A review of the direct costs of rheumatoid arthritis: managed care versus fee-for-service settings.

Rheumatoid arthritis (RA) is a prevalent condition associated with pain, joint destruction and morbidity. Direct healthcare costs are 2 to 3 times higher than average costs for individuals of similar age and gender. Furthermore, utilisation and costs rise with age and disease duration. Managed care has become an increasingly popular way to organise and finance the delivery of healthcare. Studies comparing the quality of care in health maintenance organisations and fee-for-service settings have found few differences in outcomes, although reduced costs have been attributed to lower hospitalisation rates in patients with RA. We reviewed 10 studies of the direct costs of RA. In 1996 dollars, direct costs ranged from $US 2,299 per person per year in Canada to $US 13,549 in a US study focusing on patients who have been hospitalised only. Surprisingly, the contributions to direct costs--hospital care, medications and physician visits--remained relatively stable over time and the setting of care. Hospitalisation costs were the highest component of direct costs accounting, generally, for 60% or more of costs while only approximately 10% of patients with RA were hospitalised. The only exception was a managed care setting where hospitalisation costs were 16% of total direct costs. In managed care settings, costs of medications were proportionately higher than in fee-for-service settings. We conclude that in studies of the direct costs of RA the components of costs have remained relatively stable over time. This may change with the development and growing use of new RA medications including cyclo-oxygenase 2 inhibitors, interleukins, cytokines, treatments that inhibit tumour necrosis factor, and combination therapies. The effectiveness of managed care in controlling direct costs needs to be evaluated in more targeted studies.