New challenges, opportunities in autoimmune disease treatment

Susan Manzi, MD, MPH, chair of the department of medicine at Allegheny Health Network (AHN), in Pittsburgh, Pennsylvania, is on a mission to improve the education and healthcare needs of those impacted by lupus and other autoimmune disorders.

Lupus is a chronic, inflammatory, autoimmune disease that can affect virtually any organ system in the body.  It is potentially fatal and there is no cure. Common signs and symptoms include aching joints, skin rashes, chest pain, hair loss, kidney failure, seizures, fevers and fatigue. Lupus can be characterized by periods of illness known as “flares.” But with appropriate treatment, there can be periods of remission or less disease activity.

Manzi

“Education is critical-and this includes those impacted with lupus as well as the healthcare professionals caring for them,” says Manzi, who directs the Lupus Center of Excellence at AHN. “We need to teach physicians how to recognize and diagnose the disease, as well as to treat it using best practices.”

Managed Healthcare Executive (MHE): Why should lupus and other autoimmune disorders be on healthcare executives’ radar screens?

Manzi: Up to 50 million Americans have an autoimmune disease. That’s one in five people in the U.S. There are more than 80 types of autoimmune diseases.  The ones that are more commonly recognized include:

·               Lupus,

·               Rheumatoid arthritis (RA),

·               Multiple sclerosis, and

·               Inflammatory bowel diseases (IBD), such as ulcerative colitis and Crohn’s.

But there are others that many people wouldn’t normally think of as being an autoimmune disorder-such as type 1 diabetes, psoriasis, autoimmune thyroid, celiac, autoimmune hepatitis, and inflammatory eye diseases like uveitis, which is a form of eye inflammation. Interestingly, autoimmune diseases tend to be more common in women, with estimates from 75% to 90% in certain conditions; they are chronic, most have no cure, and other than cancer, can be some of the most expensive diseases to treat. There are many new biological therapies-treatments that target the immune system and prevent the attack on self-that are effective, but costly.  Ensuring that we are using these agents appropriately is important. Often the upfront investment will have major benefit on quality of life and total cost of care.  

IBD (including Crohn’s disease and ulcerative colitis), lupus, rheumatoid arthritis, multiple sclerosis, and psoriasis, together have an estimated cost of $70 billion per year. These costs are shifting from inpatient hospitalizations to ambulatory drug costs that are keeping people healthy and out of the hospital.

The good news is that advances made in the treatment of one autoimmune disease can positively impact another. Effective therapies for rheumatoid arthritis also treat Crohn’s disease. Having a uniform approach to the management of autoimmune conditions is ideal. 

MHE: How is the AHN managing care for patients with autoimmune diseases?

Manzi: The AHN physician group appreciates the fact that autoimmune diseases are tough to tackle and that a lot of people in Western Pennsylvania struggle with these chronic conditions. They have answered this call to action by supporting the creation of the Autoimmunity Institute. The institute brings together under one roof all of the specialists needed to treat people with autoimmune conditions. This includes, but is not limited to, rheumatologists, gastroenterologists, dermatologists, allergists, endocrinologists, lung and kidney specialists, with wraparound services such as behavioral health, since depression is not uncommon in those impacted by chronic diseases. We will have access to pharmacists who can help with medication adherence and navigators to guide our patients through the healthcare system. We will also be conducting clinical and scientific research in the institute, because access to the latest experimental therapies, novel technologies and new diagnostic tests are important to our patients. This type of care delivery model is not only transformative, but sustainable in a truly integrated delivery and financing system like Highmark Health. The payer is acutely aware of the fact that to tackle the growing cost of healthcare, managing chronic diseases effectively is paramount. 

One of the ways that AHN and Highmark are working together is by creating pathways and protocols to minimize the unnecessary variation in care.  For example, when you have 10 medications available for the treatment of RA, Crohn’s disease, or ulcerative colitis-providing a roadmap using evidence-based recommendations to guide healthcare providers to the right drug at the right time can be a win-win for our patients, the doctors, and the health plan. 

Next: The best approaches

MHE: What approaches work best for managing care (i.e., education, care management, medication therapy management, etc.)?

Manzi: They are all equally important, but I am a big believer that patients have to be educated about their illness and actively involved in the management of their care. The days of passive patients and authoritative physicians with no room for discussion are gone.  We have very informed patients. As providers of care, we are responsible for getting them reliable and accurate educational materials, and we have to accept the fact that they are going to come in much more aware than they used to be. There has to be shared decision making about what drugs to use and when.

We have to leverage our care managers to keep our patients engaged in preventative practices and therapy plans, whether it’s telephonically, using innovative devices, or with community partners. This is a very different model from what traditional healthcare delivery systems have provided in the past. 

Finally, medication adherence is not only important, but it is a major driver of unnecessary cost to the system. It is shocking to see how frequently people either forget or choose not to take their medications, and even more surprising how infrequently they admit this to their physicians. Think about the cost of that behavior as you escalate therapy because you think it is ineffective, when they were never taking it in the first place. Measuring drug levels to assess compliance is becoming a more favorable approach. This can stimulate a discussion around adherence and may avoid changing treatment unnecessarily.  

MHE: Are there any pipeline drugs that are going to have a big impact?

Manzi: There are so many drugs in the pipeline for autoimmune diseases. Some of the newer biological therapies for RA have changed the course of the disease. When I was training 20 years ago, physical disability from joint deformities was the norm. I now tell our medical students and residents that they may never see this again in patients who are getting adequate treatment. Are these agents cheap? No. But the return on investment may be high with less disability, work loss, hospitalizations, etc. The pipeline is endless and some may ask why we need so many options. The answer is, what works like a miracle in one patient may have no impact in another. We need options.

MHE: What resources are available to health plans to better manage their members with autoimmune disorders?

Manzi: It seems as though there is less attention on autoimmune diseases and much more attention on other conditions. A lot of it is justified-heart disease and diabetes are big issues. But cumulatively, autoimmune diseases make up a large portion of the membership in a health plan and the drug costs can be extremely high. Working together, payer and provider, to standardize our approach to managing these disorders is the best path forward. In the end, we want the same thing: a healthy, productive population of people who are managing their chronic conditions in the best way possible.  Ultimately we are working together toward prevention of disease altogether.   

Tracey Walker is content manager for Managed Healthcare Executive.