RA patients face significant out-of-pocket costs under Medicare

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Better data on when to use biologics could help

Policies for better patient stratification are needed to reduce overall out-of-pocket expenses for those with RA using biologic DMARDs. This study is a very important step, and should help to generate more – and much-needed – conversation around this issue.

Dr. Michael Ward

Adding more information about younger RA patients will help refine knowledge of who should be using these agents and when they are most effective. There is a growing effort to establish a multilayer research database that would cover a younger population to augment the large and publicly available Medicare database of those 65 and older. CMS data are widely used and publicly available, and effectively track a national population, but are limited by capturing only information about older adults who are further along in their disease course.

An important part of the cost-effectiveness conversation going forward will revolve around understanding whether there is utility in using biologic DMARDs very early in the disease process of RA to gain control of the disease. This early intervention may allow patients to taper off medication at a later point. However, clinicians currently don’t have clear indications for when to taper a patient off a biologic DMARD. Better delineation of answers to these clinical questions will help to clarify the cost-effectiveness analysis.

Dr. Michael M. Ward is a senior investigator at the National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, Md. These remarks were drawn from a telephone interview. He reported no disclosures.




Medicare Part D recipients with rheumatoid arthritis face an average of over $2,700 per year in out-of-pocket expenses for biologic disease-modifying antirheumatic drugs, a figure that constitutes a “substantial disincentive” to adherence, according to Dr. Jinoos Yazdany of the division of rheumatology at the University of California, San Francisco, and her colleagues.

For patients with rheumatoid arthritis (RA) who do not respond to less costly nonbiologic disease-modifying antirheumatic drugs (DMARDs), early and aggressive treatment with biologic agents is key to slowing disease progression. However, biologic DMARDs can cost $20,000 or more per year, and may need to be taken over the course of a lifetime.

Dr. Jinoos Yazdany

Dr. Jinoos Yazdany

Dr. Yazdany and her colleagues’ current study examined 2013 data for all 2,737 Medicare Part D formularies, drawn from the Centers for Medicare & Medicaid Services Prescription Drug Plan Formulary and Pharmacy Network Files. Outpatient formularies from all 50 states and the District of Columbia were included. Although all plans covered at least one biologic DMARD, 95% required prior authorization and patients’ coinsurance averaged nearly 30% (Arthritis Rheumatol. 2015 April 21 [doi:10.1002/art.39079]).

A study from 2006 previously showed that estimated out-of-pocket costs for biological DMARDs would exceed $4,000 annually for low-income Medicare beneficiaries in the first year of Part D (Arthritis Rheum. 2009;61:745-54). The current study indicates that even 8 years after Part D plans were implemented, they continued “to use high cost sharing as a primary cost-control mechanism for biologic DMARDs, placing a substantial financial burden on patients who require such drugs for adequate control of their RA symptoms,” the investigators wrote.

Dr. Yazdany and her associates reported that during the period before spending limits were reached and catastrophic coverage was triggered, mean patient cost-sharing for biologic DMARDs was $835 per month. Infliximab was the least expensive option at $269 per month, while anakinra cost patients a mean $2,993 per month. Medicare Advantage plans were more likely to cover biologic agents, but at a higher average patient cost of $862 per month.

Of the nine nonbiologic DMARDs, six were covered by almost all plans with copayments of $5-$10 per month; the least expensive option in each plan averaged $48 per year in out-of-pocket costs. Prior authorizations were not needed for nonbiologic agents.

Dr. Yazdany and colleagues raised the question of whether the policies of prior authorizations, tiered coverage, and high levels of patient cost-sharing contribute to achieving high value care for those with RA who fail first-line therapy. Evidence-based guidelines would move these patients to biologic therapy, but the high level of patient cost-sharing in the current Medicare payment structure has previously been shown to reduce adherence, potentially speeding disease progression and worsening outcomes.

“We have avoided the issue of cost-effectiveness analysis,” Dr. Yazdany said, noting that to date, Medicare has not used reference pricing or negotiated drug costs, in contrast to government payers in many other countries. “We should all work to decrease out-of-pocket costs for people grappling with this serious disease,” she said. “The current situation is really unacceptable. That’s why we need to talk about it.”

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