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Value Propositions - August 2017

VBCR - August 2017, Vol 6, No 3 - Value Propositions

Switching from Oral to Subcutaneous Methotrexate Before Initiating Biologics Lowers Cost Burden

Over a time frame of 5 years, drug costs for patients with rheumatoid arthritis (RA) were 4- to 8-fold higher among those who started with oral methotrexate (MTX) and switched to biologics compared with those who continued oral or subcutaneous (SC) MTX, according to the results of a recent trial.

With biologics being more expensive than MTX and other traditional disease-modifying antirheumatic drugs, and with titration to higher doses of oral MTX and SC MTX underused, Joseph Lee, PhD, Statistician, Evidera, San Francisco, CA, and colleagues sought to evaluate the 5-year healthcare costs of 35,640 patients who initiate and use only oral MTX continuously; switch to SC MTX; or switch to or add a biologic therapy to their regimen.

Using patients with RA from the Symphony Health Solutions database (Integrated Dataverse) who began taking oral MTX in 2009 and had claims pertaining to RA for each year through 2014, Dr Lee and colleagues divided up 4 treatment cohort groups for analysis. These 4 groups included patients who (1) maintained use of oral MTX, (2) switched to SC MTX, (3) switched to SC MTX before adding or switching to a biologic therapy, or (4) switched to or added a biologic therapy. Costs were estimated for each cohort with regard to office visits, emergency department visits, hospitalizations, and pharmaceuticals.

A total of 15,599 patients continued to use oral MTX, with an average per-patient cost of $47,464 throughout the 5-year period; 1802 patients switched to using SC MTX, with an average cost of $59,058 per patient; 711 patients switched to SC MTX before adding or switching to a biologic, with an average per-patient cost of $175,391 and a mean time of 1184 days until biologic use; and 17,528 patients added or switched to a biologic from oral MTX, with an average per-patient cost of $212,595 and a mean time of 478 days to biologic use.

Dr Lee and colleagues asserted that biologic treatments were responsible for cost variances between cohorts, and that patients who used oral MTX exclusively before using biologics incurred higher costs than patients who switched to SC MTX.

“Increasing the use of oral or subcutaneous MTX in appropriate patients can shift patients from higher-cost treatment pathways to lower-cost treatment pathways. Avoiding or delaying the use of expensive biologic therapies for this patient population will alter the cost distribution and may reduce the economic burden of RA on the US healthcare system,” Dr Lee and colleagues concluded. Lee J, et al. Am Health Drug Benefits. 2017;10:42-49.

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“One-Size-Fits-All” Cost-Sharing Approach May Not Encourage Appropriate Medication Use

According to the results of a recent roundtable based on the fairness and ethics related to variable cost-sharing, formulary tier–based cost-sharing (which typically relies more on cost of treatment than medical appropriateness) may intentionally and unintentionally affect patient outcomes.

Seeking to determine whether a “one-size-fits-all” method encourages appropriate medication use, Jennifer S. Graff, PharmD, Vice President, Comparative Effectiveness Research, National Pharmaceutical Council, Washington, DC, and colleagues assembled a roundtable comprising expert patient, payer, and employer representatives. After studying background documents that included white papers; stakeholder perspectives of health plan, employer, and patient views; an actuarial analysis; and a legal review, the experts were asked to use case studies and reflect on 3 posited factors. These factors included the acceptability of requiring higher-cost sharing; ideal dispersal of financial burden across patients, plan members, and employers; and obstacles and potential solutions for aligning out-of-pocket costs with therapies that are clinically appropriate.

Roundtable panelists expressed that it was less acceptable for patients to face greater out-of-pocket costs if they received higher-cost treatment because of biologic reasons (eg, step therapy or diagnostic results), and more acceptable if the therapy patients received was chosen based on preferences regarding side-effect risk, or drug administration route or frequency.

