Rheumatoid Arthritis: A Condition Ripe for Innovation

Testing new ways to lower costs for payors

BRIEFING
January 13, 2022
Executive Director, Product Development & Innovation, CVS Specialty

Rheumatoid arthritis (RA) is a leading spend driver for payors. While the condition affects less than 1 percent of the U.S. population, it accounts for nearly $22.3 billion in total health care costs per year.https://onlinelibrary.wiley.com/doi/full/10.1002/acr.21755 Patients on a non-biologic disease-modifying anti-rheumatic drug (DMARD) cost about $1,100 per year, as compared with $38,000 per year for patients who have progressed to a biologic DMARD.https://www.nytimes.com/2018/01/06/business/humira-drug-prices.html

We are constantly innovating in complex therapeutic categories, testing and learning to identify new ways to improve health outcomes and member experience while lowering overall health care costs.

Our foundation of connected cost management strategies, including formulary, plan design and UM, is designed to maximize savings. We have two innovative pilots underway to explore how to slow disease progression and contain costs throughout the duration of therapy. The first focuses on improving early DMARD adherence, while the second uses sophisticated testing and digital connectivity for delaying progression to biologics and de-escalating biologic therapy when in sustained clinical remission.

RA DMARD Earlier Intervention Pilot

Plan members who have been confirmed to have rheumatoid arthritis and are new to non-biologic DMARD therapy are proactively engaged by a nurse for support. The nurse helps members better manage their condition, treatment plan and side effects, and communicates the importance of adherence. The goal is to enable the member to maintain disease control with the non-biologic DMARD for as long as clinically appropriate, delaying transition to a costly biologic.

Traditional RA member experience
Sally starts DMARD Sally experiences side effects and is not adherent to her medication Sally’s disease continues to progress; Sally is experiencing pain and joint damage Sally visits her doctor and is prescribed a biologic
Improved RA member experience with nurse support
Sally starts DMARD; nurse helps her understand disease process Proactive engagement helps ensure adherence and address any of Sally’s side effects Ongoing outreach helps Sally address any questions about her therapy Sally is engaged and adherent to her DMARD therapy
Traditional RA member experience
Sally starts DMARD
Sally experiences side effects and is not adherent to her medication
Sally’s disease continues to progress; Sally is experiencing pain and joint damage
Sally visits her doctor and is prescribed a biologic
Improved RA member experience with nurse support
Sally starts DMARD; nurse helps her understand disease process
Proactive engagement helps ensure adherence and address any of Sally’s side effects
Ongoing outreach helps Sally address any questions about her therapy
Sally is engaged and adherent to her DMARD therapy

During an early stage of the pilot, the interventions had a favorable effect on improving non-biologic DMARD adherence and delaying specialty drug adoption in a small study population. Phase II, involving a larger population, is underway.

RA Therapy Management Pilot

The second pilot focuses on therapy management in patients who have been on a DMARD or biologic for three to six months. Developed in partnership with several expert rheumatologists, this novel approach can help improve outcomes and reduce cost by applying integrated end-to-end therapy management to optimize the treatment plan for each member with RA.

Dedicated pharmacists focused on RA engage plan members and their providers to deliver high-touch support throughout the treatment journey

The pilot uses our existing member engagement capabilities as well as our physician connectivity to optimize first-line therapy and a combination of self-reported data and diagnostic test results to inform biologic therapy management. Its goals are to support providers with more precise data, eliminate waste, improve health outcomes and enhance member experience.

In this concierge model, pharmacists proactively reach out to members to offer education, adherence support and clinical assessment to ensure that the DMARD is working as expected. They will use members’ self-reported outcomes to engage with providers and recommend next best actions to help optimize therapy. This can help ensure that escalation of therapy to a biologic is done with data-driven precision.

Dedicated pharmacists provide real-time access to members and provider follow-up to help optimize first-line therapy


Member

Pharmacist

Provider

Proactive outreach after diagnosis to help ensure members are more engaged in their care
Provider outreach to share data and recommend next best actions
Checkmark Medication therapy education and adherence support
Checkmark Monthly clinical assessments to monitor disease activity and therapy effectiveness
Checkmark Suggest the physician conduct a polyglutamate blood test
Checkmark Optimize current dose
Checkmark Switch to injectable

Member

Pharmacist

Proactive outreach after diagnosis to help ensure members are more engaged in their care


Checkmark Medication therapy education and adherence support
Checkmark Monthly clinical assessments to monitor disease activity and therapy effectiveness

Pharmacist

Provider

Provider outreach to share data and recommend next best actions


Checkmark Suggest the physician conduct a polyglutamate blood test
Checkmark Optimize current dose
Checkmark Switch to injectable

When a member starts on first-time therapy, ideally a traditional DMARD, lab testing can be employed to help determine what initial dosage might deliver clinical benefit and prevent disease progression.

If first-line treatments are unsuccessful, molecular diagnostics can be used to gauge whether the initial DMARD therapy can be further optimized or provide verification that the decision to move to a biologic is clinically sound.

Data science, molecular diagnostic tests and clinical assessments help ensure each member starts on the most clinically appropriate therapy at every stage of their treatment journey.

Once a member starts on a biologic therapy, our pharmacists will proactively engage and encourage them to take the RAPID3, a clinically validated RA condition severity assessment.

This helps monitor disease activity and progression and, depending on the member’s response, it may mean the dosage can be tapered. The pharmacist will continue to share the assessment results with the member’s provider to help them make informed, data-driven decisions on the member’s RA care.

The two pilot programs can work together to optimize RA therapy management.

Ensure members start and stay on most appropriate biologic to help eliminate wasteful spend

Checkmark EHR connectivity gives pharmacist visibility to patient disease progression, awareness when patient will transition to biologic
Checkmark Physician outreach. Pharmacist suggests use of biomarker testing to select optimal treatment for patient
Checkmark Member begins appropriate biologic
Checkmark High-touch member support continues. Pharmacist administers clinical assessments to gauge disease activity and therapy effectiveness
Checkmark Member responses show remission and/or low disease activity
Checkmark Physician outreach. Pharmacist talks to physician about dose tapering or suggests use of biomarker test to determine member eligibility for dose tapering

Real and enduring cost savings in specialty and RA

In 2019, we began overhauling our Specialty Guideline Management (SGM) criteria to better meet our clients’ and patients’ needs; enhancements have continued into 2021. As a result, we have been able to help our clients better manage RA drug costs.

SGM RA
2019 denial rates: 14.1%
Q2 2021 denial rates: 21.5%
7.4% point difference
Enhanced SGM RA
2019 denial rates: 14.9%
Q2 2021 denial rates: 18.8%
3.9% point difference
SGM RA
2019 denial rates: 14.1%
Q2 2021 denial rates: 21.5%
7.4% point difference
Enhanced SGM RA
2019 denial rates: 14.9%
Q2 2021 denial rates: 18.8%
3.9% point difference
Want to learn how proactive RA management can lower your plan's specialty costs? Ask Us
BRIEFING
January 13, 2022
Executive Director, Product Development & Innovation, CVS Specialty