, Volume 19, Issue 8, pp 811–818 | Cite as

A Review of the Direct Costs of Rheumatoid Arthritis

Managed Care versus Fee-for-Service Settings
  • Deborah P. Lubeck
Review Article


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 $US2299 per person per year in Canada to $US13 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.


Rheumatoid Arthritis Direct Cost Physician Visit Inhibit Tumour Necrosis Factor Total Joint Replacement 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Supported in part by a grant (NIH-AR-20610) to Stanford University, Arthritis, Rheumatism and Aging Medical Information System (ARAMIS).


  1. 1.
    Lawrence RC, Hochberg MC, Kelsey JL, et al. Estimates of the prevalence of selected arthritic and musculoskeletal diseases in the United States. J Rheumatol 1989; 16: 427–41PubMedGoogle Scholar
  2. 2.
    Pincus T, Callahan LF. Reassessment of twelve traditional paradigms concerning the diagnosis, prevalence, morbidity and mortality of rheumatoid arthritis. Scand J Rheumatol 1989; 79 Suppl.: 67–95CrossRefGoogle Scholar
  3. 3.
    Badley EM. The economic burden of musculoskeletal disorders in Canada is similar to that for cancer and may be higher [editorial]. J Rheumatol 1995; 22: 204–6PubMedGoogle Scholar
  4. 4.
    Badley EM, Rasooly I, Webster GK. Relative importance of musculoskeletal disorders as a cause of chronic health problems, disability, and health care utilization: findings from the 1990 Ontario health Survey. J Rheumatol 1994; 21: 505–14PubMedGoogle Scholar
  5. 5.
    Felts W, Yelin E. The economic impact of the rheumatic diseases in the United States. J Rheumatol 1989; 16: 867–84PubMedGoogle Scholar
  6. 6.
    Sullivan S, Swims M. Rheumatoid arthritis: focus on appropriate drug therapy. Am J Manag Care 1998; 4 (6): 900–10Google Scholar
  7. 7.
    Ward MM, Lubeck D, Leigh JP. Long term health outcomes of patients with rheumatoid arthritis treated in managed care and fee-for-service practice settings. J Rheumatol 1998; 25: 641–9PubMedGoogle Scholar
  8. 8.
    Leigh JP, Fries JF, Parikn N. Severity of disability and duration of disease in rheumatoid arthritis. J Rheumatol 1992; 19: 1906–1PubMedGoogle Scholar
  9. 9.
    Yelin EH, Henke CJ, Kramer JS, et al. A comparison of the treatment of rheumatoid arthritis in health maintenance organizations and fee-for-service practices. N Engl J Med 1985; 312: 962–7PubMedCrossRefGoogle Scholar
  10. 10.
    Yelin E. The costs of rheumatoid arthritis: absolute, incremental, and marginal estimates. J Rheumatol 1996; 23 Suppl.: 47–51Google Scholar
  11. 11.
    Yelin E, Wanke LA. An assessment of the annual and long-term direct costs of rheumatoid arthritis. Arthritis Rheum 1999; 42 (6): 1209–18PubMedCrossRefGoogle Scholar
  12. 12.
    Allaire S, Prashker M, Meenan R. The cost of rheumatoid arthritis. Pharmacoeconomics 1994; 6: 513–22PubMedCrossRefGoogle Scholar
  13. 13.
    MacLean CH, Knight KK, Shekelle PG, et al. Costs attributable to arthritis: implications of costs [abstract]. Arthritis Rheum 1996; 39 (9 Suppl.): S317Google Scholar
  14. 14.
    Gabriel SE, Crowson CS, Campion ME, et al. Direct medical costs unique to people with arthritis. J Rheumatol 1997; 24: 719–25PubMedGoogle Scholar
  15. 15.
