Dallas, TX— Insurance claims for individuals with rheumatoid arthritis (RA) accounted for a mean total cost of care 3.5 times higher than that of individuals without RA, with approximately 67% of the difference attributed to biologic or targeted synthetic disease-modifying antirheumatic drug (DMARD) use, according to the results of a recent study presented via poster at the Academy of Managed Care Pharmacy Nexus 2017 Conference.
The objectives of the study were to determine the prevalence of RA in a commercially insured population of 15 million members, and to define the total medical and pharmacy expense claims by category for members with RA stratified by treatment, as well as for members with RA compared with a matched sample of members without RA. To accomplish these objectives, Kevin Bowen, MD, MBA, Principal Health Outcomes Researcher, and Patrick Gleason, PharmD, FCCP, BCPS, Director of Health Outcomes, Prime Therapeutics, Eagan, MN, evaluated the claims of 3.25 million members who were enrolled in the insurance plan continuously from 2013 to 2016.
“Health plans need to understand which categories of claims expense occur in excess for members with rheumatoid arthritis...and, of these, which are potentially modifiable by improved drug therapy,” Dr Bowen and Dr Gleason explained.
In their study, Dr Bowen and Dr Gleason classified members as having RA (ie, having ≥2 medical claims with a diagnosis code for RA) or not having RA (ie, having no claims with a diagnosis code for RA). A random sample of members without RA were sex-, age-, and plan-matched 5:1 to members with RA. Members with RA were categorized, based on 2016 pharmacy and medical drug claims information, as using biologic or targeted synthetic DMARDs, using conventional synthetic DMARDs only, or as not using DMARDs.
A total of 26,098 members were categorized as having RA. The mean age of these members was 52.9 years, and the total cost per patient per year (PPPY) for 2016 was $27,993. These members were matched with 130,490 members who did not have RA who also had a mean age of 52.9 years. The total cost PPPY for 2016 for these nonRA members was $8,149.
Among those with RA, the total costs for 2016 PPPY by drug were $51,911 for the 8761 members using biologic or targeted synthetic DMARDs; $15,068 for the 9135 members using conventional synthetic DMARDs only; and $16,841 for the 8202 members not using DMARDs. Biologic or targeted synthetic DMARDs accounted for $35,896 (69.2%) PPPY of the total costs for members using these agents, and 61.3% of the difference in PPPY between all RA and nonRA members.
Of the excess costs PPPY for all members with RA, other medical outpatient costs, medical inpatient costs, and other pharmacy costs accounted for 19.9%, 11%, and 7.8%, respectively.
“The results suggest the greatest opportunities for reduction in the direct costs of RA may be strategies that optimize therapy with cs [conventional synthetic] DMARDs prior to escalating to b/ts [biologic or targeted synthetic] DMARDs,” Dr Bowen and Dr Gleason concluded.