1,000 prescriptions in the Exchange plans were for a medication to treat HIV. This proportion is nearly four times higher in Exchange plans than in commercial health plans.


  • The proportion of contraceptives was 31% lower in Exchange plans

What can we infer from these data points?  There are a couple of inferences.  The first is that early Exchange population is sicker than the typical person covered in an employer sponsored health plan.  We can infer this from the higher use of specialty drugs, and the higher use of HIV drugs.  This was expected. 

The second is that the average age of the early Exchange utilization pool is older than the average age of the typical person covered by an employer sponsored health plan.  The tell here is the much lower use of contraceptives.  Contraceptives are heavily used by women between their late teens to early 40s.  Prescription contraceptive useage spikes in the twenties and steadily declines as women either have children, have permanent birth control, enter menopause or use barrier methods.  If prescription contraceptive usage has cliff-dived, it is probably because there are fewer 53 year olds who need or want to use it.

So what does this mean?

Does the data suggest a pharmaceutical death spiral?

No, as there is one other massive caveat in the dat set, and that is the population examined. 

The analysis is based on a national sample of more than 650,000 de-identified pharmacy claims from Jan. 1, 2014 through Feb. 28, 2014  [my emphasis] for patients enrolled in a Public Health Insurance Exchange

We know one critical thing about the population being analyzed.  

The people who were eligible for this analysis were the first adapters of Exchange insurance.  The January cohort being studied are  are the two million or so people who signed up on the Exchange in October, November and December.  They are the people who were so desperate and self-identifying as needing insurance that they were willing to keep on coming back again and again until the fucked up website worked well enough for them.  Of course, we should expect this group to have higher than expected claim utilization.  The February cohort is the January cohort plus the people who signed up on the Exchanges by January 15th.  This is another million or so individuals.  This cohort should be slightly healthier and slightly younger than the January only cohort. 

The Express Scripts data is reflecting a limited universe of claims utilization by people who self-identified as needing insurance now.  We know from enrollment data that January eligible individuals skewed old and skewed female.  We knowfrom  the February data the risk and utilization pool was slightly younger.  The March enrollment surge pushed the average age of the entire Exchange risk pool down further still, and the April extended blue box enrollment will probably reduce the average age again. 

Express Scripts data is confirming what the enrollment demographic data suggests.  The older and sicker signed up first and got care first.  The younger and healthier are coming in late.  This is not surprising.

32 replies
  1. 1
    burnspbesq says:

    It’s also possible that people in states that had functioning exchanges, e.g., California, are over-represented in those data. Don’t know how that might skew the data.

  2. 2
    Richard Mayhew says:

    @burnspbesq: minimal skew as the truly jacked up months of October and November had low aggregate enrollment, so it got swamped by enrollment in December where HC.gov and the state exchanges on the whole were functional.

  3. 3
    mai naem says:

    The GDP figures that came out yesterday showed that healthcare spending had a huge spike during the first quarter. Is health insurance considered part of healthcare spending or is only actual patient care considered healthcare spending?

  4. 4
    Tommy says:

    Correct me here if I am wrong but doesn’t this mean that maybe people that need drugs are now getting them, when before the ACA, maybe they were not? This is a good thing isn’t it?

  5. 5
    Richard Mayhew says:

    @Tommy: Oh definately it is a good thing, but an analysis of the risk pool based on preliminary data is important to figure out if the Exchange based model is sustainable (it is) and what the 2015 rates may look like (who knows)

  6. 6
    Tommy says:

    Let me tell you a story. I like stories.

    About ten years ago my father had a mild heart attack. The doctors put in a stint and told him to do this or that. They also gave him a script for Lipitor to help with his cholesterol. I thought his lifestyle would change.

    When he comes over I have to make sure I’ve bought enough cheap salt. He thinks my sea salt is some “hippie liberal” thing. He salts his food (not sure if that is directly related to cholesterol) in a manner that doesn’t seem natural to me. I’ve said to him as I watch it happen, “wait what are you doing?”

    What I am saying is the drug, Lipitor, has gotten his results to the point the doctor doesn’t bagger him. I’ve looked at it, Lipitor isn’t a cheap drug. My father worked for the DoD for 30+ years and pretty sure he has government provided health coverage. My gut is it would have been cheaper (and better) for the government just to hire a chief to come into this house for a few weeks and help him learn other ways to cook. You know, with out a pound of salt.

    But he takes that drug each day, not a fan.

    OK, my rant ended, but this just pisses me off to no end. We should be better about this stuff.

  7. 7
    Higgs Boson's Mate says:


    My uncle liberally sprinkled salt and pepper on everything he ate – including watermelon. He predeceased my aunt by thirty years.

  8. 8
    NJDave says:

    It must be a generational thing: my dad would ALWAYS interfere with mom’s cooking by arbitrarily tossing in a tablespoon or more of salt to just about everything she cooked. It was only when I moved away that I discovered that vegetables were really quite good, without salt. But, in the end, it wasn’t the salt that got him but 70+ years of smoking.

  9. 9
    gene108 says:


    When he comes over I have to make sure I’ve bought enough cheap salt. He thinks my sea salt is some “hippie liberal” thing.

    I do not understand the appeal of sea salt versus mined salt. I can understand people wanting to avoid iodized salt, if they feel they are not at risk for thyroid problems, but otherwise both are the same. Mined salt has been sitting under the earth for millions of years, when ancient bodies of water evaporated, while sea salt is just evaporated ocean water. They are both basically the same.

  10. 10
    raven says:

    @gene108: Which one’s pink?

  11. 11
    dmsilev says:

    @raven: The Himalayan stuff. That’s because it’s lightly flavored with Yeti blood.

