HMOs Want Evidence About Arthritis Drugs

Long-term research needs to be done on the cost effectiveness of biologics in fighting rheumatoid arthritis before health plans can be convinced that coverage of the new agents will save money in the long run, a recent study suggests.

“Taking into consideration the high costs of biologic agents and relatively high rates of use, health care plans may begin to demand evidence of cost effectiveness,” says “Impact of Managed Care on the Use of Biologic Agents for Rheumatoid Arthritis” in the June 15, 2005 issue of Arthritis & Rheumatism. “To establish the cost effectiveness of treatments for RA, it is imperative to show a reduction in rates of joint replacement surgery and work loss, because the former may account for as much as 25 percent of direct costs . . . and the latter may account for as much as 70 percent of total costs of this illness. Because rates of joint replacement are relatively low in any one year and work loss unfolds over a decade or more, it will be difficult to establish that the biologic agents are cost effective without long-term trials of these agents.”

HMOs were much less likely to cover biologics than were other forms of insurance, such as fee-for-service care, from 1999 to 2002, according to the study. In addition, biologic coverage for patients in HMOs was much more likely to be terminated, according to the data that were collected mainly through telephone surveys. One caveat: It wasn’t clear whether the financial incentives in HMOs were the factors that most caused this apparent gap in use of biologics. In addition, the study says that the hesitancy on the part of HMOs may be due to lack of information.

Other factors must also be weighed. “For example, older age, longer disease duration, and a slightly higher number of comorbid conditions of persons with RA in fee-for-service settings may play a role in their higher rates of use of biologic agents,” says the study.

There are some implications for the newly launched Medicare Part D program. “Many persons with arthritis are currently choosing Medicare drug plans,” Edward H. Yelin, PhD, and the main author of the study, is quoted on the Arthritis Foundation Web site. “As they make the choice among plans, they should be cognizant not only of the drugs they are currently taking but of those that may be prescribed for them in the years to come.”

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