    Wolfe F, Kleinheksel SM, Spitz PQ, et al. A multicenter study of hospitalization in rheumatoid arthritis: effect of health care system, severity, and regional difference. J Rheumatol 1986; 13: 277–84PubMedGoogle Scholar
  16. 16.
    Lubeck DP, Spitz PW, Fries JF, et al. A multicenter study of annual health service utilization and costs in rheumatoid arthritis. Arthritis Rheum 1986; 29: 488–93PubMedCrossRefGoogle Scholar
  17. 17.
    Mitchell DM, Spitz PW, Young DY, et al. Survival, prognosis, and causes of death in rheumatoid arthritis. Arthritis Rheum 1986; 29: 706–14PubMedCrossRefGoogle Scholar
  18. 18.
    Smedstad LM, Moum T, Guillemin F, et al. Correlates of functional disability in early rheumatoid arthritis: a cross-sectional study of 706 patients in four European countries. Br J Rheumatol 1996; 35: 746–51PubMedCrossRefGoogle Scholar
  19. 19.
    Hawley DJ, Wolfe F. Anxiety and depression in patients with rheumatoid arthritis: a prospective study of 400 patients. J Rheumatol 1988; 15: 932–41PubMedGoogle Scholar
  20. 20.
    Katz PP, Yelin EH. Prevalence and correlates of depressive symptoms among persons with rheumatoid arthritis. J Rheumatol 1993; 20: 790–6PubMedGoogle Scholar
  21. 21.
    Fries JF, Williams CA, Morfeld D, et al. Reduction in long-term disability in patients with rheumatoid arthritis by disease modifying antirheumatic drug-based treatment strategies. Arthritis Rheum 1996; 39: 616–22PubMedCrossRefGoogle Scholar
  22. 22.
    Ward MM, Fries JF. Trends in antirheumatic medication use among patients with rheumatoid arthritis, 1981–1996. J Rheumatol 1998; 25: 408–16PubMedGoogle Scholar
  23. 23.
    Fries JF, Williams CA, Bloch DA, et al. NSAID-associated gastropathy: incidence and risk factor models. Am J Med 1991; 91 (3): 213–22PubMedCrossRefGoogle Scholar
  24. 24.
    Fries JF, Williams CA, Ramey D, et al. The relative toxicity of disease modifying anti-rheumatic drugs (DMARDs). Arthritis Rheum 1993; 36: 297–306PubMedCrossRefGoogle Scholar
  25. 25.
    Wilske KR, Healey LA. Challenging the therapeutic pyramid: a new look at treatment strategies for rheumatoid arthritis. J Rheumatol Suppl 1990 Nov; 25: 4–7PubMedGoogle Scholar
  26. 26.
    Luft HS. How do health-maintenance organizations achieve their ‘savings’? N Engl J Med 1978; 298: 1336–43PubMedCrossRefGoogle Scholar
  27. 27.
    Miller RH, Luft HS. Managed care plan performance since 1980: a literature analysis. JAMA 1994; 271: 1512–9PubMedCrossRefGoogle Scholar
  28. 28.
    Inglehart JK. Second thoughts about HMOs for Medicare patients. N Engl J Med 1987; 316: 1487–92CrossRefGoogle Scholar
  29. 29.
    Inglehart JK. Medicaid and managed care. N Engl J Med 1995; 332: 1727–31CrossRefGoogle Scholar
  30. 30.
    Ware Jr JE, Brook RH, Rogers WH, et al. Comparison of health outcomes at a health maintenance organization with those of fee-for-service care. Lancet 1986; I: 1017–22CrossRefGoogle Scholar
  31. 31.
    Carlisle DM, Siu AL, Keeler EB, et al. HMO vs. Fee-for-service care of older persons with acute myocardial infarction. Am J Public Health 1992; 82: 1626–30PubMedCrossRefGoogle Scholar
  32. 32.
    Safran DG, Tarlov AR, Rogers WH. Primary care performance in fee-for-service and prepaid health care systems: results from the Medical Outcomes Study. JAMA 1994; 271: 1579–86PubMedCrossRefGoogle Scholar
