Rheumatoid Arthritis costs the U.S. more than $19 billion annually, accounting for nearly half of the overall specialty drug trend for the first half of 2017 for CVS Health’s pharmacy benefit management clients.
In response to the growing cost and utilization of RA drugs, the company introduced a program to help better manage the care and cost of this condition. Transform Rheumatoid Arthritis Care is the latest addition to the company’s suite of condition-specific and highly personalized interventions designed to help PBM members manage chronic conditions more effectively. The objective is to improve clinical outcomes, as well as reduce hospitalization, emergency care and overall costs.
The combination of clinical and cost management strategies, including value-based contracting from the RA program, can produce up to 5% savings for PBM clients, reports Troyen A. Brennan, M.D., executive vice president and chief medical officer of CVS Health. Those savings can quickly add up. An employer with 100,000 lives, for example, could save $500,000 a year.
Transform RA Care also includes a trend guarantee for PBM clients based on the program’s ability to improve both clinical care and cost management for RA, as well as predictability in cost for employers.
As the second most common form of arthritis, RA affects more than 1.5 million Americans, Characterized by chronic inflammation of the joints, over time it can lead to bone deformation. “RA is a very complex disease to manage,” Brennan explains. “Patients often struggle to stay on medication and need help managing their symptoms, side effects and the condition.” He describes adverse events, including disease-related complications and hospitalizations, as can “very costly for payers.”
Incremental savings
Nevertheless, there are cost-saving opportunities. Less expensive, disease-modifying anti-rheumatic drugs known as DMARDs “are often very effective and a good first line of defense for treating patients with RA,” according to Brennan.
While biologic therapies are increasingly popular for treating RA, they come with a higher price tag. Under Transform RA Care, CVS Health negotiates several outcomes-based contracts for autoimmune agents, which he says help deliver incremental savings while enabling better patient outcomes. These contracts tie reimbursement for a drug to achieving a specific target or goal.
When a drug does not effectively treat a condition or is not well tolerated, most patients will discontinue therapy. For certain RA drugs, he says “outcomes-based contracts ensure that if the member discontinues therapy, the manufacturer will be required to provide additional value.”
Formulary management is also a cornerstone of cost control for payers and key to managing spend across traditional and specialty therapies, he adds.
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Transform RA Care provides clinical support from specialty nurses and pharmacists at CVS Health’s Accordant subsidiary who offer disease management support. RA CareTeam services include an initial clinical assessment, benefits verification, care coordination and medication dispensing and distribution options.
The national drugstore chain’s Specialty Connect program allows RA patients to pick up their medication at their local CVS pharmacy or through a home delivery mail-order option for greater convenience. Brennan says 18.5% of new autoimmune patients prefer the former over the latter to pick-up their prescriptions. In addition, he cites “innovative digital tools” that can help members start and stay on therapy, which can lead to better medication adherence and clinical outcomes.
As part of Transform RA Care, CVS Health also is expanding its indication-based management offering to include autoimmune conditions. The effort determines formulary placement for specific drugs rather than the therapy class. “By providing preferred placement for clinically appropriate, cost-effective drugs to treat specific indications, we can negotiate better pricing and rebates with manufacturers on behalf of our clients,” Brennan explains.
In addition to Transform RA Care, CVS Health launched Transform Diabetes Care in 2016 to help PBM members lower A1C levels and better manage their condition. The program integrates PBM cost management strategies with personalized, high-touch support, including in-person pharmacist counseling, diabetes-specific coaching and care by a nurse practitioner at CVS’s MinuteClinic. Brennan says the program “guarantees single-digit year-over-year trend for anti-diabetic drugs.”
The specialty drug category for CVS Caremark grew to nearly 36% of overall gross spend on prescription drugs last year and is expected to reach 55% by 2020. Apart from anti-inflammatory medications for RA and psoriasis, other major cost-drivers included antineoplastics and adjunctive therapies used to treat cancer, as well as psychotherapeutic and neurological agents, including multiple sclerosis therapies.