“When patients have tried lower-cost therapies unsuccessfully, the benefits of higher-cost treatments were certain and significant, the cost difference between treatments was aligned with improved benefits, and penalties due to bad luck were mitigated, then cost-sharing differences should be minimized but not eliminated,” Dr Graff and colleagues explained. Graff JS, et al. J Manag Care Spec Pharm. 2017;23:621-627.

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Shared Decision-Making Linked to Improved Medication Adherence and Patient Satisfaction

Patients who engage in shared decision-making have a greater probability for medication adherence and satisfaction compared with those who do not, according to the results of a recent study by Jennifer H. Lofland, Janssen Global Commercial Strategic Organization–Immunology, Raritan, NJ, and colleagues.

Using a cross-sectional survey linked to administrative claims that covered a time span of 6 months before and 6 months after therapy initiation, Ms Lofland and colleagues analyzed the survey results of 357 patients initiating therapy for Crohn’s disease or ulcerative colitis, or psoriatic arthritis or RA.

Outcome measures for the survey analysis included the Shared Decision Making Questionnaire, Morisky Medication Adherence Scale, and treatment satisfaction, and patients were compared with one another based on their participation in shared decision-making. Healthcare costs were also measured.

Results indicated that patients who engaged in shared decision-making were more likely to be women and have lower health statuses than those who did not engage in shared decision-making (75.0% vs 62.5%; P = .018, and 48.0 vs 55.4; P = .005, respectively). Ms Lofland and colleagues also found that patients with lower Morisky Medication Adherence Scale scores were more likely to be adherent to their medications than those with higher scores, and that patients who participated in shared decision-making reported higher rates of satisfaction with their therapy, and had greater treatment activation, than their counterparts.

There was no difference in overall costs between the study arms, regardless of engagement in shared decision-making, or among patients with psoriatic arthritis/RA.

“This study provides a basis for defining SDM [shared decision-making] participation and detecting differences by SDM participation for biologic treatment selection for autoimmune conditions,” Ms Lofland and colleagues concluded.

Lofland JH, et al. Patient Prefer Adherence. 2017;11:947-958.

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Response to TNFi Therapy Associated with Lower Healthcare Costs Up to 3 Years Following Initiation

Healthcare costs differ greatly between patients with RA who respond to treatment with tumor necrosis factor inhibitor (TNFi) therapy and those who do not, according to the results of a recent study by Michael Grabner, PhD, Associate Director of Life Sciences Research, HealthCore, Inc, Wilmington, DE, and colleagues.

With the aim of comparing the clinical and economic outcomes of patients with RA who do and do not respond to TNFi therapy, Dr Grabner and colleagues conducted a retrospective cohort analysis using claims from 14 large commercial health plans in the HealthCore Integrated Research Database. The study population included 7797 patients with RA who were starting TNFi therapy between January 1, 2007, and April 30, 2014, and treatment response data were evaluated using an authorized claims-based algorithm.

A total of 2337 patients were considered to be treatment responders; these patients were matched 1:1 to patients who did not respond to TNFi therapy for comparison of important baseline characteristics (eg, sex, age, index TNFi agent, and comorbidities). Overall and RA-related healthcare resource use was compared between the 2 groups, as were associated costs.

Patients who responded to treatment had significantly lower all-cause hospitalizations, emergency department visits, and physical/occupational therapy visits than their counterparts who did not respond to TNFi therapy. In addition, total all-cause medical costs were $5737 higher for nonresponders than for responders, which the authors asserted was primarily because of outpatient visits and hospitalizations.

With the exclusion of biologics, mean all-cause pharmacy costs were $354 higher for patients who did not respond to treatment than for those who did. Alternatively, the mean costs for conventional synthetic and biologic drugs were $8579 higher for those who responded to treatment than for those who did not; the investigators attributed this to the responding patients’ higher adherence to their index TNFi drug (P <.01).

“Findings derived from this real-world analysis suggest that patients with treatment response, compared to patients without response, had lower all-cause medical, pharmacy, and total costs (excluding biologics) over up to 3 years from initiation of TNFi therapy,” concluded Dr Grabner and colleagues. Grabner M, et al. Arthritis Res Ther. 2017;19:92.

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