Rheumatoid arthritis: Clinical guidelines can improve standard of care, Part 3

Data shows us whether members are getting the most effective treatment

December 27, 2017
Advances in the treatment for rheumatoid arthritis (RA) have helped to help make RA a chronic, manageable condition.

PBMs and plan sponsors can help smooth out the bumps of our health care system. We can design benefit plans that support informed decision making by members and doctors.

Integration can help improve care for members with RA

Prime’s research of integrated medical and pharmacy claims gives us a window into the relationship between members and doctors. It has its limitations, of course. But it does provide valuable insights.

Part 1 of this series looks at “treat to target” guidelines for the member diagnosed with RA:

Starting on drug therapy as soon as possible to stop progression of the disease.
Meeting with the doctor regularly and adjusting the treatment regimen as needed until the member is stable.

Get on DMARDS quickly

The research found that 44 percent of members identified as newly diagnosed did not have a claim for any disease-modifying anti antirheumatic drug (DMARD) within 1 year of diagnosis and almost 40 percent did not have a claim within 2 years.1

Time to first DMARD claim among members newly diagnosed with RA in 2014

Find a doctor

The data show that 25 percent of members with RA are not seeing a rheumatologist. The American College of Rheumatology suggests that the United States projected a shortage of more than 4,000 rheumatologists for its population.3

Most rheumatologists practice in major urban areas. For many people living in cities with a population under 50,000 or in rural areas, they might need to drive as far as 200 miles to see a rheumatologist. Many may see a family general practitioner instead.

But 25 percent of members with RA did not have an appointment with any doctor in the year studied. DMARD drug therapy and regular doctor visits go hand in hand and are part of RA treatment guidelines.

Don’t skip annual tests

40 percent of members with RA did not get the routine annual tests recommended to monitor the progression of RA.

Intervention: If our GuidedHealth system identifies a member’s diagnosis of RA in medical claims without a corresponding DMARD drug claim, this triggers an outreach to a doctor. This is a gap in care module in GuidedHealth. The importance of regular testing and doctor visits could be included with this.

Pharmacy guidance built into benefit design can support treatment regimens

Only 4 percent of members received treatment that followed guidelines, using triple therapy of conventional (csDMARDs) before progressing to biologic (b/tsDMARDs).1

Intervention: Benefit design and UM strategies can support RA treatment guidelines.

Because of the high cost of b/tsDMARDs, initiating, discontinuing, or switching therapy are big decisions. They impact both direct and indirect costs. Health plans should evaluate whether their utilization management strategies encourage compliance with RA guideline recommendations.2

GuidedHealth® could provide additional outreach to doctors, customized based on their prescribing behavior (see Part 2 of this series).

Use of a specialty pharmacy supports the needs of the member with RA
Prime has conducted extensive research on members with specialty conditions, including RA. With effective treatment, the member with RA can live a full, productive life. But they have unique needs.4

Intervention: Prime recommends benefit design that that uses an accredited specialty pharmacy. This maximizes high-touch member service from staff experienced with this disease.

For the member with RA, life is sorted between good and bad days. The world can become smaller, often including only close friends and family. Fatigue and depression may be frequent and oppressive.

Medicine may become routine, but members with RA need it to be absolutely reliable.4 Insurance details must be handled meticulously. Refill details are important. Members can’t be surprised with a week’s delay for a refill request that needs to go back through their doctor. Symptoms fluctuate. Changes in medicine routine can trigger many kinds of physical issues. Members may need to be able to talk to someone knowledgeable about their medicine and its side effects.4 Plan sponsors that select a specialty pharmacy to deliver specialty medicines can should expect consistent, high quality member care. AllianceRx Walgreens Prime specialty pharmacy is designed to coordinate care and improve health outcomes.

Nothing will replace the doctor’s relationship with a patient. But in today’s environment, we can look for ways to inform decision making. And we can support members in following the treatment regimen outlined by their doctors.


1. Bowen KL, Gleason PP. Rheumatoid arthritis 2016 prevalence, drug treatment, and total medical and pharmacy claims expense in a 15 million member commercially insured population. Poster presentation, Dallas, Texas, AMCP October 2017.

2. Bowen KL, Gleason PP. Incidence Rate of Biologic/Targeted Synthetic (b/ts) Disease Modifying Antirheumatic Drugs (DMARDs) for Rheumatoid Arthritis (RA), Preceding Therapy and Time to Discontinuation in a Commercially Insured Population. Poster presentation, Dallas, Texas, AMCP October 2017. AMCP 2017.

3. “Shortage of Rheumatologists–In Some U.S. Regions Closest Doctor May Be 200 Miles Away.” Nov. 06, 2013. 2017 American College of Rheumatology. Acccessed at: https://www.rheumatology.org/About-Us/Newsroom/Press-Releases/ID/29/Shortage-of-RheumatologistsIn-Some-US-Regions-Closest-Doctor-May-Be-200-Miles-Away

4. “Therapeutic Category Member Profile: Rheumatoid Arthritis,” by Customer Experience & Market Research at Prime Therapeutics, December 2015. © Prime Therapeutics LLC.

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