Managed Care Considerations for the Management of Rheumatoid Arthritis

Rheumatoid arthritis (RA) affects about 1.3 million Americans and, in 2010, was associated with $39 billion in medical costs. Choosing a treatment option can be difficult due to the complex treatment landscape, disease heterogeneity, and patient-related factors, thus individualized treatment is warranted. During a presentation at NAMCP 2020 Virtual Spring Managed Care Forum, Allan Gibofsky, MD, JD, MACR, FACP, FCLM, professor of medicine at Weill Cornell Medicine and attending rheumatologist at the Hospital for Special Surgery, discussed treatment considerations and options for RA.

There is a critical treatment window in early-stage disease, as 50% to 70% of patients have radiographic damage within the first two years of symptom onset. Disease activity can be measured via patient- and provider-reported outcomes, as well as laboratory measurements.

The 2017 European League Against Rheumatism recommendations highlighted the following as unfavorable prognostic factors: moderate to high disease activity after conventional, synthetic disease-modifying anti-rheumatic drugs (csDMARDs); acute phase reactant levels; high swollen joint counts; presence of rheumatoid factor and/or anti-citrullinated protein antibodies, especially at high levels; presence of erosions; and failure of two or more csDMARDs.

Dr. Gibofsky noted the ways managed care programs and policies can impact RA care. Medication therapy management can provide patient education and support; care coordination and case management can facilitate the diagnosis and treatment of the condition; utilization management and review can ensure the “right therapy for the right patient at the right time”; contracting and distributing programs can optimize the availability of and access to therapy; and benefit and formulary designs can find a balance between access, use, and cost.

He noted the following treatment access barriers associated with RA:

  • Health systems coverage and management
    • Insufficient supply and coverage
    • Delay in authorization, pricing, and reimbursement system
    • Unequal eligibility rules for treatments
  • Performance and organization of healthcare services
    • Delay in timely access to diagnosis and treatment
    • Lack of care pathways and standards of care
    • Lack of integration of electronic information
  • Interaction with healthcare providers
    • Patients and healthcare providers have insufficient time together
    • Cultural differences and power imbalance between patients and providers
    • Insufficient access to other health professionals (e.g., nurses)
  • Access to therapies
    • High direct costs
    • Insufficient patient involvement in the development of new therapies

He noted that according to a 2010 study published in the Journal of Managed Care & Specialty Pharmacy, patients with RA who are offered medication therapy management programs have significantly higher treatment adherence and improved patient-reported outcomes. These programs provide education and counseling, treat to target support, and a medication review.

Dr. Gibofsky concluded that following guideline-recommended care, initiating early treatment, assessing appropriate use of biologics, and maximizing adherence can help make informed decisions to improve RA outcomes.

Presentation: Novel Treatment Approaches in Moderate-to-Severe Rheumatoid Arthritis: Expert Perspectives on an Evolving Treatment Paradigm. NAMCP 2020 Virtual Spring Managed Care Forum, April 16-17.