Twelve Part D urology meds top $100 million in spending

As providers whose patient populations generally contain a significant percentage of Medicare beneficiaries, it is in urologists’ best interest to be aware of trends in drug costs and spending for both Medicare’s Part B program (generally injectable medications purchased by providers and administered in a clinical setting) and Part D program (generally prescribed oral and patient-administered medications).

In my previous column (“CMS data reveal trends in Part B drug spending,” May 2019), I discussed the most common Part B drugs used by urologists in the office setting, where “drug costs” also represent gross revenue to the practice in a “buy-and-bill” model. In this article, I will discuss Part D drug spending that may be of interest to the practicing urologist: those drugs prescribed, and in some cases, dispensed in the urology practice. (For more on this, see bit.ly/PartDdashboard.)

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The Centers for Medicare & Medicaid Services (CMS) recently released detailed drug spending data for the years 2013-2017. “Spending” in this context includes the estimated total costs-including deductible, coinsurance, and Medicare spending. Total spending in 2017 for the Part D program was $151.6 billion, up 4.05% from 2016. (This compares to about $30 billion and a 6% increase in the Part B program.) Spending on any single drug may increase because of increased price, increased utilization, or both.

Let’s take a closer look at some individual drugs that urologists typically prescribe in their practice. Note: It is not possible using this data to determine what fraction of spending is “ordered” by urologists, or the indication for any individual drug.

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Among 12 drugs commonly prescribed by urologists with spending over $100 million in 2017, the drug with the largest 2017 total spend was the prostate cancer agent abiraterone acetate (ZYTIGA) ($878 million). In 2017, utilization for abiraterone decreased 3.5%, spending per dose increased 10.5%, and total spending increased 6.6% compared to 2016. Spending on this expensive drug (over $50,000 per patient per year in 2017) has increased 9.76% per year over the last 5 years.

Total spending in 2017 on enzalutamide (XTANDI), another oral oncolytic drug prescribed for similar indications, was $855 million-down 5.8% compared to 2016. Utilization was down 15.6% for the same time period, and annual growth in average spending is 7% over the last 5 years. Both of these drugs are also commonly dispensed in large urology practices or practice-owned retail pharmacies (table).

Among six drugs prescribed to more than 1 million unique beneficiaries in 2017 and commonly prescribed by urologists were four common antibiotics (ciprofloxacin, cephalexin, levofloxacin, and nitrofurantoin Monohyd/M-Cryst), tamsulosin, and finasteride. All of these “generic” drugs have multiple manufacturers and decreased cost/unit in 2017 compared to 2016. Almost all have negative annual growth rates in spending per dose over the last 5 years and are a good example of how multiple manufacturers can drive competition and lower costs for the Medicare program.

In the overactive bladder market, 15 drugs accounted for over $2 billion in Medicare Part D spending in 2017. Total spending on mirabegron (Myrbetriq) ($787 million) increased almost 52% in 2017, and spending on this drug has increased 10% per year for the last 5 years. The inverse relationship between annual growth rates and numbers of manufacturers in this market is particularly striking.

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Sildenafil is another drug often prescribed by urologists and dispensed in urology offices or pharmacies. Generic sildenafil spending per dosage unit decreased 3.1% in 2017 despite increased utilization (9%) and has seen almost 20% annual decline in spending per dose over the last 5 years. (The cost numbers in this category may not reflect actual utilization, as many Medicare beneficiaries buy sildenafil without filing insurance and/or from Canadian or online pharmacies.)

Bottom line: Drug costs to the Medicare Part D program as a whole continue to increase each year, and the most important determinant of a drug’s price is the number of manufacturers competing in the market. Expensive oral drugs used to treat cancer are under close scrutiny, and urologists prescribe-and in some cases dispense-these drugs. Urologists should be familiar with the costs under their direct or indirect control, and understand the availability and costs of generic alternatives when clinically appropriate.