Medical Costs and Health Care Utilization Among Self-Insured Members with Carve-In Versus Carve-Out Pharmacy Benefits.

Journal of Managed Care & Specialty Pharmacy
Julia J SmithPatrick P Gleason

Abstract

Pharmacy benefit can be purchased as part of an integrated medical and pharmacy health package-a carve-in model-or purchased separately and administered by an external pharmacy benefit manager-a carve-out model. Limited peer-reviewed information is available assessing differences in use and medical costs among carve-in versus carve-out populations. To compare total medical costs per member per year (PMPY) and utilization between commercially self-insured members receiving carve-in to those receiving carve-out pharmacy benefits overall and by 7 chronic condition subgroups. This study used deidentified data of members continuously enrolled in Cambia Health Solutions self-insured Blue plans without benefit changes from 2017 through 2018. Cambia covers 1.6 million members in Oregon, Washington, Idaho, and Utah. The medical cost PMPY comparison was performed using multivariable general linear regression with gamma distribution adjusting for age, gender, state, insured group size, case or disease management enrollment, 7 chronic diseases, risk score (illness severity proxy), and plan paid to total paid ratio (benefit richness proxy). Medical event objectives were assessed using multivariable logistic regression comparing odds of hosp...Continue Reading

References

Jan 21, 2006·Journal of Evaluation in Clinical Practice·Susanna DoddPaula Williamson
Jan 21, 2017·Journal of the American College of Cardiology·Markus C ElzeStuart J Pocock
Feb 26, 2019·Current Opinion in Critical Care·Evert Christiaan Boerma, Inge Tjitske Bootsma
Mar 1, 2019·Journal of Managed Care & Specialty Pharmacy·Xiaoxue ChenAbiy Agiro
Mar 26, 2019·Population Health Management·Steven E GoldbergJay G Wohlgemuth

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Citations

Oct 1, 2020·Journal of Managed Care & Specialty Pharmacy·Natasha ParekhChester B Good

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