Chronic Autoimmune: A Hidden High-Cost Subpopulation - CrossBridge
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Chronic Autoimmune: A Hidden High-Cost Subpopulation

Chronic Autoimmune: A Hidden High-Cost Subpopulation

Whether you manage payer, payvider, Medicare Advantage or employer healthcare plans, high-risk, high-cost chronic autoimmune conditions hide in your population. They may be called inflammatory, immuno-inflammatory or immune-mediated inflammatory disorders (IMIDs). Some are familiar: Rheumatoid arthritis (RA), Crohn’s disease, multiple sclerosis (MS); others are rare. In total, there are some 100 such diseases. Surprising to most, this category can cost as much as cancer. And, like cancer, specialty medicines are the biggest cost driver. How to find these patients to improve outcomes, increase provider productivity and reduce costs? First, you need disease-specific expertise, plus an integrated platform that analyses administrative and clinical data that identifies this high-risk subpopulation to 1) Enable value-based decisions in specialist (e.g., rheumatologist) workflow, 2) Facilitate care coordination, including multidisciplinary collaboration, and 3) Better engage patients in care plans, improve medication adherence and support communication with care teams through digital channels (telehealth, mobile, text, etc.).

What is driving the high cost of autoimmune?

Chronic inflammatory diseases involve complex, long-term episodes of care. Moreover, the biggest cost driver is specialty therapeutics.

  • Specialty medications accounted for 52% of pharmacy spend in 2020.[i]
  • Inflammatory conditions accounted for 1/3 of total specialty spending in 2019.[ii]
  • 90% of specialty therapy spend was driven by five categories, inflammatory is on top, ahead of oncology. [iii]
  • 98% of utilization increase is from new therapies and indications, many autoimmune.
  • In 2019, 32 of 54 new agents approved by the U.S. FDA and 80 of 135 expanded indications were for specialty drugs.
  • Looking forward, specialty meds account for 75% of ~7,000 drugs in development and 60% of the 600 drugs expected to win FDA approval by 2022.[iv] 


What’s more, despite the complexity of chronic autoimmune patient journeys, 26% of care plans are not yet evidence based.[v]

There are now nearly 200 drugs in use for RA, including a dozen bDMARDs.[vi]. And bDMARDs are costly. For example, Humira (adalimumab), was the first bDMARD approved for RA in 2002. Since then, it has been approved for a dozen more autoimmune disorders. With $16B of sales in the US alone and a PPPY cost of $40-50,000 (depending on indication), it’s easy to see how a few patients can drive plan costs up. Furthermore, the new bDMARDs are also costly. For instance, Rinvoq (upadacitinib), approved in 2019 for RA, is priced at $60-70,000 PPPY.

As payers/PBMs see this wave of high-cost therapies coming, they are looking beyond the standard blunt-force utilization management tactics of prior authorization and step-therapy restrictions. Specifically, payer/payviders are focusing on value as a market access lever for life science manufacturers. This means they are increasingly looking to pharma contracts within a value-based paradigm.

Autoimmune: as prevalent and high-cost as cancer

Based on CrossBridge’s own real-world data (RWD) analysis, perhaps as many as 50 million (1 in 6) Americans have some type of inflammatory or rheumatological disease. Therefore, as much as 16% of your population may have an autoimmune disorder, including many members who are undiagnosed. Moreover, the prevalence of autoimmunity has been growing for decades, and this growth is expected to continue.[ix]

It is not hard to find the high-cost RA & MS patients in your population, but they are only the tip of the iceberg. The ~100 other IMIDs can add up to significant unanticipated costs.

Why are autoimmune disorders so invisible?

Unlike cancer, autoimmune diseases aren’t aggregated in CDC statistics and most payers don’t look at them as a class. For example, the CDC’s arthritis category includes 54.4 million Americans [ix] with total medical spend of $140B[x]. But that’s only one specialty—rheumatology. Autoimmune diseases are scattered over multiple other specialties, including dermatology, endocrinology and neurology.  

Nevertheless, rheumatology is the best place to start, because it includes the most prevalent autoimmune disease, RA, plus many others. Moreover, the growing demand for rheumatologists outstrips supply by 2:1. Clearly, this slows diagnoses and decreases access to high-quality treatment.

Why is chronic autoimmune so high-cost?

