Part 1: Brian Gifford on the Hidden Costs of Rheumatoid Arthritis

The Center for Biosimilars® (CfB): Hello, I'm Matthew Gavidia. Today on MJH Life Sciences' Medical World News, The Center for Biosimilars is pleased to welcome Brian Gifford, research director of the Integrated Benefits Institute [IBI].

Can you just introduce yourself and tell us a little bit about your work at [IBI]?

Gifford: For those of you who don't know, we are a nonprofit research and educational association and we focus on workforce health and productivity. What that means is we're the hub of the network of people who are really looking for ways to invest properly and invest wisely in the health of their workforce, not because it's necessarily the right thing to do, although, of course, many businesses tell us that that's one of the reasons that they make investments in health, but because that there is a longer term business proposition to it, such as healthier employees, employees with well managed chronic conditions, which allows people who are going to be on the job more often to perform at a higher level. So, we're always looking for ways to show business leaders that there's an advantage to investments in healthy workers. We'll usually focus on sick day absences and short-term disability leaves, but also on things such as on-the-job performance.

CfB: Can you describe rheumatoid arthritis and how it affects employee wellness?

Gifford: One of the things about rheumatoid arthritis is, for a lot of people who have it, it could have some of the same symptoms as osteoarthritis. For example, osteoarthritis causes wear and tear on a person's joints as they age. It's going to happen to a lot of people. There may be a genetic component, but usually it's really just old age where you get aching, tender, and stiff joints.

With rheumatoid arthritis, it's different because you can have a lot of the same symptoms, but the cause is a little bit different. So, it's when the immune system is actually attacking the lining of the joints for reasons that aren't really well understood. For example, you get inflammation pain and stiffness. People report fatigue not just in 1 joint or 2 joints, but in the same joint on both sides of the body. The cause is, again, not really well understood. We know that there are some comorbidities around smoking and obesity. Very importantly, this can happen to anybody or in a lot of stages of life. It can come on rapidly and it can be pretty hard to diagnose. It's like a lot of inflammatory diseases. Crohn disease, ulcerative colitis, lupus, and so on. There are tests for it, but it can really come down to a diagnosis based on a wide range of symptoms.

CfB: Statistically, rheumatoid arthritis affects a relatively small population of employees but the cost to employers and payers is disproportionately larger than for more common conditions. Can you explain this phenomenon?

Gifford: Well, think of some of the conditions that we might compare it to. I already mentioned osteoarthritis but also musculoskeletal conditions like back pain. You're right that you're going to see those kinds of conditions show up a lot more often in a working population.

Where we start to see the high costs of rheumatoid arthritis is in 2 different ways. One is that if you look at a population of people with rheumatoid arthritis compared with people without rheumatoid arthritis and you do whatever statistical controls you need to do to account for comorbid conditions, this is where you start to see some of the medical costs go up and this is for all kinds of treatments. For example, one of the analyses we did showed that somebody with rheumatoid arthritis compared with somebody without rheumatoid arthritis is going to have $7500 more in health care and pharmacy spending than somebody without rheumatoid arthritis. If you do the same analysis for osteoarthritis, it's going to be about $4000 more. And for back pain, which afflicts a lot more people, it's going to be about $2400 more.

Overall, this is where we're really starting to see this high cost. I should probably be a little more careful of my terms. I'm talking about expenses. So, these are excess medical and pharmacy expenses. Cost is going to encompass a lot more things and that's what a lot of IBI's work is about. But just in terms of what the health care system usually thinks about spending for treatments, and what employers often think about, this is where we're going to see rheumatoid arthritis have relatively high expenses.

And here's where the costs are going to come in. A lot of people refer to these as indirect costs, but I would still say they're direct costs. If we look at sick days, the number of sick days that we can attribute to people with rheumatoid arthritis, in addition to what people without rheumatoid arthritis have, that's about $530 a year. So, it's about 2 and a half extra sick days that people are not at work and they're getting paid. That's an additional cost. I'm not really sure that that's high on the on the list of employers’ concerns.

Of course, one of the other things that we focus on in IBI are the longer-term productivity costs. And this is going to be primarily in short-term disability leaves from work. So, a lot of people have insurance policies paid for by their employer that say that if you need time off to recover from an illness, for example, or to undergo treatments for an illness, or if you're having a really extreme bout of symptoms, you can get paid about 60% of your wages and take the time off you need to recover.

