A Payer's Perspective on Value-Based Care and Treatment Costs for Rheumatic Conditions

Dr Steven Peskin, general internal medicine specialist and CEO of SRP Advisors, joins us today to discuss value-based care and treatment costs for patients with rheumatic conditions.

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Dr Steven Peskin, general internal medicine specialist and CEO of SRP Advisors, joins us today to discuss value-based care and treatment costs for patients with rheumatic conditions.

Do you want to start off by telling us a little about yourself?

Dr Steven Peskin: Steven Peskin. I'm a general internal medicine specialist, teach at Rutgers Robert Wood Johnson, the internal Medicine Residency Program at a federally qualified health center, precepting interns and residents in internal medicine. I have my own organization, CEO of SRP Advisors, where I'm working with several companies, a lot around value-based payment designs and companies that have services or products that they're wanting to get adopted by payers, health plans, health systems.

Prior to that was executive medical director at Horizon Blue Cross, a 3.8 million member plan in New Jersey with approximately 2.7 million commercial, 960,000 managed Medicaid, and 60 or so thousand Medicare Advantage. And in that role was one of the leaders for what we were doing in value-based payment models, population health management and transformation.

Rheumatic conditions can be challenging to manage and may require long-term treatment. Can you provide insights into the key differences in the treatment approaches and associated costs of these conditions?

Dr Steven Peskin: Well, first I'd ask you how you're defining rheumatic conditions. It can be everything from osteoarthritis to autoimmune diseases like systemic lupus erythematosus. Probably a lot of people, when you say the word rheumatic, they think of rheumatoid, which is of course rheumatoid arthritis. That has gotten a lot of attention the last 20 or so years among payers. Psoriatic arthritis would be another example of one that's gotten a lot of attention. Others include scleroderma, Sjögren's, so forth.

With osteoarthritis, a rheumatic condition, one of the major approaches is something called major joint replacement, total hip arthroplasty or total knee arthroplasty. Of course, with rheumatoid arthritis, it's significantly around drug management and physical therapy.

With osteoarthritis, as it advances beyond the ability to control it with nonsteroidal anti-inflammatories and possibly injections of prednisone or hyaluronic acid products, then it moves into major joint replacement. We have deep expertise for my former organization in developing episodes of care bundle payment models around major joint placement, focusing on quality measures and total cost of care, whereby the orthopedic surgery group has a budget for the particular part of the state they're in. Higher cost and the northern, somewhat lower cost in the southern part of New Jersey.

And then the ability to come in below budget results in shared savings. There also are, again, key quality measures that if they're not met, that may disallow the availability of shared savings.

How do payer organizations evaluate the clinical and economic evidence for treatments for rheumatic conditions? What considerations influence formulary decisions in each case?

Dr Steven Peskin: So then we turn our attention to something like RA, where we worked with a large group in New Jersey around an approach to responsibly use the vast array of biologic response modifiers, disease-modifying anti-rheumatic agents, including things like deescalation, selecting drugs that are less costly that deliver the same outcomes.

Certainly moving a patient from one product that maybe is no longer working to another, with oftentimes methotrexate being the backbone therapy in RA, and then adding a TNF-inhibitor or an IL drug, interleukin. There's several interleukin drugs available.

A lot of what you described does tie into value-based care and patient-centered outcomes. How do payer organizations assess the value and outcomes of treatments for patients with these conditions? Are there any specific measures or real-world evidence significantly determining coverage and reimbursement policies for them?

Dr Steven Peskin: Well, certainly in terms of formulary and reimbursement and medical policy, it's predicated on the evidence that's submitted to the Food and Drug Administration that's available in peer-reviewed literature that where it stands in guidelines or recommendations from an authoritative source like the American College of Rheumatology.

In terms of the outcomes, it's total cost of care per year per treatment episode. Also looking at some patient-reported outcome measures, satisfaction measures, and the ability to demonstrate good longitudinal care and coordination of care, perhaps with other physicians, most notably the person's primary care physician, say a rheumatologist who's seeing the patient for rheumatoid arthritis and then coordinating with primary care for other clinical problems that they may have like asthma or diabetes or peripheral vascular disease.

Recent research suggesting that more than half of patients with polymyalgia rheumatic experience relapse during tapering of glucocorticoid therapy, and the potential use of interleukin-6 blockade (particularly with sarilumab), could you share your insights on the potential impact of interlukin-6 blockades on rheumatic conditions?

Dr Steven Peskin: It's one of a pantheon of various interleukins. In terms of specifically in polymyalgia rheumatica, I'm not up to speed on the most recent literature of IL-6 and PMR. Certainly being able to come up with steroid-sparing, there are lots of untoward side effects of using chronic steroids, diabetes, weight gain, thinning of the skin changes, and more predisposed to fractures and the like, cataracts. So the ability to taper or use something other than high dose or moderately high dose glucocorticoids corticosteroids would be advantageous.

Do you foresee any of its cost-effectiveness for health care professionals who do taper patients off of glucocorticoid corticosteroid therapy with interleukin-6?

Dr Steven Peskin: Interleukin-6 is going to be way more expensive. On a initial crossover, the health plan is going to be paying more money not less. Question is what the outcomes or consequences are over a several year period with respect to the complications of chronic corticosteroid glucocorticoid use.

Great. Is there anything else you'd like share with our audience?

Dr Steven Peskin: There are a broad range of initiatives in my former organization and other payers around condition-specific programs, models that take into account the best use of perhaps a number of potential biopharmaceuticals, and therefore having the clinical partners really look assiduously at selecting the best one and also looking at considerations around deescalation to manage that particular cost.

Other aspects also are equally as important in terms of being able to maintain a person's activities of daily living or providing support through the myriad of SDOH, social determinants of health, programs that companies like ours and United and others are currently doing to address things like problems with transportation, health literacy, evaluation of safety in the home and that sort of thing.