The causes of autoimmune disorders such as lupus, diabetes (type 1), rheumatoid arthritis, and Sjogren’s syndrome have not been determined, but an abnormal immune response is the common feature. While symptoms are mild in some patients, these can be highly debilitating (and even life-threatening) in other individuals. Due to the chronic nature of these disorders, the financial cost to both patients and insurers is often high. Lost productivity due to an inability to participate in the workforce or frequent use of employer “sick time” has a national cost.

Lupus Management and Expenditures:

There are around 1.5 million people in the U.S. currently living with Systemic Lupus Erythythematosis (SLE)1. Diagnosed in 20-150 of every 100 persons2, an ANA (anti-nuclear antibodies) blood test is typically performed to confirm the diagnosis. The most common symptom associated with lupus is a butterfly rash on the face. For some patients, this rash or joint pain may be the only manifestation. However, lupus can have multi-organ effects and result in death. Sixty percent of people diagnosed with lupus have lupus nephritis3—and kidney failure can be a consequence. Moreover, lupus nephritis is one of the primary conditions related to kidney transplantation.

The average direct healthcare cost annually for a patient with lupus is around $12,643, according to the Lupus Foundation of America4. Besides non-steroidal anti-inflammatory medications (NSAIDS), drugs used to treat lupus include corticosteroids, antimalarials, steroids, and immunosuppressives. While immunosuppressives are utilized in over 50 percent of all severely symptomatic lupus patients, adverse side effects are common5. These adverse effects can include infection, cytopenia, and GI difficulties (as well as others)6, and these side effects can lead to hospitalization. Pregnant women with lupus are at high risk for complications such as toxemia and miscarriage.

Diabetes (Type 1):

This type of diabetes—formerly termed juvenile diabetes—affects around 1.25 million children and adults in the United States, according to the American Diabetes Association7. The prevalence of Type 1 diabetes has increased chiefly due to the decreased childhood mortality associated with improved diagnosis  and treatment. Insulin injections enabled diabetic children to reach adulthood and have their own children. A sharp upturn in incidence occurred in the mid-1950s, and its incidence is now at an epidemic level8. The average medical expenditure for an individual living with diabetes is $13,700 annually9. Total estimated cost of diabetes in 2012 was $245 billion (with $176 billion in direct medical costs and $69 billion in reduced productivity)10.

The myriad complications of diabetes can hugely impact overall health status. From hypercholesterolemia leading to cardiac disease—to nephropathy leading to kidney failure—the cost to insurers can be exorbitant. Notably, over a five year period ending in 2012, expenditures associated with diabetes increased by 45 percent11. Costs associated with diabetes care are distributed as follows: 1) inpatient care (43 percent); 2) prescription medications  for the treatment of complications (18 percent); antidiabetic agents and diabetes supplies (12 percent); physician office visits (9 percent); and stays in nursing/residential facilities (8 percent)12.

Rheumatoid Arthritis (RA):

Rheumatoid arthritis (RA) the most common autoimmune disorder, and affects approximately 1.3 million people (including 300,000 children) in the United States13. The linings of joints are attacked by the afflicted person’s immune system, and the outcome can be joint destruction. While RA is characterized by joint pain, stiffness and swelling, it can also affect the other organs (e.g., lungs and heart).This chronic disorder is also associated with an increased risk of osteoporosis and fractures. Pharmaceutical treatments include NSAIDS,DMARDs (Disease-Modifying Antirheumatic Drugs), and biologics14. Many afflicted individuals require hip and knee replacement surgeries in later life.

The annual national cost for RA management is around $19.3 billion15.  Direct annual medical costs per patient ranged from $2,298 to $13,549, according to 2004 study16. These costs are typically associated with clinical consultations, imaging assessments, outpatient appointments, and hospitalizations (plus emergency room visits, physical therapy, and medications)17.

Sjogren’s Syndrome:

An attack by an individual’s white blood cells on moisture-producing glands (e.g., salivary glands) characterizes this disorder. It occurs most often in patients with other autoimmune conditions. Besides a genetic predisposition as a causal factor, steroids and chemotherapy agents have also been implicated. This disorder is also associated with an increased risk of developing non-Hodgkin’s lymphoma18.

Common symptoms of Sjogren’s include difficulty swallowing due to dry mouth, and dry eyes with an inability to produce tears. However, central nervous system (CNS) involvement can result in peripheral neuropathy and cognitive disturbances (and diverse organ systems can also be affected).  According to Callaghan et al in Rheumatology, the lowered quality of life associated with Sjogren’s Syndrome would suggest that healthcare costs would be high19.

Emerging Concerns of Health Insurers:

Pharmacy spending by patients with autoimmune disorders accounts for 39 percent of all covered pharmacy expenses by health insurance companies20. Meanwhile, bone marrow (stem-cell) transplantation as a therapeutic intervention for autoimmune disorders is increasing. This is still considered experimental for autoimmune disorders, and coverage exclusion for experimental treatments is commonly offered as the reason for payment denial.

A research study by Steinberg et al in 1995 showed that a major private insurer based its decisions regarding coverage of experimental drugs and procedures on the following criteria: 1) approval by the appropriate federal regulatory agency; 2) scientific evidence; 3) proven net health outcomes; 4) beneficial as an established alternative; and 5) improvement must be attainable outside of an investigational setting21.

