Out-of-Pocket Costs Put Arthritis Drugs Out of Reach for Some

People with rheumatoid arthritis whose health insurance requires them to pay a higher share of the cost are less likely to use biotech drugs than those with coverage that is more generous. High family medical bills also appear to reduce the use of these powerful but expensive medications, according to a new study in Health Services Research.

Drugs that alter immune system function directly — also known as biologics or biological response modifiers — are often effective when conventional drugs fail. Their use for cancer, autoimmune diseases such as rheumatoid arthritis and other diseases has increased sharply in recent years.

“Our study showed that out-of-pocket cost is a concern in the decision to initiate these drugs,” said lead study author Pinar Karaca-Mandic, Ph.D., an assistant professor in the School of Public Health at the University of Minnesota. “If higher cost-sharing forces people away from preferred, effective therapy, they could end up with higher complication and medical costs.”

The researchers analyzed health insurance data for 35 large private employers during 2000 to 2005 to determine which of 8,557 patients newly diagnosed with rheumatoid arthritis began to use the three most commonly prescribed biotech drugs — etanercept, adalimumab and infliximab — and which of the 2,066 patients who used these drugs then stayed on them.

They found that patients who paid more for these drugs were less likely to start taking them and were less likely to continue taking them once started, although the latter effect was smaller.

Patients whose families had high health care expenses were less than half as likely to start biotech drugs as were those from households with average costs. Once they were taking the medication, however, patients continued to use it regardless of family circumstances.

A growing trend among insurers to apply cost-containment strategies such as stiffer coinsurance rates for biotech drugs makes this possibility worrisome, Karaca-Mandic said.

She said that the influence of household finances on biotech drugs use suggests that, “families have a separate budget for health care, and may not be flexible around expanding it. If other members are getting sick, they may want to draw resources away from the rheumatoid arthritis patient.”

Kevin Schulman, M.D., a professor of medicine and business administration at Duke University, said that the “real core question is: If innovations come in the form of biologics, do we have a mechanism in place to fund them?”

He said that benefits typically are far more generous for hospital services, “which are not innovative,” than for pharmaceuticals.

“The moral of the story is: As we make choices about benefit design, we shouldn’t blindly pursue what we did yesterday, addressing pharmaceutical costs in the absence of mechanisms to address other parts of the health care dollar,” Schulman said.