Medicare Must Support Innovations in Rheumatoid Arthritis Care

COMMENTARY

What makes the American medical community the envy of the world is its fierce commitment to cutting-edge research and innovation. Now, a new innovation in the treatment of rheumatoid arthritis could help millions of patients receive effective care more efficiently, and ultimately live healthier, happier lives. However, whether most patients will have access to this technology going forward remains in doubt.

RA is an insidious autoimmune condition that attacks a patient’s joints, causing severe and painful symptoms that can lead to life-threatening comorbidities if left untreated. In fact, as many as 70% of RA patients become work disabled within 10 years if their disease isn’t properly managed.

As a practicing rheumatologist with more than 38 years of experience treating RA, I’ve learned the key to helping patients avoid the worst symptoms of the disease is early intervention. If you can catch it early and treat it aggressively, you’re much more likely to help the patient achieve remission or low disease activity. I always explain it to my patients like this: When you have an inflammatory disease like RA, it’s like you have a kitchen fire. If you can put that fire out when it’s on the stove, you’ll have a much better result than if you wait until the house is engulfed in flames.

Unfortunately, putting out the fire of RA early is easier said than done. As a complex disease that develops based on any number of factors unique to a patient’s biology, it can be tricky to know which of the myriad RA treatments will be most effective. Typically, following a diagnosis, a provider will first prescribe a disease-modifying anti-rheumatic drug, such as methotrexate or leflunomide. If the patient fails to achieve low disease activity, the patient may next receive one of the five classes of RA medication-targeting tumor necrosis factor inhibitors. If those don’t work adequately — which is the reality in roughly two-thirds of cases — providers must go down the list of other available treatments until one works.

As you can imagine, this method is hardly efficient. In my experience, it can take six months or even a year before a patient receives the most effective treatment, wasting precious time in the early days, a delay that precipitates acceleration of the disease and associated treatment costs. While we spend time trying ineffective treatments, the proverbial fire continues to spread.

However, new innovations in precision medicine testing for RA patients have shown improved patient outcomes when care is guided by PrismRA.

Here’s how it works. Using a simple blood test, this technology analyzes a patient’s unique biology to determine inadequate response to TNFi treatment. If the test shows that a patient is highly unlikely to respond to a TNFi, then a provider can save time by not prescribing those treatments and can instead start with other treatments that are more likely to work. In fact, peer-reviewed research found that this technology would nearly double a patient’s likelihood of reaching low disease activity, and would triple the likelihood of reaching remission.

This technology has the potential to improve patient care, which is why it’s disappointing that America’s largest health insurer, Medicare, doesn’t cover it.

Recently, Medicare tasked a contractor called Palmetto-GBA MolDx to review data surrounding predictive testing for RA and make a coverage determination. I, along with all the other rheumatologists interviewed, endorsed the need for precision medicine tests in RA. Despite our testimonials and evidence supporting the need for predictive testing for RA, the panel issued a draft recommendation that the technology should not be covered.

This represents a roadblock in the battle against RA. Already, 1.5 million Americans suffer from RA, and there are new diagnoses every day. Predictive testing would be an invaluable tool empowering rheumatologists to make more informed decisions when prescribing treatment, helping patients more effectively battle their disease and get back to their healthy lives. It is critical that Medicare reverse course and cover precision medicine tests.

Dr. J.E. Huffstutter is a member of the American Medical Association, a fellow in the American College of Rheumatology and the American College of Physicians, a member of the Tennessee Medical Association, Chattanooga-Hamilton County Medical Society, Tennessee Rheumatology Society and United Rheumatology.  He is a past-president of the Chattanooga-Hamilton County Medical Society and continues to participate in various positions at the American College of Rheumatology. You can reach his Hixson, Tennessee, practice by calling  (423) 826-0800.