Ryan Haumschild, PharmD, MS, MBA: One thing you talked about was what’s driving the expense, and the great thing is we have new therapeutics that are providing really good resolution of disease, limiting the type of progression that we’re used to with patients and as Dr Kay mentioned, living productive lives.

Now the main thing we’re working on is how we control those comorbidities that lead to nonadherence or may lead to exacerbation of current symptoms and also making sure that we have the right coverage—so dealing with financial toxicity, transportation vulnerability, and having a great proportion of days covered. Even with that, we know there continue to be drivers, and a lot of times those drivers exist within the pharmacy in terms of acquisition cost, but also as you talked about Dr Chen, the medical benefit and some of those medical costs.

Dr Chen, I’ll turn to you once more. What are some of the key drivers contributing to the economic impact of inflammatory diseases as a whole within the US?

Kimberly C. Chen, DO, MSHLM: One thing we have learned because of the add-ins of new pharmaceutical drugs is that specialty drugs have come into play as one of the key cost drivers and also unplanned care, even though our surgical has gone down just because of these specialty drugs. I do want to also point out [that] the treatment for the chronic inflammatory condition has actually nearly doubled in the past 20 years. So even though the surgical costs have gone down, pharmaceutical spending continues to increase and has become one of the highest costs for almost all the health plans as well as health care providers.

Jonathan Kay, MD: The acquisition costs of the medication are most important because surgery down the road may be covered by different insurance. Patients typically switch insurance coverage every several years, and the insurance provider that is covering the cost of the expensive medication may not be held responsible for the cost of surgery down the road. So the cost to the insurance provider of current medications may not mitigate savings in the future, which is an important consideration to the payers because their expenses may not be balanced by savings.

Kimberly C. Chen, DO, MSHLM: I think that’s a great point, and something that I always think is so fascinating, at least for inflammatory bowel disease, is we thought that as we had these biologics being approved and a lot more guidelines were incorporating them that we would see reduced surgery rates, for example, or we would see reduced extraintestinal manifestations and reduced disability.

In the United States, there is still a big delay to start [our patients on] these medications…, so there’s a long lead-up to start the biologic. And during that time, the patient might be inappropriately managed with medications that are not therapeutic enough for them or optimized enough for them, and that’s the curative time [during which] they’re most vulnerable. The window of opportunity to start a good drug is not happening, so they’re getting surgery, and the costs are high in that up-front phase, and they still need to go on a biologic [postoperatively].

At least in the United States, unfortunately, the community hasn’t necessarily adopted the early use of biologics, which is really important. So the costs haven’t necessarily been driven down.

Jonathan Kay, MD: You point out a very interesting dichotomy between gastrointestinal disease and rheumatologic disease [because] in gastrointestinal disease, inflammatory disease, surgery is the initial treatment for active disease, whereas in rheumatologic disease, the surgery is usually a result—or treats the results—of chronically active disease later on.

Maia Kayal, MD, MS: I think it’s the same. It’s just that we do think it’s a chronic progressive disease similar to rheumatoid arthritis and other rheum conditions, but we do have this window of opportunity if we start the drug at the right time. If it’s early, you can prevent that progression, and the surgeries that we typically perform in inflammatory bowel disease are either resection for obstruction or resection for very active colonic disease, so a colectomy. Both of these conditions can be prevented if the right drug is started at the right time.

Sometimes by the time a patient is going to surgery, they’ve had years of chronic progressive disease that has been inappropriately managed, not optimized, no outcomes being met, and the ultimate result is surgery. By the time they see some of us, the disease has smoldered for so long that you haven’t had a chance to make an impact, so surgery becomes the only option. You do want to protect against that progression again, and you want to kind of do some postoperative prophylaxis, and that’s where the biologic [postoperatively] comes into play.

Kimberly C. Chen, DO, MSHLM: One thing I do want to add is we talked about the driver the specialty drugs is one biologic but the other things that unplanned care- while we talk about the surgery because surgery could be planned or unplanned but those unplanned as you said, obstruction, the patient coming in for emergency care as well as readmission because many of these patients have multiple readmissions. These unplanned in-patient visits and multiple readmissions are where it really drives up their medical cost as well.

Ryan Haumschild, PharmD, MS, MBA: You all brought up some great points, from readmissions to therapeutic cost to delaying surgery and also the impact that has. If it’s a 3-year benefit and we have high turnover in a plan, you might not see the benefit or the return on investment to that patient that you’ve paid for. These are all really great comments.

One thing that really resonated with me, though, was starting the right therapy for the right patient at the right time. We utilize step therapies, stepping through different frontline treatments that may not always be best, but they might be in terms of a treatment pathway. One of the things we’re seeing in psoriasis and other diseases is certain patients with certain risk factors might need a higher-cost therapy up front. They don’t end up saving on the cost over time based on the cycling through different therapies and the avoidance of those loading doses that really cost a lot to the plan. I really like how you teased that out.

Transcript edited for clarity.

This activity is supported by an educational grant from Boehringer Ingelheim.