Multiple sclerosis disease-modifying therapy use in the department of veteran affairs and Medicare: A comparative...

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.