  33. 33.
    Leibowitz A, Buchanan JL, Mann J. A randomized trial to evaluate the effectiveness of a Medicaid HMO. J Health Econ 1992; 235–57Google Scholar
  34. 34.
    Murray JP, Greenfield S, Kaplan SH, et al. Ambulatory testing for capitation and fee-for-service patients in the same practice setting: relationship to outcomes. Med Care 1992; 30: 252–61PubMedCrossRefGoogle Scholar
  35. 35.
    Lubeck DP, Brown BW, Holman HR. Chronic disease and health system performance: care of osteoarthritis across three health services. Med Care 1985; 23: 266–77PubMedCrossRefGoogle Scholar
  36. 36.
    Yelin EH, Criswell LA, Feigenbaum PG. Health care utilization and outcomes among persons with rheumatoid arthritis in fee-for-service and prepaid group practice settings. JAMA 1996; 276: 1048–53PubMedCrossRefGoogle Scholar
  37. 37.
    Henke CJ, Epstein WV. Practice variation in rheumatologists’ encounters with their patients who have rheumatoid arthritis. Med Care 1991; 29 (8): 799–812PubMedCrossRefGoogle Scholar
  38. 38.
    Davis K, Schoen C. Assuring quality, information, and choice in managed care. Inquiry 1998; 35: 104–4PubMedGoogle Scholar
  39. 39.
    Katz PP, Yelin EH. Leong A, et al. Health insurance characteristics and health care evaluations among persons with rheumatic diseases in California. Arthritis Rheum 1999; 42: 2710–18PubMedCrossRefGoogle Scholar
  40. 40.
    Meenan RF, Yelin EH, Henke CJ, et al. The impact of chronic disease. Arthritis Rheum 1981; 24: 544–9PubMedCrossRefGoogle Scholar
  41. 41.
    Liang MH, Larson M, Thompson M, et al. Costs and outcomes in rheumatoid arthritis and osteoarthritis. Arthritis Rheum 1984; 27: 522–9PubMedCrossRefGoogle Scholar
  42. 42.
    Lanes SF, Lanza LL, Radensky PW, et al. Resource utilization and cost of care for rheumatoid arthritis and osteoarthritis in a managed care setting: the importance of drug and surgery costs. Arthritis Rheum 1997; 40: 1475–81PubMedCrossRefGoogle Scholar
  43. 43.
    Ward MM, Javitz HS, Yelin EH. The direct cost of rheumatoid arthritis. Value in Health. In pressGoogle Scholar
  44. 44.
    Wolfe F, Mitchell DM, Sibley JR, et al. The mortality of rheumatoid arthritis. Arthritis Rheum 1994; 37: 481–94PubMedCrossRefGoogle Scholar
  45. 45.
    Wolfe F, Hawley DJ. The relationship between clinical activity and depression on rheumatoid arthritis. J Rheumatol 1993; 20: 2032–37PubMedGoogle Scholar
  46. 46.
    Clarke AE, Zowall H, Levington C, et al. Direct and indirect medical costs incurred by Canadian patients with rheumatoid arthritis: a 12-year study. J Rheumatol 1997; 24 (6): 1051–60PubMedGoogle Scholar
  47. 47.
    Newhall-Perry K, Law NJ, Ramos B, et al. Direct and indirect costs associated with the onset of seropositive rheumatoid arthritis. J Rheumatol 2000; 27: 1156–63PubMedGoogle Scholar
  48. 48.
    Wolfe F, Kleinheksel SM, Spitz PW, et al. A multicenter study of hospitalization in rheumatoid arthritis: frequency, medical-surgical admissions, and charges. Arthritis Rheum 1986; 29: 614–9PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 2001

Authors and Affiliations

  1. 1.Department of MedicineStanford UniversityStanfordUSA
  2. 2.Department of MedicineUniversity of CaliforniaSan FranciscoUSA

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