Methotrexate remains a first-line choice of treatment for patients with rheumatoid arthritis (RA), with an average of 72 percent of patients receiving the agent as first-line therapy. Rheumatologists believe it is the best first-line therapy — it’s cost effective, and evidence of its efficacy is supported by three decades of clinical study.

Among biologic treatments for patients with RA, however, tumor necrosis factor (TNF) inhibitors seem to be the favored first-line treatment (82 percent), according to Datamonitor’s report “Stakeholder Insight: Rheumatoid Arthritis,” a survey of 180 rheumatologists in seven major world markets (the United States, Japan, France, Germany, Italy, Spain, and the United Kingdom).

But that position may change by 2015, when first-line use of TNF inhibitors is predicted to fall to 64 percent, in the face of higher usage of drugs with other mechanisms of action. Further, the report predicts a proportional decline in the use of TNF inhibitors from first line to fourth line.

“We also predict an overall increase in the number of biologic therapies, so even though the proportions are changing, TNF therapy still remains a growth area. We would expect sales to start falling as a result of the biosimilars coming on the market in 2014,” says Clare Davies, a lead analyst at Datamonitor.

TNF inhibitors are currently a mainstay of early biologic management of RA, whereas therapies using alternative mechanisms are used when the disease progresses or when TNF inhibitors lose their efficacy. By 2015, rheumatologists will be considering drug therapies with other mechanisms of action, such as interleukin (IL-6) and CD20. It is predicted that earlier usage of non-TNF biologics will increase more than 2.5 times from 14 percent of first-line RA patients to as much as 36 percent in 2015.

“RA is difficult to treat, so clinical executives in managed care companies are going to have a hard time setting up guidelines,” Davies says. “Physicians are worried because there are new biologics on the horizon, and managed care will be setting up different restrictions on their use.” She says the rumblings of concerned physicians may soon move from the background to the foreground.

Tina Taylor, an associate analyst at Datamonitor, says the RA arena is really changing, “and how rheumatologists approach the management of RA in 2015 should be a consideration as clinical executives make policy and decisions.”

Mean percentage of patients receiving TNF inhibitors, 2010 and 2015

Source: Datamonitor. Stakeholder Insight: Rheumatoid Arthritis — Rising competition by line and severity, 2010

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.