This year, health plans will start collecting data on the utilization of disease-modifying antirheumatic drugs in rheumatoid arthritis patients as part of a new arthritis-focused endeavor by the National Committee for Quality Assurance.
The measurement of disease-modifying antirheumatic drug (DMARD) usage is being added to the list of more than 60 quality measures that comprise the Health Plan Employer Data and Information Set (HEDIS)—a quality assessment and reporting system used by most U.S. health plans.
Under the new HEDIS measure, health plans will be asked to assess whether rheumatoid arthritis (RA) patients have had at least one ambulatory prescription dispensed for a DMARD during the calendar year.
Allowable DMARDs include methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, infliximab, cyclophosphamide, penicillamine, etanercept, anakinra, gold (oral or intramuscular), cyclosporine, azathioprine, adalimumab, minocycline, and staphylococcal protein A.
In September 2006, NCQA will report aggregate data on the performance of plans at the regional and national level. Starting in 2007, the organization will provide annual reports on performance at the individual health plan level. Such information can then inform the decisions of health plan purchasers when making their contact decisions.
Despite strong evidence that backs their effectiveness, DMARDs are underutilized, which is why NCQA officials created the measure, explained Phil Renner, assistant vice president for quality measurement at NCQA.
NCQA officials expect the use of DMARDs in rheumatoid arthritis patients will rise sharply within the first few years as health plans and physicians begin to conduct quality improvement programs, Mr. Renner said. And they expect to see steady improvement over time.
“This is incredibly good news for patients,” said Patience White, M.D., a rheumatologist and chief public health officer for the Arthritis Foundation.
Physicians already know that DMARDs have a huge impact on RA prognosis, Dr. White said, but the high cost of the drugs has been a significant barrier to their use.
The development of a HEDIS measure puts this information in the hands of patients, physicians, insurers and—most importantly—health plan purchasers. And it gives physicians more leverage to make the case to insurance companies that expensive biologics ought to be covered, she said.
“It is another way to get the marketplace to do the right thing,” Dr. White said.
Similarly, plans at the Centers for Medicare and Medicaid Services to cover injectable drugs as part of the new Medicare prescription drug benefit will probably have an even greater impact on what gets covered in the marketplace, Dr. White predicted.
At the same time, evidence is now available for professional associations such as the American College of Rheumatology to issue guidelines on how to prescribe DMARDs in these patients.
The combination of these forces is likely to increase the availability of DMARDs for RA patients, Dr. White said.
Although the DMARD measure is the first arthritis-related HEDIS measure, Mr. Renner said, it's unlikely to be the last. “We're very interested in developing measures for arthritis,” he said.
Previous attempts by NCQA to measure arthritis care quality have been encumbered by difficulty in capturing this information through health plan databases, he said. As a result, NCQA is considering ways to gather this information at the provider level.
Already established NCQA programs that measure quality at the provider level include the Diabetes Physician Recognition Program and the Heart/Stroke Physician Recognition Program, which recognize physicians who voluntarily comply with their standards.
This is a nonpunitive program, Mr. Renner said. If a physician does not achieve recognition, that status is not published. But for physicians who do meet the qualifications, it can be an opportunity to be recognized by health plans, he said.
Some health plans are already using these programs as part of their pay for performance efforts. They highlight recognized physicians in their directories or encourage other physicians to use the recognition as a basis for referrals, he said.