Rheumatoid arthritis: A condition ripe for innovation

Rheumatoid arthritis (RA) is a leading spend driver for payors. While the condition affects less than 1 percent of the U.S. population, it accounts for nearly $22.3 billion in total health care costs per year.¹ Patients on a non-biologic disease-modifying anti-rheumatic drug (DMARD) cost about $1,100 per year, as compared with $38,000 per year for patients who have progressed to a biologic DMARD.²

We are constantly innovating in complex therapeutic categories, testing and learning to identify new ways to improve health outcomes and member experience while lowering overall health care costs.

Our foundation of connected cost management strategies, including formulary, plan design and UM, is designed to maximize savings. We have two innovative pilots underway to explore how to slow disease progression and contain costs throughout the duration of therapy. The first focuses on improving early DMARD adherence, while the second uses sophisticated testing and digital connectivity for delaying progression to biologics and de-escalating biologic therapy when in sustained clinical remission.

RA DMARD Earlier Intervention Pilot

Plan members who have been confirmed to have rheumatoid arthritis and are new to non-biologic DMARD therapy are proactively engaged by a nurse for support. The nurse helps members better manage their condition, treatment plan and side effects, and communicates the importance of adherence. The goal is to enable the member to maintain disease control with the non-biologic DMARD for as long as clinically appropriate, delaying transition to a costly biologic.

Traditional RA member experience

1. Sally starts DMARD
2. Sally experiences side effects and is not adherent to her medication
3. Sally's disease continues to progress; Sally is experiencing pain and joint damage
4. Sally visits her doctor and is prescribed a biologic

Improved RA member experience with nurse support

During an early stage of the pilot, the interventions had a favorable effect on improving non-biologic DMARD adherence and delaying specialty drug adoption in a small study population. Phase II, involving a larger population, is underway.

RA Therapy Management Pilot

The second pilot focuses on therapy management in patients who have been on a DMARD or biologic for three to six months. Developed in partnership with several expert rheumatologists, this novel approach can help improve outcomes and reduce cost by applying integrated end-to-end therapy management to optimize the treatment plan for each member with RA.

The pilot uses our existing member engagement capabilities as well as our physician connectivity to optimize first-line therapy and a combination of self-reported data and diagnostic test results to inform biologic therapy management. Its goals are to support providers with more precise data, eliminate waste, improve health outcomes and enhance member experience.

In this concierge model, pharmacists proactively reach out to members to offer education, adherence support and clinical assessment to ensure that the DMARD is working as expected. They will use members’ self-reported outcomes to engage with providers and recommend next best actions to help optimize therapy. This can help ensure that escalation of therapy to a biologic is done with data-driven precision.

They also provide:

• Medication therapy and adherence support 
• Monthly clinical assessments to monitor disease activity and therapy effectiveness

When a member starts on first-time therapy, ideally a traditional DMARD, lab testing can be employed to help determine what initial dosage might deliver clinical benefit and prevent disease progression.

If first-line treatments are unsuccessful, molecular diagnostics can be used to gauge whether the initial DMARD therapy can be further optimized or provide verification that the decision to move to a biologic is clinically sound.

Data science, molecular diagnostic tests and clinical assessments help ensure each member starts on the most clinically appropriate therapy at every stage of their treatment journey.

Once a member starts on a biologic therapy, our pharmacists will proactively engage and encourage them to take the RAPID3, a clinically validated RA condition severity assessment.

This helps monitor disease activity and progression and, depending on the member’s response, it may mean the dosage can be tapered. The pharmacist will continue to share the assessment results with the member’s provider to help them make informed, data-driven decisions on the member’s RA care.

They may recommend that the provider:

• Conduct a polyglumate blood test
• Optimize the current dose of the DMARD 
• Switch the medication to an injectable formulation

The two pilot programs can work together to optimize RA therapy management.

Ensure members start and stay on most appropriate biologic to help eliminate wasteful spend

1. EHR connectivity gives pharmacists visibility to patient disease progression, awareness when patient will transition to biologic
2. Physician outreach. Pharmacist suggests use of biomarker testing to select optimal treatment for patient
3. Member begins appropriate biologic
4. High-touch member support continues. Pharmacist administers clinical assessments to gauge disease activity and therapy effectiveness
5. Member responses show remission and/or low disease activity
6. Physician outreach. Pharmacist talks to physician about dose tapering or suggests use of biomarker test to determine member eligibility for dose tapering

Real and enduring cost savings in specialty and RA

In 2019, we began overhauling our Specialty Guideline Management (SGM) criteria to better meet our clients’ and patients’ needs; enhancements have continued into 2021. As a result, we have been able to help our clients better manage RA drug costs.