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Today CVS Health issued a news release announcing their Transform Rheumatoid Arthritis Care™ program. At least they were honest. In the first sentence, it clearly states that the purpose of this program is to “help the company’s pharmacy benefit management (PBM) clients better manage care and costs for rheumatoid arthritis (RA).” At least they didn’t lie and say it was for the benefit of patients.

For those of you who don’t know what a PBM is, they are the organizations that insurance companies use to determine such things as what drugs are covered and for how much and whether step therapy is required before approval. They exert an amazing amount of control over what drugs are available to patients and what those drugs cost. In a previous post, I debunked one of the major PBM’s assertions where they misstated the American College of Rheumatology treatment guidelines for their own purposes.

It’s a known fact that RA drugs – particularly biologics – are some of the most expensive medications prescribed. I acknowledge that we need to manage these costs as much as possible – but I disagree that it should be at the expense of patient care or interfere with the doctor’s right to design the best treatment plan possible. Even the National Institute of Health (NIH) has stated, “The treatment of RA has been transformed in the last decade with the introduction of several targeted biologic agents. Although biologic agents are more costly in the short term than conventional disease-modifying antirheumatic drugs, drug-specific costs may be offset by significant improvements in RA symptoms, slowed disease progression, and improved physical function and quality of life for patients.”

What are some of the key points CVS Health’s new program that I think may be directly or indirectly harmful to patients?

  • It encourages the “use of lower-cost therapies”. Translated into patient language, that means that patients may not have immediate access to biologic medications until first “failing” on older, less costly treatments such as triple therapy (sulfasalazine [a sulfa drug], hydroxychloroquine (Plaquenil), and methotrexate).
  • Under outcomes-based contracts, pharmaceutical companies might be penalized if patient targets or goals are not reached. Most patients are prescribed an anti-TNF drug as their first biologic. It’s a well-documented fact that approximately 30% of patients fail on their first TNF biologic within the first year. How will penalizing the manufacturer (1) help the patient or (2) lower drug costs (the program’s goal)?
  • Changing to an indication-based formulary. This means that instead of a certain class of drugs being covered for a condition, medications are placed on the formulary (payment scale) based on the specific drug. For example, all anti-TNF drugs (the most commonly prescribed RA biologics) might not be covered. According to CVS’s Carefirst statement the following, commonly prescribed RA drugs have been removed from the formulary for rheumatoid arthritis: Actemra, Cimzia, Kineret, Orencia (infused), Simponi, and Xeljanz/XR. This can severely limit the affordable treatment choices for patients.
  • According to the news release, a PBM could save up to 5 percent on RA drugs. That translates to $500,000 over 100,000 patients – or about $5 a patient. First of all, I will gladly pay the $5 to be given access to the drugs that my doctor thinks is the best treatment plan. And second – back to the patient – while this might save the PBM money, there is no indication that these health care savings will be passed to the patient.

For me, there are two inescapable conclusions. The first is that these types of pharmacy programs border on practicing medicine by dictating what treatments are available on an affordable basis to the patient. The second is that all the focus is on saving money while apparently no thought is given to the debilitating effects on patients who are denied effective treatments.

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