Mitigating the impact of RA — one of the most expensive autoimmune conditions to care for

A healthcare professional holds a patient's hand.

Prem Shah, Executive Vice President, Specialty and Product Innovation, CVS Health

Rheumatoid arthritis (RA) affects less than 1% of the U.S. population, but has a significant impact on those living with it, and places a cost burden on the broader health care system.

RA is an autoimmune disorder where the immune system attacks otherwise healthy joints. This can cause chronic pain, joint stiffness, and deformities. About 40% of patients also experience symptoms in the kidneys, heart, lungs, bone marrow, and other parts of the body. It can increase the risk of heart disease and diabetes and affect employment and overall quality of life.

Although there is no cure, the right therapy regimen can help patients manage symptoms and slow disease progression. However, treatment can be complex and costly. As the costs of treating RA continue to rise, starting patients on the most appropriate treatment for their disease stage is critical to managing spend. Solutions that focus on improving the RA care journey and ease the financial burden could benefit both patients and payors.

The what and why of RA’s financial impact

Autoimmune conditions are among the top drivers of pharmacy spend for payors, according to CVS Caremark book of business data. RA alone contributes an estimated $22.3 billion in annual U.S. healthcare costs. Key cost factors include diagnosis timing and therapy selection.

One CVS Health analysis found that 7% to 12% of patients newly diagnosed with RA were diagnosed “late” — in a hospital inpatient or emergency room setting rather than at a physician’s office — leading to $4,055 more in medical spend.

Once diagnosed, RA treatment typically begins with low-cost traditional disease-modifying anti-rheumatic drugs (DMARDs) such as methotrexate, which are administered orally. Biologic DMARDs are a newer class of specialty RA treatment for patients who fail initial therapy with oral DMARDs and can cost $10,000 to $30,000 per year. Our analysis of prescription claims history shows that some patients are prescribed treatments that don’t follow clinical guidelines on recommended drugs or are progressed to a biologic medication without trying a non-specialty first-line therapy.

Patients may also need to try multiple drugs before finding one that’s most clinically effective for them. One survey found that nearly half of patients cycled through at least two biologics during the course of their disease, while 43% had to try three. Two common biologic classes for treating RA include tumor necrosis factor (TNF) inhibitors and Janus kinase (JAK) inhibitors. In recent years, TNF inhibitors have become one of the largest selling, highest-cost drug classes, and yet research shows that 30% to 40% of patients may not respond to TNF inhibiting medications, either initially or over time. Trying multiple therapies can make the patient experience unnecessarily complicated and lead to wasteful spending.

Therapy selection and dose optimization

When a patient 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. We hope that newer tests will be able to also predict which biologic a patient is most likely to respond to, potentially reducing wasted spend on those who may not benefit from them. Clinical evidence suggests tapering off biologic therapy once symptoms are successfully managed may be possible for many patients. 

Expanded use of testing in treating RA could improve clinical outcomes while delivering payor and patient cost savings by personalizing treatments for each individual patient, preventing early advancement to biologics, and using testing to inform when, and for how long, treatment with a biologic therapy is appropriate.

Patient engagement and support

COVID-19 has accelerated the already rising consumer demand for more digitally enabled, connected health care. Digital tools can help patients better manage their conditions, treatments, and side effects while providing continuity of care between provider visits. They also expand the point-of-care to patients’ computers and phones.

Patients taking specialty medications, such as biologics, can benefit from an extra layer of support. For example, CVS Specialty patients can use secure messaging from an app, within the patient portal, or on the phone to ask specially trained teams of pharmacists and nurses medication related questions. Symptom tracking and targeted clinical interventions conducted by a pharmacist can also help improve clinical outcomes and prevent wasteful spend.

Multiple approaches to deliver payor and patient value

Using our integrated model and capabilities, we’re innovating to deliver approaches that collectively help patients manage their condition and lower costs.

When patients start on oral DMARDs, a dedicated pharmacist could help monitor their therapy progress and support medication adherence. We can then work with prescribers and payors to ensure patients obtain the right lab test to help confirm the treatment is working for them.

For patients whose condition is not successfully managed on oral DMARDs, we can work with their providers to help make their transition to a biologic as seamless as possible. At the same time, we can work with their prescribers to reduce the dose when they decide a change is appropriate, to support patient clinical outcomes and better manage cost.

Throughout therapy, we’re able to provide patients with the Routine Assessment of Patient Index Data 3 (RAPID3) questionnaire, which has shown promise in helping clinicians determine how well RA is being managed, and ensuring a stronger patient voice in their care.

By innovating with prescribers and our payor clients, we have designed a program aimed at improving the patient experience, following the American College of Rheumatology (ACR) guidelines for individuals diagnosed with RA. Through a collaborative approach, we aim to develop and scale a comprehensive RA management solution for plan sponsors that supports plan member health and lowers costs across the RA journey.