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Survival and Cost of Biologic DMARDs in a Military Medical Center: A Quality Improvement Project

From the 2019 HVPAA National Conference

Dr. Caleb Anderson (Walter Reed National Military Medical Center), Dr. Sarah Smilow (Walter Reed National Military Medical Center), Dr. Victoria Sullivan (Walter Reed National Military Medical Center), Dr. Rodger Stitt (Walter Reed National Military Medical Center), Dr. Patrick Mastin (William Beaumont Army Medical Center), Dr. Angelique Collamer (Walter Reed National Military Medical Center), Dr. Jess Edison (Walter Reed National Military Medical Center)

Background

High drug costs and lack of transparency of these costs is a major concern in the United States. Biologic therapy for rheumatoid arthritis (RA) is expensive, ranging from $7,000 to $203,000 per patient annually. At our institution, the Department of Defense (DoD) negotiated cost for biologic therapies is not readily available to prescribing physicians. Additionally, there is little guidance on the next best therapy in RA treatment if oral DMARD therapy and an initial TNF inhibitor fails. As a Quality Improvement initiative, we investigated the DoD costs of available biologic treatments for RA.

Objective

We hypothesized that there would be a change in prescribing patterns and substantial cost reductions if rheumatologists had readily available information on biologic medication prices.

Methods

During phase I of this QI project, we conducted a chart review of RA patients on biologics between January 2015 and December 2016. We documented which biologics were used, assigned a monetary cost for each patient, and assessed the overall impact on cost for each biologic therapy switch.

Phase II of the project started with a ‘cost awareness curriculum.’ We acquired and distributed the biologic price-list to Rheumatology clinic personnel. We reviewed the prices and phase I results on a quarterly basis. Fifteen months after implementing the curriculum, we performed a second chart review to document which biologic treatments were utilized.

Results

The Phase I data analysis identified a lower overall use of non-anti-TNF biologic therapies. Among these other biologic therapies, there was an increased use of rituximab ($21,887/4 doses) and abatacept ($29,785/year) over the less costly tofacitinib ($14,633/year).

Fifteen months after instituting the ‘cost awareness curriculum’ we again analyzed the use of biologics. We found that there was increased used of tofacitinib and decreased use of both abatacept and rituximab. This change in practice habits represented a cost savings of $10,232/month or $122,794 over 15 months.

Conclusions

We recognize that many next line treatment decisions involving the use of biologic therapies are based upon patient preference, contraindications, and patient specific factors. In our clinic, rheumatologists selected the lower cost medication more often following education on the costs of available biologics.

Clinical Implications

Biologic drugs are now commonly used in Rheumatology, Gastroenterology, Oncology and many other specialties. In the United States, there is little competition for biologics, but some are less expensive, especially when comparing oral medications to those that require infusions or injections.

Drug costs are not transparent and co-pays vary between insurance companies. Rebate traps and patient assistance programs can obscure the actual cost of drugs, making it difficult for a patient to know what their long-term costs for a drug will be. Physicians often prescribe the drug that is deemed ‘first-line’ or ‘on formulary’ by insurance companies. However, as demonstrated here, once empowered with knowledge of drug costs, physicians are able to save the patient and institution money by practicing cost-conscious medical care, and choosing the less costly medication.