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Research Highlights Areas to Address in Diagnosis, Treatment, and Engagement
In the U.S. from 2013 to 2015, rheumatic diseases — arthritis, rheumatoid arthritis (RA), gout, lupus, and fibromyalgia — affected an estimated 54.4 million adults. By 2040, the number of adults diagnosed with a rheumatic disease is expected to rise to 78 million.
This year’s annual meeting of the American College of Rheumatology — held virtually — brought together medical professionals from across the world with clinical and research interests in rheumatology. CVS Health researchers presented original research highlighting gaps in diagnosis and treatment of RA — one of the most common autoimmune diseases — that could help address cost and patient outcomes.
Earlier RA Diagnosis Helps Lower Costs
Annual direct costs for RA patients are estimated to range from $12,509 to $36,053.
In addition, the adjusted total cost of care per member per year (PMPY) for new RA patients diagnosed in an emergency department or in-patient (ED/IP) setting was significantly higher than new RA patients diagnosed in other settings.
Choosing Treatment and Dispensing Options
Once someone is diagnosed with RA, rheumatologists may prescribe either a biologic disease-modifying antirheumatic drug (bDMARD therapy or a biosimilar, which are standard treatments for RA.
We surveyed rheumatologists to better understand potential barriers to use of lower-cost options such as biosimilars or a different dispensing method. Physicians must purchase, manage, and bill for a medication using buy-and-bill, whereas white bagging refers to treatments dispensed from a specialty pharmacy to the physician.
Rheumatologists also reported prescribing an originator bDMARD more often than a biosimilar, even though the majority of survey respondents stated that they considered biosimilars as being the same in safety, effectiveness, and quality as the brand biologic. Although survey respondents indicated they “often” or “always” prescribe originator bDMARDs, a significant percentage would consider prescribing a biosimilar for new patients - given financial equivalence. A smaller percentage would prescribe a biosimilar for existing patients.
The top three reasons rheumatologists gave for prescribing a biosimilar in either fee-for-service or value-based reimbursement arrangements were:
- Patient’s out-of-pocket cost
- Value of reimbursement
- Cost to the practice
Decreasing Adherence when Member Costs Increase
We also analyzed prescription claims to evaluate the impact of cost as a barrier to care and found that higher out-of-pocket costs led to a significant decrease in member adherence. A member’s adherence differed significantly by drug class — IL-6 inhibitors, T-cell blockers, TNF-alpha inhibitors, and Janus kinase inhibitors. Adherence also differed when considering whether or not it was a direct referral source such as an incoming referral from a prescriber, another specialty pharmacy, a payor, or a patient.
Managing RA Total Treatment Cost
Effectively managing RA includes slowing down disease progression while also controlling health care cost. In addition to prescription costs, other factors that drive the total cost of care for patients with RA include inpatient facilities, specialist physicians, and ambulatory facilities. According to our research, pharmacy costs account for the majority of total costs for patients with RA. Of those patients prescribed infliximab, a bDMARD, for their RA treatment, the majority received infusions in their physician’s office. Annual costs were significantly higher for those patients who received infliximab infusions in a hospital.
Improving RA Outcomes with Regular Interventions
Members who were actively engaged in their treatment were able to take steps to achieve better clinical outcomes. RA treatment can include a treat-to-target care approach that establishes regimen targets and a treatment goal, often aiming for remission. A treat-to-target plan can be modified, and drug treatments changed if targets aren’t met.
Our research also showed a high rate of therapy change in patients who were active engaged in their care. Those with higher engagement who used nurse-led care management, had greater adherence and symptom reporting improved. Identifying gaps in RA treatment and care can help address cost and patient outcomes. Our research shows that addressing various factors such as a timely diagnosis, treatment or dispensing choices, and cost of disease management can also influence patient engagement.
Data source, unless noted otherwise, CVS Health Enterprise Analytics, 2020.
All data sharing complies with applicable law, our information firewall and any applicable contractual limitations.
Adherence results and savings projections are based on CVS Caremark data. Actual results may vary depending on benefit plan design, member demographics,
programs implemented by the plan and other factors. Client-specific modeling available upon request.
Image source: Licensed from Getty Images, 2020.