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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
Cost-Effectiveness of Biologics
Even before the recent increase in biologic drug prices, the National Institutes of Health and similar agencies in other countries identified the cost-effectiveness of these medicines as one of the “highest-priority research topics in the pharmacologic treatment of RA.”23 As a result, dozens of studies evaluating the cost-effectiveness of biologics for RA have been published. Such studies are quite heterogeneous, using different willingness-to-pay thresholds (eg, $50,000 or $100,000 per quality-adjusted life-year [QALY] gain), perspectives (payer or societal), costs of drugs studied, severity of disease state, outcomes, intensities of treatment, and comparators, making it difficult to determine which drugs are most cost-effective overall.23-35 One systematic review of 18 economic evaluations of biologic monotherapies or combination therapies (eg, adalimumab, etanercept, and infliximab) compared the cost with conventional DMARDs. The authors determined that biologics were not cost-effective in patients with no previous DMARD exposure or those who failed methotrexate combination therapy or sequential DMARD administration. They used a willingness-to-pay threshold of $50,000 per QALY gain. Some evidence of cost-effectiveness was observed at a willingness-to-pay threshold of $100,000 per QALY gain, although the results were mixed.23 It is important to note that most studies were conducted using costs far lower than today’s prices.
 
Managed Care Strategies
Payers have little control over the price of biologics. Therefore, managed care organizations must adopt a rational approach to weigh the direct and indirect costs of RA to make informed decisions regarding costs and benefits. Part of that approach involves addressing the overall costs of the disease and identifying opportunities to reduce costs while maintaining quality. Potential approaches are described below.
 
Follow Guideline-Recommended Care
Current guidelines from the American College of Rheumatology (ACR) recommend beginning DMARDs in patients with symptomatic RA, regardless of disease activity level.36 Meanwhile, international guidelines highlight the importance of treating to target (T2T), with clinical remission, defined as the absence of signs and symptoms of significant inflammatory disease activity, identified as the primary target for treatment. Until the treatment target is met, drug therapy should be adjusted every 3 months.37

Compared with symptomatic treatment, T2T in early RA is cost-effective. An analysis of 2 years of data, in the DREAM (Dutch Rheumatoid Arthritis Monitoring) registry, from 261 patients who received a T2T approach to care and 213 who received usual care found that T2T was associated with higher costs and significantly higher effectiveness. At 3 years, there was a 64% chance that the T2T strategy would result in lower costs with continued higher effectiveness.38

Patients are more likely to receive such guideline-recommended care when seen by a rheumatologist. An analysis of 27 studies published between 2002 and 2012 determined that DMARD use among patients followed by rheumatologists ranged from 77% to 98% compared with 39% to 63% among those seen by other types of physicians (mainly primary care).39 Given the growing shortage of rheumatologists in this country and the increasing number of people with joint-related and autoimmune diseases, this is an important point.40,41
 
Initiate Early Treatment
Much of the joint damage inherent in RA begins early in the disease. At 2 years after diagnosis, more than 80% of patients demonstrate signs of space narrowing on radiographs of the hands and wrists, and two-thirds show erosions.42 A very early window of opportunity exists within the first 12 weeks of the disease during which DMARDs may lead to better outcomes than later treatment, including the prevention of erosions and even complete remission.43,44 Thus, early diagnosis and treatment are crucial to slowing the progression and degree of disability in RA.45-47

Several studies found significant gaps in patients receiving early treatment, primarily related to the length of time between disease symptom occurrence, referral to a rheumatologist, and DMARD initiation.48 One study revealed that just one-third of patients with RA were assessed less than 12 weeks after their symptoms began, with a median of 13 weeks before they saw a rheumatologist. Patients who saw a rheumatologist within 12 weeks of symptom onset demonstrated a lower rate of progression over 6 years than those whose initial rheumatology visit was delayed (P = .001).47

Treatment with DMARDs not only improves patient outcomes, but can be cost-effective.32,46,49,50 In the United Kingdom’s TICORA (TIght COntrol for Rheumatoid Arthritis) trial, a single-blind, randomized, controlled study conducted in 2 teaching hospitals, 111 patients were randomized to intensive management or usual care. The intervention group was seen monthly and assessed using a validated disease activity score. The usual care group was seen every 3 months with no formal composite measure of disease activity used in clinical decision making.49 More DMARDs were started in the intensive group and fewer were stopped because of toxic effects, with more treatment episodes continuing beyond the trial end. They had a mean reduction in disease activity score of 3.5 versus 1.9 in the usual care group (P <.0001), and were more likely to have a good response or reach remission. Total costs were lower in the intensive group as a result of lower inpatient costs, although outpatient and drug-related costs were higher.49
 


 
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