In 2023 alone, the U.S. spent a staggering $722.5 billion on pharmaceutical drugs, marking a 13.6% increase from the previous year. Projections for 2024 suggest a further 10-12% increase in spending, potentially reaching nearly $900 billion.

The use of existing drugs for conditions beyond those currently approved by the FDA is an increasingly frequent occurrence, accounting for up to one-third of all common drug prescriptions in the United States and up to 97% of drug use in some patient populations. While this can be attributed at least in part to expanding knowledge of conditions that these drugs may help to treat in real-time, the downstream impact is that the business side of healthcare is left ill-equipped to manage the expanding use of high-cost pharmaceuticals to treat different conditions.

Increasing drug prices and long-term treatment requirements

I spoke to my colleague Emily Ehle, PharmD, Vice President of Expert Claims Review® Operations at Zelis, and she told me that the American Society of Health-System Pharmacists reported a 6.5% increase in prescription drug use in 2023.

“More patients are being prescribed medications, and existing patients are continuing their treatments for longer periods,” Emily shares. “High-cost drugs, particularly those requiring long-term use, can leave payers in the difficult position of balancing cost and quality of care.”

The introduction of new, often high-cost specialty medications saw a 4.2% market increase in 2023.

“Drugs like Semaglutide [Ozempic, Rybelsus, Wegovy], Adalimumab [Humira] and Apixaban [Eliquis] can cost around $1,000 per patient per month,” Emily says. “The financial strain these drugs pose when used off-label further exacerbates the challenges of managing and pricing pharmaceuticals.”

Conditions such as obesity do put people at greater risk for illnesses like diabetes, high blood pressure and high cholesterol, so many health plans are actively debating whether coverage of GLP-1 medications for weight loss may be a strategy to prevent worse conditions from developing down the road.

Emily points out that, though GLP-1 drugs are gaining a lot of attention right now, they are hardly the only examples of off-label drug use. “Just look at the use of dexmedetomidine – approved for sedation in surgical settings – for alcohol withdrawal and the use of sugammadex – only approved for reversal of rocuronium and vecuronium – for the reversal of other neuromuscular agents,” Emily says.

Finding solutions with data-driven insights

The healthcare financial industry needs more modern and effective solutions that can keep pace with clinical innovation and find the right balance between cost and care. More specifically, we need insight into clinical trends and how certain treatments are being used by patients – and how those treatments should be priced. Experts in claims management and compliance can be a tremendous resource for this, with both the data and clinical knowledge to manage the complexities of high-cost drugs and help reduce unnecessary expenditures.

To that end, Zelis offers comprehensive solutions to help with these very challenges, including Clinical Chart Review – part of Zelis Expert Claims Review® – and a suite of intelligent drugs and biologics claims edits. Learn more here.