Sunday, December 8, 2013

Money and IBD

Costs of Care

The cost of continuous healthcare for those with inflammatory bowel disease is a frequent concern for patients, but also for insurance companies and public health systems.  Cost of treatment is a factor in many diagnostic and treatment decisions – do we do an MRI or is a less expensive x-ray the best option?  What treatment approach do we start with – less expensive prednisone or more expensive anti-TNF-alpha drugs?  

The cost equation is complex – if everyone with abdominal pain was subjected to a small bowel series/MRI, colonoscopy, and extensive bloodwork, everyone’s insurance premiums would go through the roof and no one would be able to afford medical care (and generate numerous false positives, unnecessarily worrying many individuals).  On the other hand, early diagnosis may reduce the lifetime costs of care.  Finding the balance between the most effective treatment and cost effective diagnostics requires understanding the true costs associated with IBD. 

Costs are very difficult to calculate in many cases.  The incremental cost of conducting an MRI is similar to that of a small bowel follow-through.  That said, the cost of purchasing and maintaining an MRI unit is significantly higher, and that cost must be amortized across the patients or the imaging center could not afford to implement it.  Similarly, if the lesser cost diagnostic tools are used but more tests are required, the costs could even out or even exceed those of using the pricier test first.  On the ongoing case side, if a particular drug is more effective, it may mean fewer tests and procedures, saving money in the long run over lesser cost drugs.  How do we untangle this mess?  Fortunately, epidemiologists and others have done extensive work in determining the cost of ulcerative colitis and Crohn’s on a continuing basis.

One of the general concerns regarding the anti-TNF-alpha drugs is their cost.  With generic versions at least 5 years away, they can represent some of the highest costs for an IBD patient.  How much do they cost?  A provider analysis showed the following average annual costs for the three main drugs for continuing care (after remission or a stable state has been achieved) in US dollars:

·         $15,836 etanercept (Enbrel)
·         $19,457 adalimumab (Humira)
·         $25,748 infliximab (Remicade) (1)

Another study in the UK looked at costs as well, and noted that infliximab is weight-dependent for the dosage and has a higher variable cost.  The mean costs were calculated as follows:

·         £6,294 Infliximab
·         £5,720 adalimumab(2)

After reviewing the spread of the costs in the patients reviewed, the infliximab and adalimumab ended up having negligible cost difference.  The differences between the two countries may be due to an increased cost of infusion facilities in the United States or different cost structures for the drugs based on the UK’s collective purchasing.  Either way, those without insurance (and not on a cost assistance program, which most of the pharma companies have available), are looking at approximately $20,000 per year in drug costs alone.

Most of the larger cost studies on overall costs of the diseases were done prior to the biologicals achieving the level of usage they currently have.  A 1995 study looked at the annual cost of treating a patient with Crohn’s disease and found the following costs:

·         Individuals Requiring Hospitalization - $37,135 ($55,261 in 2013 dollars)
·         Individuals Requiring Steroids and Immunosuppressants - $10,033 ($14,930 in 2013 dollars)
·         Other Individuals - $6,277 ($9,341 in 2013 dollars)

The overall mean cost came out to be $12,417.(3)

A 2008 study (after the introduction of anti-TNF-alpha therapies) found the following costs per person each year:

·         Mean annual costs for Crohn’s Disease - $8,265
·         Mean annual costs for Ulcerative Colitis - $5,066

The breakdown of the costs was as follows:

·         Surgery – 12.4%
·         Hospitalization (non-surgical) – 19%
·         Medications – 35.3%
·         Outpatient Services – 33.3%(4)

Overall, the cost to treat IBD has come down in both absolute and relative dollars – likely due to the improved detection and medical treatment reducing the surgical and hospital-stay related costs, even though the medication costs are higher (the 5-ASA drugs standard at the time were extremely inexpensive but much less effective than the biologicals, and the 6-MP treatments and AZA treatments had lower costs as well).

Bottom Line

·         The bulk of the costs in IBD has shifted from surgeries in 1995 to medications in 2008.
·         While expensive, the biologicals have reduced overall IBD treatment costs.
·         Biological costs are not likely to drop much until 2018, when Remicade comes off-patent.

1.       Bonafede, Machaon MK, Shravanthi R. Gandra, Crystal Watson, Nicole Princic, and Kathleen M. Fox. "Cost per treated patient for etanercept, adalimumab, and infliximab across adult indications: a claims analysis." Advances in therapy 29, no. 3 (2012): 234-248.
2.       Lamb, C. A., M. Price, M. Robinson, M. C. Gunn, N. P. Thompson, and J. C. Mansfield. "A real life retrospective analysis of drug expenditure reveals no significant cost difference between infliximab and adalimumab in the treatment of adult crohn's disease." Gut 60, no. Suppl 1 (2011): A251-A252.
3.       Feagan, Brian G., Mary Glenn Vreeland, Leanne R. Larson, and Mohan V. Bala. "Annual cost of care for Crohn's disease: a payor perspective." The American journal of gastroenterology 95, no. 8 (2000): 1955-1960.

4.       Kappelman, Michael D., Sheryl L. Rifas–Shiman, Carol Q. Porter, Daniel A. Ollendorf, Robert S. Sandler, Joseph A. Galanko, and Jonathan A. Finkelstein. "Direct health care costs of Crohn's disease and ulcerative colitis in US children and adults." Gastroenterology 135, no. 6 (2008): 1907-1913.

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