As the pharmaceutical pipeline begins to churn out specialty products at a higher rate than traditional therapies, the nation’s healthcare payers are experiencing double-digit growth in their costs for biologics and other high-cost specialties, with specialty drugs expected to consume half of the drug spend by 2018. Perhaps the concern is nowhere more magnified than in the autoimmune disease category (especially rheumatoid arthritis[RA]), given that it represents the highest-cost disease category in the U.S. (according to the pharmacy benefit management industry) and one for which cost trend is expected to accelerate the most, next to oncology.
U.S. managed care organizations (MCOs) have responded by enacting a series of cost-control strategies to tame the trend toward high-cost biologics—from prior authorization and step therapy protocols and increased member cost-sharing to the use of lower-cost sites of care for provider-administered therapies and the use of specialty and mail order pharmacies to better control tracking, reporting, and utilization of drugs.
A variety of therapy options exist for the treatment of the autoimmune conditions RA, psoriatic arthritis (PsA), and ankylosing spondylitis (AS). Typically, conventional disease-modifying antirheumatic drugs (DMARDs) are prescribed first, and the wide availability of generic products in the class helps hold down costs for payers and patients. For patients who do not respond to those treatments, the highly effective newer biologic versions of DMARDs, including the frequently prescribed tumor necrosis factor-alpha (TNF-α) inhibitors (i.e., Enbrel [etanercept, Amgen/Pfizer], Humira [adalimumab, AbbVie], and Remicade [infliximab, Janssen/Biotech]), offer patients a chance to get relief and resume life’s activities. These and other later-line and emerging therapies—including some of the first biosimilars to come to the U.S. marketplace—will create more cost pressures for managed care companies, but also set the stage for competitive contracting and preferred drug tiering, a key strategy in holding down costs.