Background/Purpose

Use of biologic agents for the treatment of rheumatoid arthritis continues to grow rapidly, with the cost of these agents putting a significant strain on health care budgets.  Although rheumatologists and third party payers share the goal of ensuring quality of care for RA patients, rheumatologists fear potential limitation of access to biologics due to cost while third party payers are concerned about the rising expenses associated with the use of these agents.  New models of healthcare delivery stress the relationship of cost to quality and improved outcomes. This results in adversarial and inefficient procedures between physician and insurer. Treatment pathways have been suggested as a means to address these issues.

Methods

At the request of CareFirst/Blue Cross and Cardinal Health,  we organized a committee of 12 community based rheumatologists to create a treatment pathway for RA patients based on published evidence and community standard of care.  CareFirst did not participate in the specific details of the pathway in accordance of the belief that structure should be driven by community standards. Practices that reached 80 % compliance with the program were offered increased reimbursements to offset the cost of data collection and program compliance.  Compliance was judged as follows.  All patients insured by CareFirst with the RA ICD-9 code of 714.0 were required to be entered into the pathway.  Patient visits were required at a minimum of every 3-6 month intervals with a Clinical Disease Activity Index (CDAI) measure recorded at each visit.  The use of a non -biologic DMARD (methotrexate unless contraindicated) was mandated for 3 months prior to initiation of first biologic therapy.  Indication and dosing of biologics were to be within the package insert guidelines but no specific biologic agent was preferred by the pathway.  Site of infusion was required to be non-hospital based.  Patients were not required to change biologics for ongoing disease activity, but biologics could not be initiated, switched or increased if the patient was in CDAI remission.  Data was captured using a real time iPad based tool.   

Results

Over the first 12 months, 80 physicians from 37 practices in the mid Atlantic were recruited and 1800 patients were entered into the pathway.  Over 90% of patients were on compliant pathways and 74 % of practices reached compliance.  Over 70% of patients were in remission or low disease activity by CDAI measurement.    Biologic switches were infrequent.  Within the program, site of infusion was more likely non-hospital based. 

Conclusion

To our knowledge this is the first collaboration between rheumatologists and a third party payer to create a Rheumatoid Arthritis treatment pathway to assure proper biologic use and assess outcomes.  We believe this is a powerful model to assess and improve cost and effectiveness of treatment strategies for rheumatoid arthritis.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/collaboration-between-a-third-party-payer-and-community-rheumatologists-to-create-a-clinical-pathway-for-the-treatment-of-rheumatoid-arthritis-to-assure-proper-use-of-biologics-and-quality-of-care/