Out-of-Pocket Spending Remains High for Chronic Hepatitis B Treatments

Jonathan D. Alpern, MD

While in some ways to the cost to treat chronic hepatitis B (CHB) has been reduced in recent years, out-of-pocket costs remain high and burdensome for some patients.

A team, led by Jonathan D. Alpern, MD, HealthPartners Infectious Diseases, assessed trends in the number of manufacturers, average wholesale price, National Average Drug Acquisition Cost (NADAC), and out-of-pocket spending for entecavir among a commercially insured patient population with CHB between 2014-2018.

The Cost of Treating Chronic Hepatitis B

While CHB is treatable and cost-effective in the US, high out-of-packet spending on first-line therapies could be a treatment barrier preventing better care.

One positive is entecavir, which is a first-line agent treating CHB, has had a steep decline in the average price pharmacies pay due to manufacturer competition.

However, the list price has remained high.

The Study

In the cross-sectional study, the investigators identified yearly NADAC prices of entecavir 0.5 mg tablets using Medicaid’s publicly available NADAC database for the last week of December 2014 through December 2018.

The team calculated the yearly average wholesale price based on a weighted average calculation of Medicaid expeditions and average wholesale price derived from a criterion standard drug database.

The investigators also used the US Food and Drug Administration’s Orange Book to identify the yearly number of drug manufacturers and analyzed a commercial database of health claims using cloud-based analytic interface from 2014-2018.

Costs

In total, there were 1000 annual entecavir fills between 2014-2018, with a mean of 6.7 annual fills per member. For costs, as the number of entecavir manufacturers increased from 1-11, the NADAC decreased from $30.12 to $1.93 per 0.5 mg tablet.

Wholesale prices on average remained constant at $44.43.

In addition, the mean out-of-pocket spending per 30-day supply of generic entecavir was $41 in 2014 and $52 in 2018 for commercially insured members.

However, for members with a high-deductible plan, the mean out-of-pocket spending per 30-day supply of generic entecavir was $103 in 2014 and $133 in 2018.

The mean total spending per 30-day supply of the generic version was $981 in 2014, compared to $591 in 2018.

“Out-of-pocket spending on generic entecavir increased between 2014 and 2016 and remained elevated through 2018 despite robust generic competition and a marked decline in the price that pharmacies paid for entecavir,” the authors wrote. “The artificially high average wholesale price for entecavir is a likely driver of such high out-of-pocket spending, as drugs are often paid for based on a discount of average wholesale price, benefiting supply chain intermediaries—such as pharmaceutical benefit managers and wholesalers—while contributing to drug price inflation.”

There were several limitations found in the study, including the lack of health plan rebates or patient coupons in spending calculations. The investigators did not account for other strategies, including pill splitting of 1 mg tablets, which could lower out-of-pocket spending.

The team also said the study underscores the importance for policies that improve transparency around generic drug financing and pharmaceutical benefit manager practices.

The study, “Trends in Pricing and Out-of-Pocket Spending on Entecavir Among Commercially Insured Patients, 2014-2018,” was published online in JAMA Network Open.