Perspectives on Health Care Reform: What’s to Be Done About Cost Containment?

In the December 14, 2009, issue of The New Yorker magazine, Atul Gawande observed, "Cost is the specter haunting health care reform." The idea (or better, mantra?) of cost as central to health care's reform is not new but is surely a topic that demands this generation's consideration. Most of the economic debate has been general, looking at national "bottom lines" rather than focusing on the "dollars and cents" of individual diseases. Let's take a sobering look at rising costs in the context of specific diseases, beginning with psoriasis.¹

THE COST OF TREATING PSORIASIS

Somewhere between 4.5 and 7 million Americans have psoriasis. Approximately one-third of them do not improve optimally with topical therapy. Systemic therapy has become the next step in therapeutics and is now the standard of care. The reference revealed some pricey annual costs for pharmaceuticals used for the treatment of psoriasis: $1197 for methotrexate 7.5 mg/wk versus $27,577 for alefacept for a 12-week course!

Another treatment modality available as well as successful for psoriasis is phototherapy. Psoralen–UV-A therapy can cost $7288 per year. Acitretin at higher dosages (50 mg/d) could cost a patient or his or her third-party payer $17,613 annually. The so-called biologics can run up to $27,577 yearly. Loading doses for some (infliximab, for example) can total more dollars, at least during the first year of administration.

The authors looked at the economics of treating psoriasis another way. Even though the costs for methotrexate decreased approximately 20% from the years 2000 to 2008, brand-name methoxsalen increased 316% and acitretin rose 157.5%. Newer agents such as the biologics efalizumab and adalimumab have been around approximately 4 years and have increased in cost 35.1% and 27.2%, respectively, over the same interval. Since the new vocabulary of reform compares rising costs with inflation or with costs in other arenas, these figures became even more stunning. Overall increases for these and other drugs targeting psoriasis approximated 66%! Outpacing inflation and costs for other services by an impressive order of magnitude was not a problem.

RISING COSTS OF TREATING OTHER DISEASES

Direct-to-consumer marketing on television constantly reminds patients of the expanding spectrum of benefits associated with biologics. Inflammatory bowel diseases (ulcerative colitis and Crohn disease), rheumatoid arthritis, multiple sclerosis, and other inflammatory conditions are debilitating diseases mitigated by these remarkable agents. Unfortunately, that therapeutic success (real as it is) is accompanied by what some may consider a prohibitive cost. Furthermore, patients with these diseases, but without insurance, cannot afford the price tag. Is reform going to find someone to pick up the tab?

Similar rising costs can be identified in other areas. Bevacizumab, a monoclonal antibody used to treat colon, lung, and breast cancer, is predicted to generate sales of $7 billion for its maker.² This particular drug can cost $48,490 and $39,614 when administered to patients with lung and colorectal cancer, respectively.³ The additional longevity acquired at these remarkable costs is nil. One study demonstrated no overall increase in survival at a cost of $90,816 for the drug!⁴

SOMETHING HAS TO GIVE

Since continuing technological advancements are going to add to these and other rising costs (dialysis, for example, with more "baby boomers" coming of Medicare age), one has to wonder what the something is that "has to give" in the future. We will be seeing patients with psoriasis, renal failure, and advanced cancer—and considering the high costs of pharmaceuticals for those who can and those who cannot afford to take them. When should we begin to determine, as in reference 2, how much is more life worth? Since it is apparent that these rising costs cannot be sustained indefinitely, will we ration, will we stop and draw the line for some of these miracle drugs and the people who want to take them?