By Brantley Scott
The COVID-19 pandemic affected Utahns in many ways, from work arrangements, how we shop, and regular religious and social gatherings. Health care, as an industry, was also unquestionably impacted by the pandemic. In this DataByte, we examine how the pandemic influenced the amount of medication (days supplied) per prescription and use of mail order prescriptions.
The data used for this DataByte is from the Utah All-Payer Claims Database (APCD), which includes commercial, Medicaid, and Medicare Advantage plans. Medicaid normally doesn’t cover 90-day supplies or mail order prescriptions and were not included in this analysis. Only health care plans with consistent pharmacy and eligibility information were included. This means the plans had to have accurate insurance product type information (used in classifying line of business), were not missing claims or eligibility months during the time period, and were not duplicate health plan information (some claims are submitted both by a pharmacy benefit manager and the health plan). Mail order prescriptions were identified in the dataset by using the primary taxonomy (specialty) code of the pharmacy.
One factor that stood out in the analysis is Medicare recipients fill more prescriptions on average than people who have commercial insurance. As depicted in the following graph, Medicare recipients fill more than three times the amount of prescriptions than people with commercial insurance fill. The higher prescription rate for Medicare recipients may be due to the age of Medicare recipients as compared with those who have commercial insurance.
This analysis was designed, in part, to determine how the pandemic impacted the number of days supplied per prescription and use of mail order prescriptions. The data was grouped into three timeline categories: pre-pandemic (July 2019–February 2020), the shutdown period (March–April 2020), and the post-shutdown period (May 2020–December 2020). Although the shutdown period impacted pharmacy use, this analysis focuses on changes that occurred after the pandemic began, but excludes the shutdown period from the statistical testing. All statistical tests conducted for this study used a two-sample t-test assuming equal variation , with an alpha level (cutoff level for determining statistical significance) of 0.05.
The following two graphs show the total number of prescriptions per 100 insured persons for commercial and Medicare markets. For the commercial market, an upward trend during the winter months was observed, followed by a noticeable decline in the late spring and early summer months. The trend then returned to pre-pandemic levels. Using a two-sample t-test to test for equality between the average number of prescriptions per insured person during the pre-pandemic and post-shutdown periods resulted in a p-value of 0.14. This means the difference in the average number of prescriptions per insured person between the post-shutdown and pre-pandemic period was not statistically significant and may be due to normal monthly variations. Additionally, because the months included in the pre-pandemic and post-pandemic phases are different, seasonal variations could impact the analysis. Therefore, the impact of the COVID-19 pandemic on the total of commercial prescriptions filled is unclear.
The Medicare market depicted a different pattern. The Medicare data reported a decline in the number of prescriptions filled late spring and early summer, but the number of prescriptions per 100 insured persons did not regress to pre-pandemic levels. The trend for reduced Medicare prescriptions filled remained at a lower level. The analysis demonstrated the difference in the average number of prescriptions per insured person between the pre-pandemic and post-shutdown periods was statistically significant at a 95% confidence interval (p=0.02). Medicare prescriptions filled reduced overall during the COVID-19 pandemic.
When observing prescription “days supplied” for the Medicare population, the difference between these two time periods was less than 0.1%. The reason the total number of days supplied didn’t decrease, even though the overall number of prescriptions decreased, was due to the increase from 52.6 to 55.1 in the average number of days supplied per prescription. Although both the Medicare and commercial markets saw an increase in the number of 90-day supply prescriptions, most commercial prescriptions were for 30 days, while the majority of Medicare prescriptions were for 90 days or more. The following graph illustrates this, the increase in 90+ day prescriptions, and the 95% confidence interval of the monthly variation in the number of prescriptions. There is some uncertainty of the amount of increase of 90+ day prescriptions associated with the COVID-19 pandemic.
Due to the variation in the number of prescriptions for the Medicare data, the t-test failed to show a statistically significant difference (p=0.165). However, the t-test for the commercial market did show a statistically significant (p-value < 0.01) change.
This analysis also explored how the pandemic affected the use of mail order pharmacies/prescriptions. Similar to the 90+ day supply, Medicare-insured persons used mail order prescriptions at a higher rate than the commercially insured population. Running a two sample t-test on the number of mail order prescriptions per insured person pre-pandemic compared with the post shutdown period resulted in a p-value of 0.06 for the commercial population, and a p-value of 0.02 for the Medicare group. The change in the number of mail order prescriptions per individual for the commercial population since the onset of the pandemic was not significant, but there was a statistically significant change among Medicare beneficiaries. The following graph shows the percentage of prescriptions per 100 insured persons for mail order and non-mail prescriptions, filled before the pandemic and in the post-shutdown time periods.
It is important to note that the percentage of mail order prescriptions for both commercial and Medicare markets is fairly small. While there does appear to be a small increase in the number of Medicare mail order prescriptions filled, the increase doesn’t appear to be fundamentally changing the prescription landscape.
In conclusion, there are some important findings in this report. First, there are fundamental differences in prescription utilization between commercial and Medicare lines of business. Medicaid traditionally doesn’t cover 90 day or mail order prescriptions, while commercial plans cover these benefits but their members don’t use these benefits as much as Medicare insured persons. Second, both commercial and Medicare show evidence of a slight increase in the number of 90-day prescriptions filled. Finally, mail order prescriptions are much more common with Medicare than for commercially-insured persons and the pandemic may have resulted in a slight increase in the number of Medicare mail order prescriptions. The lasting impacts of prescribing practices during the COVID-19 pandemic are yet to be determined. Payers may want to explore if there are policy changes related to prescription amounts or mail order reimbursement in order to minimize disruption in medication access to patients in order to provide the best care for their patients.