High Out-of-Pocket Cost of Biologic DMARDs for Medicare Patients with RA

VBCR - February 2013, Volume 2, No 1 - Health Economics

Access to a rheumatologist key to appropriate drug therapy

By Phoebe Starr

Washington, DC—Medicare beneficiaries who have a low-income subsidy are more likely to have access to rheumatoid arthritis (RA) biologic therapy through their Part D drug benefit than those who face the Medicare coverage gap (also known as the “donut hole”), according to results of a study reported by Jinoos Yazdany, MD, Assistant Professor at the University of California, San Francisco, at the 2012 meeting of the American College of Rheumatology (ACR). A second study by Dr Yazdany and colleagues showed that older and poorer patients with RA face reduced access to appropriate care provided by a rheumatologist.

Medicare Part D provides prescription drug benefits to older and disabled Americans, and the program now includes many of the biologic therapies used to treat RA. However, Medicare beneficiaries pay a deductible, then 25% coinsurance up to an initial limit of $2930. Then, they face the donut hole until their total out-of-pocket (OOP) expenses reach $4700. After that figure is reached, they pay 5%, $2.50 for generic drugs and $6.30 for brand-name drugs.

Biologic versus Nonbiologic DMARD Costs

The first study compared the drug utilization and OOP costs for biologic and nonbiologic disease-modifying antirheumatic drugs (DMARDs) for 2 groups of patients who were enrolled in Medicare Part D who were subject to a coverage gap and low-income patients who were not subject to cost-sharing. The study population was a random sample of 5808 Medicare beneficiaries aged ≥65 years who had claims for Medicare Part D prescription drugs and 1414 beneficiaries with a low-income subsidy.

Overall, 679 (12%) were classified as DMARD users and 5129 (88%) were classified as nonbiologic DMARD users. Of these, 1414 (24%) received a low-income subsidy: 44% of the biologic DMARD users versus 22% of the nonbiologic users.

For the low-income subsidy group, the OOP annual costs for biologics and nonbiologics were low ($26 and $11, respectively), with little variation over the benefit phases. The nonsubsidized OOP costs for biologics and nonbiologics were $3009 and $85, respectively. Across the benefit phases, larger variations in OOP costs were for biologics (from $21 to $1805) compared with nonbiologics (from $21 to $75), with the highest costs occurring during the coverage gap phase.

“This study suggests that the coverage gap may prevent patients with RA who face substantial cost-sharing from accessing biologics through Part D. There are no generic equivalents of biologics, and 100% of patients with RA will reach the donut hole. However, low-income patients receive a subsidy to fill the donut hole, and they are not exposed to cost-sharing for Part D. We compared the population that faced the donut hole with the population that received a low-­income subsidy,” stated Dr Yazdany.

Dr Yazdany noted that the Affordable Care Act will eliminate the donut hole by 2020; however, Part D will shift the coinsurance levels so that patients will be responsible for 25% of their drug costs until they reach the “catastrophic” level of $4000 an­nually. “Our analysis suggests that patients will fare about the same as they did with the donut hole. We will still have a problem. We have to figure out how to pay for these expensive drugs,” she noted.

Access to a Rheumatologist Is Crucial

A second study showed that Medicare beneficiaries without access to a rheumatologist were more likely to be treated with suboptimal therapy.

“Access to a rheumatologist was the single strongest predictor of DMARD use. Medicare recipients who did not see a rheumatologist were more likely to be treated with steroids alone, which is not recommended therapy. This study suggests that it is important to track the use of DMARDs as a performance measure in Medicare recipients,” Dr Yazdany stated.

To look at the patterns of care, the investigators tracked the use of DMARDs, which is recommended by the ACR guidelines, and steroid therapy in a random sample of Medicare fee-for-service beneficiaries with RA. Of these, 7974 patients with RA were treated with a DMARD, and among those who did not receive a DMARD, 824 received ≥6 months of steroids as the sole therapy for their RA.

Compared with those who received a DMARD, those in the steroid-alone group were more likely to be older (17% were aged ≥85 years, 7% were 74-79 years) and to have low incomes (13% had low income vs 9% in other income groups).

The strongest predictor of steroid utilization as the sole treatment for RA was access to a rheumatologist; only 6% of the patients with RA who saw a rheumatologist received steroids alone compared with 16% of those who saw other providers. In addition, the rates of in-patient admissions and comorbidities were higher in the patients who received steroids alone.

“Patients with multiple risk factors—that is, low income, older age, and no contact with a rheumatologist—fared worse in terms of receiving recommended treatment,” Dr Yazdany said. “This information may be useful to payers and health systems seeking to improve performance on quality measures for RA.”

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