Like many types of cancer, the high cost of autoimmune involves not only specialty meds, but also long-term episodes of care and multiple specialist visits. Furthermore, many patients need comorbidity treatments, including mental health services. To manage such complex patient journeys, plans need multidisciplinary care coordination and evidence-based clinical pathways (EBCPs). What’s more, these should include longitudinal monitoring of patient response to treatment.

However, ignoring these diseases is expensive, too. Early intervention improves outcomes, slows progression and delays disability[i]. Untreated people are high users of emergency and in-patient care. Especially in employer plans, indirect costs matter: absenteeism, presenteeism, disability accommodations, leaves of absence, loss of employees. But even for payers and payviders, leaving such members untreated or delaying until advanced disease appears increases emergency and hospital costs, raising total cost of care.

With 200 drugs for RA, including a dozen bDMARDs, it is impossible, without evidence-based guidance and high-tech support, for rheumatologists to choose the best drug for each patient. Then they must monitor response and manage tapering doses, switching drugs or combination therapies. Therefore, plans should (but 26% do not)[ii] use evidence-based guidance. Improving outcomes requires data (including real-world data, patient-reported outcomes, and specific clinical disease activity measures), analysis and feedback to guide long-term care.

Such care plans require collaboration and coordination between PCPs, scarce specialists, and other critical team members like physician assistants, nurses and pharmacists. Two-way communication between patients and their teams is also essential, including telehealth, remote monitoring, texting and mobile patient apps.

What do you need to do?

So, how do you find these members and get them timely, appropriate care with consistent, long-term monitoring? Where can you find the needed experience and expertise with analytics and rheumatology? Most of all, where can you find user-friendly, end-to-end solutions that will integrate with your plan and serve your needs?

Find high-cost autoimmune members

It is impossible to effectively analyze these high-risk patient cohorts without an integrated software platform that aggregates multiple data sources and applies disease-specific analytics to find these members. A targeted program needs robust administrative and clinical datasets. Moreover, diseasespecific expertise is essential to facilitate analysis. Only then can you find high-risk patients, measure medical risk, and apply predictive analytics to identify opportunities for improving medical management.

Payviders have a unique advantage with full access to both payer and provider data. Combining administrative data from the payer side with clinical data from the provider side can enable feedback to practice teams to support better clinical decisions and education.

Turn EHR data into care delivery support

Electronic health record systems are not optimized for chronic disease management. Therefore, expert software is needed to augment standard functionality and transform data into usable care delivery support for providers. This includes reliable data capture, transformation and reassembly into actionable information dashboards.  Such dashboards enable evidence-based treatment pathway options to inform specialist treatment decisions.

Integrated software platforms can support care coordination and collaboration across multidisciplinary teams or even just between PCPs and specialists. This means bringing evidence-based guidance to physicians and staff in easy-to-use formats that support longitudinal tracking, and extend scarce specialist time through improved efficiency and better use of PCPs, NPs, PAs and other roles.

Find a partner with proven expertise and experience

CrossBridge’s capabilities are built on years of expertise in rheumatology clinical analytics and payer/provider support platforms. Our platform integrates administrative and clinical data with disease-specific analytics. This enables patient-centric, value-proven treatment pathways for better outcomes and lower total cost of care.

  • Focused: Unique, chronic specialty care model focused on autoimmune and inflammatory patients.
  • Expert: Deep knowledge of guidelines and timely research plus real-world data. Unmatched experience in specialist care pathways.
  • Proven: Model proven over years in real-world use, shown to reduce costs while improving physician productivity, patient satisfaction and outcomes.
  • Technology: Built-for-purpose SaaS platform enables smarter, more efficient service delivery that scales and adapts quickly.

 CrossBridge’s model, developed with Geisinger[xiv] has been in successful use for nearly ten years, with published, proven results.[xv] 

CrossBridge can help your plan

We help plans optimize care for patients with chronic rheumatic disease.

CrossBridge was founded to improve the model for treating and paying for chronic autoimmune diseases. Our founder, Bill Conlan, was diagnosed with ankylosing spondylitis after seven years of disjointed, unproductive and non-evidence-based encounters with the healthcare system. He is convinced there is a better way, and that is what CrossBridge has developed.

Reach out to Courtney Morris to learn more about bringing better care and lower costs to the treatment of these complex, chronic diseases. Contact us for more information.









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