Challenges in Initiating Treatment of Choice in RA

Nehad Soloman, MD: Joy,you’ve described some of the limitations and roadblocks from a patient perspective. You also touched on the insurance and third party-payer roadblocks. Bob, what’s your experience with some of those roadblocks?

Robert Levine, MD: There are a lot of roadblocks that are put in the way of patients getting access to care. Going back to your original question about a trial-and-error approach: if you look at the clinical trials across the board, a few are different, but most are placebo-controlled trials. If you look at the outcome, the top-line outcomes look similar. It’s hard to pick. One isn’t necessarily better than the other. That leads us to a trial-and-error approach. You could pick any 1 of them. I could throw a dart at a dartboard and say that might give us the same outcomes.

To Joy’s point, we have to keep in mind the patient’s preference, their lifestyle. If they travel a lot, it’s hard to get into the infusion center to get an infusion. If they’re needle adverse, oral therapies or an infusion center approach would be better. Those individual characteristics are important.

We’re also faced with insurance. Insurance and the pharmacy benefit managers [PBMs] create the formularies that dictate to us and our patients what they have access to. They really limit our choice, especially in the first line, many times in the second and third line. Sometimes those choices that they make aren’t ideally suited based on individual patient characteristics, comorbidities, and other reasons. The step-therapy protocols are set-in stone. As part of our advocacy organizations, we’ve been trying to get the states and the federal government to bring forth step-therapy bypass legislation, so it’s not appropriate for that patient to take, for example, a TNF [tumor necrosis factor] inhibitor because of comorbidities. Maybe they took it before with a different insurance company, yet they’re being forced to go back on the same drug. That’s ludicrous and we should be able to bypass those dictates from the payers in a timely way. It’s an ongoing battle to fight the payers on this. We’re working on it. We’re bound to these step-therapy protocols that dictate what we use first and often second and third.

Nehad Soloman, MD: Do you find any differences in hospital formularies vs your experience in the outpatient clinic, Bob?

Robert Levine, MD: I take care of patients in the hospital. I do inpatient consultations as a part of my practice. Mostly I feel like it’s a community service. I also take care of the hospital employees as part of my practice. It’s similar. The hospital system that I’m working most closely with has a formulary. Their formulary is a little more restrictive than a lot of the insurance company and PBM formularies that we deal with. They also have a system where if I recommend an advanced therapy biologic JAK inhibitor therapy for a patient with RA [rheumatoid arthritis], they have to get approval from 1 of their employed rheumatologists to have access to the drug. They put an extra step in there. I’m not sure why. In doing this for the past few years, I’ve never had 1 turned down by the second-opinion rheumatologist. That’s just what it is. The hospital formularies have more control, and it’s a little tighter in terms of leaving us and the patient the best option that might fit them the closest.

Nehad Soloman, MD: It’s certainly a challenge. In my experience, when I’ve treated patients, I’ve fought over the last 2 decades which to use first when considering an advancement. We consider patient preference. We consider comorbidities. Often, we’re dictated by insurance companies, third-party payers, and formularies. It’s somewhat disheartening when you’ve already tried 1 mechanism of action. Clearly, they failed, and you want to move on. There’s evidence, whether it’s by disease outcome measures, RAPID3 [Routine Assessment of Patient Index Data 3], or CDAI [Clinical Disease Activity Index], yet they insist on another drug with the same mechanism.

Transcript edited for clarity