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Managed Care Decision Makers: Understanding the Full Scope of Rheumatoid Arthritis Management
William J. Cardarelli, PharmD
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Managed Care Decision Makers: Understanding the Full Scope of Rheumatoid Arthritis Management

William J. Cardarelli, PharmD
Rheumatoid arthritis (RA) is a chronic, progressive autoimmune disease that affects an estimated 0.5% to 1% of the US population, or approximately 1.5 million individuals. The disease exerts a tremendous toll on patient health-related quality of life, driving many patients out of the workforce as their pain, fatigue, and disability grow. Additionally, with direct medical costs estimated at $22.3 billion and indirect and intangible costs of another $50.1 billion, RA also places a significant economic burden on patients, employers, and payers. The advent of disease-modifying antirheumatic drugs in the past 15 years has revolutionized the treatment of RA, slowing progression of the disease and reducing disability. However, the benefits have come with a huge financial cost, as many of these treatments exceed $20,000 a year. These drug prices have risen by double digits in the past 3 years alone.
Managed care organizations and other payers are implementing numerous approaches to address the challenge of managing the cost of care for patients with RA while improving outcomes. These include utilization review, controlling site-of-care services, shifting coverage of intravenous specialty drugs from the medical to the pharmacy benefit, improving provider adherence to national and international guidelines, and addressing comorbidities in patients with RA. This challenge will become even greater in the next decade with the introduction of new specialty drugs and the growing incidence of the disease.
Am J Manag Care. 2016;22:-S0
Rheumatoid arthritis (RA), a chronic, progressive disease, is one of the most common autoimmune diseases in the United States. In addition to other factors, the increasing costs of biologic disease-modifying antirheumatic drugs (DMARDs) are putting increasing pressure on payers to identify opportunities to control costs while providing quality care and improved outcomes.
 
Burden of Disease
RA exerts a tremendous toll on patients and their families. A study of patient self-reported quality of life found that those with RA were 40% more likely to report fair or poor general health than those without RA. The results also revealed that patients with RA are 30% more likely to need help with personal care and twice as likely to have a health-related activity limitation.1 Health-related quality of life (HRQoL) is also significantly lower in this population, primarily due to pain, fatigue, disability, and the inability to work.2 About 20% of patients stop working full time in the first year after receiving their diagnosis, and within 15 years, half have dropped out of the full-time workforce.3 However, early, aggressive treatment of RA may reduce work-related disability and keep individuals with the disease in the workplace.4
 
Economic Burden of Disease
An analysis of direct medical costs in RA, using government data from 2004 to 2006, estimated per patient annual costs in the first 3 years after diagnosis of $4422, $2902, and $1882, respectively, while a 2005 analysis estimated overall annual medical costs of $22.3 billion.5,6 Meanwhile, a study published in 2011, which used data from between 1999 and 2007 from a large employer database that assessed total healthcare costs in patients receiving a single anti-tumor necrosis factor (TNF) drug or switching from an anti-TNF drug, estimated annual costs of $20,370 and $23,388, respectively.7 In 2010, Birnbaum et al estimated annual excess healthcare costs of RA at $8.4 billion.8 The disease is responsible for approximately 9100 hospitalizations a year, at an annual cost of $374 million, as well as 2.9 million ambulatory care visits—65.5% of which are to specialists, such as rheumatologists.6

Furthermore, RA strikes the working-age population; therefore, indirect costs are very important. An estimated $252 million per year are costs attributed to just absenteeism.9 A 2005 study estimated the annual cost of earnings losses, environmental adaptations in the home and work environments, disability payments, decreased productivity, and the cost of retraining replacement workers at $10.9 billion. Intangible costs, including premature death and declines in HRQoL added another $39.2 billion.8 Direct medical costs in these patients are twice as high as those without comorbidities.10

Analysis of an insurance-claims database of 2700 employees with RA and 338,000 without RA found the mean annual cost for workers with RA was $8700 compared with $3500 for those without the condition, costing employers an additional $5.8 billion a year. Direct healthcare costs accounted for 90% of the extra $5200; the rest was related to absenteeism and short-term disability.11
 
Comorbidities in RA
The prevalence of comorbidities is higher in patients with RA than in those without RA; however, these comorbidities are underrecognized and undertreated.12 Patients with RA have an average of 2 comorbidities, and most are related to the chronic inflammation and immune dysfunction of the disease while some are related to the treatment itself. The most common comorbidities in 1 large study were hypertension (31.5%), osteoporosis (17.6%), osteoarthritis (15.5%), and hyperlipidemia (14.2%).13
 
Rising Cost of Specialty Drugs
Today, the majority of the economic burden related to RA comes from the use of biologic DMARDs, which are more than 5 times as expensive as traditional DMARDs, such as methotrexate.14,15 One Spanish study revealed that the cost of treating RA tripled between 2000 and 2005 as a result of biologics.16 An analysis of specialty drug costs in a Midwest healthcare plan’s medical and pharmacy administrative claims data between 2008 and 2010 found annual specialty drugs costs consumed 53% of the $34,163 per person annual costs. From 2008 to 2010, annual growth in the cost of care for patients with RA was 8.0%, 5.6% of which was related to drug cost growth.14 The price of specialty drugs has skyrocketed since that time. For instance, the price of etanercept has increased 80.3% since 2013, and today, it costs more than $4000 a month. Adalimumab costs nearly the same, representing a 70% price increase over the past 3 years, while the cost of tofacitinib rose 44.3% to more than $3100 a month.17

Overall, the Alliance of Community Health Plans estimates that the annual cost of treating RA in the United States with DMARDs will increase almost 50% from 2013 to 2020, reaching more than $9 billion a year.17 Although most manufacturers offer coupons and discounts to help patients meet their out-of-pocket costs, they are limited to commercially insured populations. Therefore, while coupons and discounts are not available to patients with RA who have Medicare, an estimated 1 in 4 patients with RA on Medicare receive a biologic DMARD.18 The burden is particularly heavy on this population because Medicare does not cap out-of-pocket expenses as most commercial plans do.19,20 Many coupons also have annual or even monthly maximums.21 Finally, whereas coupons may save patients money in the short term, they do not reduce the actual cost of the drug to the payer. The coupons can also lead to higher costs by encouraging patients to use higher-cost drugs because they do not have to pay any co-payment.22
 


 
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