What we find is that for [employees with] rheumatoid arthritis, compared with the [general working] population, we don't really see a lot of disability claims. To me, that's probably some evidence that all of that excess spending on treatments is actually working to keep people on the job. But when they do have to take time off from work [for rheumatoid arthritis vs] other kinds of conditions such as osteoarthritis, back pain, and other musculoskeletal conditions, this is where we start to see a really heavy burden in disability claims costs for rheumatoid arthritis.

So, yes, it's a small population, but it can be really expensive both in terms of health care spend but also in terms of productivity costs.

CfB: You described a hidden population of employees who may not be recognized as having rheumatoid arthritis and end up costing employers and payers as you just described. Can you explain what you meant by this?

So, think about the difficulties in diagnosing rheumatoid arthritis. It could take a lot of testing. It could take a lot of interactions with doctors. But that doesn't mean that people who are undergoing symptoms of rheumatoid arthritis are just going to work through the entire time that they're being diagnosed. They might take short term disability for some other cause. They might be diagnosed as [having] osteoarthritis. It might be diagnosed as just some other kind of pain, especially if the arthritis is occurring in the back—for example, ankylosing spondylitis. These are all kinds of things that people might be taking disability for.

We found that if you compare [disability claims] from the population of employees with rheumatoid arthritis [to those for the general working population], disability claims are only about 1% of that general population prevalence and, again, that could be a good thing. That could be attributable to having well-managed conditions. But it also could be that somewhere out in the rest of the population, there are people who are not getting the kinds of treatments [for rheumatoid arthritis] that they need. They're taking disability time off and the diagnosis that's being assigned to that disability leave is something else, such as generic back pain or generic joint pain.

So, employers who are really trying to get a handle on what's going on in their population and what's going on in their short-term disability system, they might not see rheumatoid arthritis. In fact, they may only see it when it's gone on long enough that the diagnosis has occurred, and it shows up in their medical and pharmacy spend. So, again, despite the small population of people with rheumatoid arthritis, it's not really clear why the disability rate is so low given what we know about the symptoms of rheumatoid arthritis and its impact on people's ability to continue working.

CfB: Can you describe the value of anti–tumor necrosis factor [anti-TNF] drugs, particularly biosimilars, in helping control rheumatoid arthritis and keep employees on the job?

I can tell you what we learned from a review of adherence studies that we did back in 2018. So, IBI combed the peer reviewed research literature for studies that looked at medication adherence and people's time off from work for short term disability and sick days. And we found a couple of studies on rheumatoid arthritis. We also had the advantage that one of the studies that we found through the peer review search was one that authors from the [IBI] had written back in 2004, I believe. And what we found was that for rheumatoid arthritis, people who were using anti-TNF treatments and who were using disease modifying treatments had fewer episodes of short-term disability. And when they had short-term disability episodes, they were off the job for a less amount of time than people who were not [receiving] these kinds of drugs.

Now, in those studies, that's a pretty clear indication that people who have well-managed rheumatoid arthritis are able to stay on the job and be as productive as anyone else in the workforce. Although, the challenge, if we think about that in terms of biosimilars, is that those studies, to my knowledge, did not include biosimilars. [Investigators] would have used reference biologics.

So, to talk about the value of biosimilars in terms of lost productivity, I think what they have is a value proposition right now. They have the value proposition that they are very similar to reference biologic drugs. But as far as I know, there have not been the kinds of studies yet to show that in terms of getting people back to work, in terms of keeping people on the job, they perform as well as reference biologics. I think, again, they have a value proposition and makeup, in which they're chemically similar [to the reference product], and they are similar in terms of their ability to return people to functionality on the job or in other aspects of their life, but I always advise employers to look for the evidence.

And so, if there aren't studies right now showing that biosimilars compared with reference biologics or compared with the usual source of care have the same or different outcomes in terms of keeping people on the job, then, what I would advise employers to is ask for the evidence. Ask for evidence in terms of your own workforce, or do whatever kinds of analyses you can do, such as observational studies.

I take some of the same guidance that a clinician from Kaiser Permanente made at [a recent] biosimilars [webinar] that IBI did with the Pacific Business Group on Health. He made the comment that when [Kaiser Permanente] was switching patients from reference biologics to biosimilars, they made sure to track those patients who were now going into biosimilars. They did that tracking, testing, re-analysis even though they've seen all the studies and believed that biosimilars could produce the same kinds of results as reference biologics. I would advise employers to take that same approach. You've seen the evidence that these are going to produce similar kinds of outcomes in different populations, but you really want to know what's going on in your own population.

To watch part 2 of this interview, click here.