The conflict between physicians and insurers over what constitutes an experimental treatment is well-documented. Patients who are suffering from debilitating forms of their autoimmune conditions are eager to try medications and procedures that have demonstrated positive results in numerous studies. However, the average cost of a bone marrow transplant ranges from $300,000-800,000 per patient22. This is a prohibitive expenditure for insurers.

The increase in utilization of novel biologics and bone marrow transplants for autoimmune disorders is causing insurers heightened concern. The result is that individuals receiving such treatments will likely be expected to shoulder more of the costs—and this may make cutting-edge treatments too expensive for most patients coping with autoimmune diseases.

References:

  1. National Kidney Foundation. Lupus and Kidney Disease (Lupus Nephritis). Webpage: https://www.kidney.org/atoz/content/lupus
  2. Maidhof W, and Hilas O. (2012). Lupus: An Overview of the Disease And Management Options. Pharmacy and Therapeutics 37(4): 240-246. Webpage: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3351863/
  3. National Institute of Diabetes and Digestive and Kidney Diseases. Lupus Nephritis. Webpage: http://www.niddk.nih.gov/health-information/health-topics/kidney-disease/lupus-nephritis/Pages/index.aspx
  4. Lupus Foundation of America. Statistics on Lupus. Webpage: http://www.lupus.org/about/statistics-on-lupus
  5. Oglesby A, Shaul AJ, Pokora T, et al. (2013). Adverse Event Burden, Resource Use, and Costs Associated with Immunosuppressant Medications for the Treatment of Systemic Lupus Erythematosus: A Systematic Literature Review. International Journal of Rheumatology [Article ID 347520] Webpage: http://www.hindawi.com/journals/ijr/2013/347520/
  6. Oglesby A, Shaul AJ, Pokora T, et al. (2013). Adverse Event Burden, Resource Use, and Costs Associated with Immunosuppressant Medications for the Treatment of Systemic Lupus Erythematosus: A Systematic Literature Review. International Journal of Rheumatology [Article ID 347520] Webpage: http://www.hindawi.com/journals/ijr/2013/347520/
  7. American Diabetes Association. Statistics about Diabetes. Webpage: http://www.diabetes.org/diabetes-basics/statistics/
  8. Gale EAM. (2002). The Rise of Childhood Type 1 Diabetes in the 20th Century. Diabetes 51(12): 3353-3361. Webpage: http://diabetes.diabetesjournals.org/content/51/12/3353.full
  9. American Diabetes Association. (2013). Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care 36(4): 1033-1046. Webpage: http://care.diabetesjournals.org/content/36/4/1033.full
  10. American Diabetes Association. (2013). Economic Costs of Diabetes in the U.S. in 2012. Diabetes Care 36(4): 1033-1046. Webpage: http://care.diabetesjournals.org/content/36/4/1033.full
  11. American Diabetes Association. The Cost of Diabetes. Webpage: http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html
  12. American Diabetes Association. The Cost of Diabetes. Webpage: http://www.diabetes.org/advocacy/news-events/cost-of-diabetes.html
  13. Healthline.com. Rheumatoid Arthritis by the Numbers: Facts, Statistics, and You. Webpage: http://www.healthline.com/health/rheumatoid-arthritis/facts-statistics-infographic
  14. Mayo Clinic. Treatments and Drugs. Webpage: http://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/basics/treatment/con-20014868
  15. Birnbaum H, Pike C, Kaufman R, et al. (2010). Societal cost of rheumatoid arthritis patients in the US. Curr Med Res Opin 26(1): 77-90. Webpage: http://www.ncbi.nlm.nih.gov/pubmed/19908947
  16. Owens GM. (May 31, 2014). Managed Care Implications in Managing Rheumatoid Arthritis. American Journal of Managed Care [online] Webpage: http://www.ajmc.com/journals/supplement/2014/ace017_may14_ra-ce/ace017_may14_ra-ce_owens_s145tos152
  17. Birnbaum H, Pike C, Kaufman R, et al. (2010). Societal cost of rheumatoid arthritis patients in the US. Curr Med Res Opin 26(1): 77-90. Webpage: http://www.ncbi.nlm.nih.gov/pubmed/19908947
  18. Voulgarelis M, Giannouli S, Tzioufas, et al. (2006). Long term remission of Sjögren’s syndrome associated aggressive B cell non‐Hodgkin’s lymphomas following combined B cell depletion therapy and CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone). Am Rheum Dis 65(8): 1033–1037. Webpage: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1798235/
  19. Callaghan R, Prabu A, Allan RB, et al. (2007). Direct healthcare costs and predictors of costs in patients with primary Sjögren’s syndrome. Rheumatology 46(1): 105-111. Webpage: http://rheumatology.oxfordjournals.org/content/46/1/105.long
  20. IMS Health. Essential Health Benefit Packages Explained: Understanding High-Cost Patients. IMS Institute for Healthcare Informatics Webpage: http://www.imshealth.com/deployedfiles/ims/Global/Content/Insights/IMS%20Institute%20for%20Healthcare%20Informatics/Healthcare%20Spending/Insurance_Report_Brief.pdf
  21. Steinberg EP, Tunis S, and Shapiro D. (1995). Insurance coverage for experimental technologies. Health Affairs 14): 143-158. Webpage: http://content.healthaffairs.org/content/14/4/143.full.pdf
  22. National Foundation for Transplants. How much does a transplant cost? Webpage: http://www.transplants.org/faq/how-much-does-transplant-cost