Consumer cost sharing and use of biopharmaceuticals for rheumatoid arthritis.

n managerial n Consumer Cost Sharing and Use of Biopharmaceuticals for Rheumatoid Arthritis James C. Robinson, PhD, MPH P harmaceutical innovation in recent years has come largely from biopharmaceuticals and other specialty drugs that need novel methods of handling, storage, transportation, and use. 1-4 Many are administered to the patient by a physician in the of- fice, in a community-based infusion center, or in a hospital ambulatory care center. Some new specialty drugs also can be administered by the patient, often through self-injection. Physicians and patients with immunity disorders, cancer, and other complex conditions now often experiment with modes of administration to find the drug that best treats the patient’s symptoms and underlying disease. The choice between office infusion and self-injection for biophar- maceuticals is based in part on clinical factors, as some patients respond Managed Care & the similarity in their reported better to one drug © than to another despite Healthcare Communications, LLC effects and US Food and Drug Administration labeling. 5 Convenience to the patient also plays an important role, with some patients preferring to avoid the time and cost of an office visit while others appreciate the single point of access, administration, and monitoring of side effects at the office. 6,7 Economic factors also may influence drug choices, to the extent the patient’s insurance coverage differentially requires cost shar- ing depending on the mode of administration. 8-10 The literature on the effects of consumer cost sharing on patient use and adherence to prescription drugs has been the subject of 3 extensive reviews. 11-13 All report that patients facing high deductibles, coinsur- ance, coverage limits, and cost sharing through tiered drug formularies are less likely to use prescribed drugs. Where outcomes data are available, the studies find worse reported outcomes among patients facing higher levels of cost sharing. However, only 1 of the published studies considers the impact of cost sharing on the use of physician office–administered specialty drugs and patient self-injected specialty drugs, given the diffi- culty in obtaining data on specialty drug use and linking it to data on in- surance benefit design and cost sharing. In that study, 14 Karaca-Mandic and colleagues report that benefit generosity affected the likelihood that rheumatoid arthritis patients initiate and continue with specialty drug therapy. The authors did not find an impact of consumer cost sharing for physician-administered (medical benefit) as distinct from patient self- administered (pharmacy benefit) specialty drugs. This study evaluated the as- sociation between consumer cost In this article sharing on the one hand and Take-Away Points / e206 the choice between physician- Published as a Web exclusive www.ajmc.com administered and patient self- VOL. 19, NO. 6 Objectives: To evaluate the effect of consumer cost sharing on use of physician-administered and patient self-administered specialty drugs for rheumatoid arthritis. Design: Multivariate statistical analysis of prob- ability and use of physician-administered spec­ ialty drugs, patient self-injected specialty drugs, non-biologic disease-modifying anti-rheumatic drugs, and symptom relief drugs. Analyses were conducted for patients enrolling in preferred pro- vider organization (PPO) plans and health main- tenance organization (HMO) plans with different cost-sharing requirements, adjusted for patient demographics, health status, and geographical location. Setting: Professional, facility, and pharmaceutical claims for beneficiaries of CalPERS, the public employee insurance purchasing alliance in California, for 2008-2009. Consumer cost-sharing requirements were obtained for each type of drug and service for each type of insurance plan. Results: PPO insurance enrollees face substan­ tially higher cost sharing for physician-adminis- tered specialty drugs, compared with HMO en- rollees in CalPERS. PPO patients with rheumatoid arthritis are only half as likely as HMO enrollees to choose a physician-administered specialty drug (4.2% vs 9.3%) (P <.05), and use 25% less of the drugs if they use any ($10,356 vs $13,678) (P <.05). They are 30% more likely to use a self-admin- istered specialty drug than are HMO enrollees (29.3% vs 22.1%) (P <.05), and use 35% more of the drugs if any ($16,015 vs $12,378) (P <.05). Conclusions: Consumer cost sharing reduces the use of physician-administered specialty drugs for rheumatoid arthritis. The higher use of patient self-administered specialty drugs suggests that the disincentives for use of physician-adminis- tered drugs were offset by an increased incentive to use self-administered drugs. Am J Manag Care. 2013;19(6):e205-e213 For author information and disclosures, see end of text. THE AMERICAN JOURNAL OF MANAGED CARE n n e205