Hartung Daniel M, Graham Glenn D, Wallin Mitchell, Leipertz Steven, Spain Rebecca
Oregon Health & Science University, Portland, OR, USA; Oregon State University, Corvallis, OR, USA.
Department of Veterans Affairs, VA Central Office, Washington, DC, USA; Department of Neurology, University of California at San Francisco School of Medicine, San Francisco, CA, USA.
Mult Scler Relat Disord. 2024 Dec;92:106159. doi: 10.1016/j.msard.2024.106159. Epub 2024 Nov 8.
High-cost disease-modifying therapies (DMT) for multiple sclerosis (MS) have created affordability challenges for people with MS (PwMS) and payers. The Department of Veterans Affairs (VA) is the largest integrated healthcare system in the US and uses a variety of approaches to manage utilization and cost of MS DMT. The objective of this paper is to compare national utilization trends in the VA to the US Medicare program, another large federal public healthcare program.
Counts of PwMS prescribed DMT from 2012 to 2021 in the VA and Medicare programs were used to estimate changes utilization over this period. For each DMT, we estimated the proportion of all DMT users treated in each year. Trends in utilization were compared to identify differences in how these systems manage DMT use. We compared demographics and DMT use between PwMS in the VA to previously published estimates from a Medicare cohort of PwMS.
DMT use in PwMS was comparable in VA and Medicare programs (65.9 % vs 69.7 %). In younger (<50 years) PwMS, DMT use was more prevalent in the VA compared to Medicare (85.8 % vs 76.9 %). Between 2012 and 2021, the proportion of patients on DMT using a lower-efficacy agent (interferon beta and glatiramer) declined in both the VA (90-32 %) and Medicare (81-38 %). Oral DMT use (primarily fumarates and sphingosine 1-phosphate [S1P] modulators) increased to a similar degree such that by 2021, 39 % of patients in both systems were receiving oral DMT. Use of high-efficacy B cell depleting DMT (ocrelizumab, ofatumumab, and rituximab) was consistently higher in the VA than in Medicare. Despite the approval of generic glatiramer and dimethyl fumarate in 2015 and 2020 respectively, 49 % of glatiramer and 58 % of fumarate utilization in the Medicare program continued to be for a branded product in 2021.
Greater DMT use among younger PwMS along with more frequent use of high-efficacy B cell depleting DMT in VA has the potential to reduce disability and attendant healthcare system costs. Generic DMT adoption in the Medicare program was lower than might be expected. Future studies should evaluate the relationship between DMT utilization, costs, and health outcomes in these populations.
用于治疗多发性硬化症（MS）的高成本疾病修饰疗法（DMT）给MS患者（PwMS）和支付方带来了可负担性挑战。美国退伍军人事务部（VA）是美国最大的综合医疗保健系统，采用多种方法来管理MS DMT的使用和成本。本文的目的是将VA中的全国使用趋势与美国医疗保险计划（另一个大型联邦公共医疗保健计划）进行比较。
使用2012年至2021年VA和医疗保险计划中开具DMT处方的PwMS数量来估计这一时期使用情况的变化。对于每种DMT，我们估计了每年接受治疗的所有DMT使用者的比例。比较使用趋势以确定这些系统在管理DMT使用方面的差异。我们将VA中PwMS的人口统计学特征和DMT使用情况与先前发表的医疗保险PwMS队列的估计值进行了比较。
VA和医疗保险计划中PwMS的DMT使用情况相当（65.9%对69.7%）。在年龄较小（<50岁）的PwMS中，与医疗保险相比，VA中DMT的使用更为普遍（85.8%对76.9%）。在2012年至2021年期间，VA（90%-32%）和医疗保险（81%-38%）中使用低效药物（干扰素β和格拉替雷）的DMT患者比例均有所下降。口服DMT的使用（主要是富马酸盐和鞘氨醇1-磷酸[S1P]调节剂）增加到了相似的程度，以至于到2021年，两个系统中39%的患者都在接受口服DMT治疗。VA中高效B细胞耗竭性DMT（奥瑞珠单抗、奥法木单抗和利妥昔单抗）的使用一直高于医疗保险。尽管2015年和2020年分别批准了格拉替雷和富马酸二甲酯的仿制药，但2021年医疗保险计划中49%的格拉替雷使用量和58%的富马酸盐使用量仍用于品牌产品。
年龄较小的PwMS中DMT使用增加，以及VA中更频繁地使用高效B细胞耗竭性DMT，有可能减少残疾和随之而来的医疗保健系统成本。医疗保险计划中仿制药DMT的采用率低于预期。未来的研究应评估这些人群中DMT使用、成本和健康结果之间的关系。
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