Dr. Dowling is president of Dowling Medical Director Services, a private health care consulting firm specializing in quality improvement, clinical informatics, and health care policy affecting specialty care. He is the former medical director of a large,
In this article, Robert A. Dowling, MD, discusses 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.
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.
Continue to the next page for more.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.
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.