  12. 12
    Tommy says:

    @Higgs Boson’s Mate: As a kid growing up in the 70s I though you had to put salt on a watermelon. Only way it was presented to me. Then I learned ……

  13. 13
    raven says:

    @dmsilev: It’s my brother’s Floyd tribute band too!

  14. 14
    Tommy says:

    @gene108: Well my sea salt makes me think I am superior to you :).

    Now you will enjoy this. I was in a store the other week and they wanted salt and pepper off the scale. Price. My dad is looking at me, not sure what I’d do, I said these folks are shit all stupid. Good pepper and salt. Not an life changing experience.

  15. 15
    JoyfulA says:

    @Tommy: Lipitor is off patent, and cheap. It has nothing to do with salt. Lipitor has to do with blood cholesterol; salt can affect blood pressure.

  16. 16
    Eljai says:

    @gene108: I have read that the same amount of sea salt has less sodium than regular salt.

  17. 17
    raven says:

    Apparently this blog has eaten too much salt.

  18. 18
    WereBear says:

    Not all salt tastes the same. We use the salt that costs $19 for five pounds. I don’t believe I need to buy salt again for ten years. I’m fine with that.

    Regular salt tastes like metal. This stuff tastes good.

  19. 19
    Belafon says:

    @raven: While we may have an opinion about a lot of things, there’s not much to add on this topic. None of us are prone to screaming “Obamacare might kill my grandmother!”

  20. 20
    grape_crush says:

    “The first is that early Exchange population is sicker than the typical person covered in an employer sponsored health plan.”

    I don’t have the data to back this up, but it seems to me that persons with chronic or longer-in-duration illnesses like HIV or cancer are generally less likely to be employed or employed with a company that has health benefits…which would mean that those who are working for a company that offers health insurance benefits are generally healthier than those who either work for a business with no health insurance benefits or are unemployed.

    Survival of the fittest, you could call it.

    Again, no data, but I’ve seen and heard enough stories where people who got seriously ill were fired and couldn’t afford the COBRA payments needed to keep their insurance in force.

  21. 21
    Richard Mayhew says:

    @grape_crush: Exactly, employer sponsored health insurance presupposes someone is employed or more importantly employed close to full time for a prolonged period of time. that is a minimal health cut-off and a screening mechanism. The employer sponsored risk pool is healthier, on average, than the general population.

  22. 22
    raven says:

    @Belafon: I heard dat!

  23. 23
    Amir Khalid says:

    Probably true, to the extent that sea salt is less pure than this “regular” salt you speak of. But common salt is basically just sodium and chlorine atoms in equal numbers. The difference in taste between one kind of salt and another (if it exists — as far as my own taste buds can tell, salt is salt) is attributable to trace impurities, I suppose. Maybe a difference in texture also contributes to the sense of a difference in taste. Has anyone here tasted reagent-grade NaCl from a laboratory supply house?

  24. 24
    dmsilev says:

    @Amir Khalid:

    Has anyone here tasted reagent-grade NaCl from a laboratory supply house?

    I haven’t myself, but I know people who have. Just tastes like regular salt, according to my sources.

  25. 25
    wasabi gasp says:

    The sodium content of sea salt vs table salt is the same: http://www.heart.org/HEARTORG/.....rticle.jsp

    Ain’t troublin’ Lizzie none: http://www.youtube.com/watch?v=z0qYV5S3u8s

  26. 26
    grape_crush says:

    @Richard Mayhew: “The employer sponsored risk pool is healthier, on average, than the general population.”

    Which in turn makes a comparison between those groups – employed-sponsored-insured and employed/unemployed uninsured-underinsured a little apple-orangey, correct?

  27. 27
    narya says:

    Someone who is living with HIV might have been unable to get health insurance, even if an employer-sponsored plan was available, if it’s a pre-existing condition the employer’s health insurance company wouldn’t touch. This is probably also contributing to the lower use of contraceptives: gay men don’t need prescription contraceptives. Also, signing up on the exchange is still going to be less hassle than renewing an ADAP application twice a year.

  28. 28
    grrljock says:

    Nice analysis confirming what we suspected (older and sicker signed up first). Sad that they had to endure so many years of being uninsured before finally, finally, getting what they need. Sadder still that millions still don’t have access to healthcare.

    Boy, I’m a veritable sunshine today. Sorry.

  29. 29
    JaneE says:

    @Tommy: As you age some people lose the ability to taste. My mother was the worlds greatest cook, when I was a child. The last 5 years of her life, her cooking was literally inedible, because of how much salt she put in things. She would taste the dish, and keep adding salt until it tasted right for her. When it got to the point that I was cooking for her, her only complaint about my food was that it “needed salt”.

  30. 30
    Richard Mayhew says:

    @grape_crush: Apples to crab apples — the most important question when looking at cost projections for PPACA plans is not how do they compare to employer sponsored experiences but how do the Exchange individuals in reality compare to the pricing models developped as a stab in the dark by the actuaries last year.

    And honestly, if the early adapters are reasonably close to the employer sponsored experience, then the entire Exchange pool will be either close enough or slightly better than projected by most actuaies… and I think I have my post for tomorrow.

  31. 31
    namekarB1 says:

    Democrat leaning folks flocked to the exchanges while Republican leaning folks avoided the exchanges. Ergo Democrats as a group have a higher percentage of HIV and require more specialty medications than Republicans. On the other hand, Republicans require more birth control . . . wait minute . . . I need to think about how to frame that data set to make conservatives look bad. Stay tuned . . .

  32. 32

    […] About that Express-Scripts data […]

Trackbacks & Pingbacks

Comments are closed.