The cost of treating heart disease has become a key factor in decisions by US cardiologists grappling with the nation's number one killer.
Record prices for drugs and devices, reduced reimbursement by insurance plans and the looming full implementation of the healthcare reform law are convincing doctors to consider not only novel treatments, but also how to get the most bang for the buck.
The trend has been reflected at the annual scientific meetings of the American Heart Association, generally a forum for presenting groundbreaking research on medications and devices to combat heart disease.
The conference for the first time last year featured an entire session on the economics of healthcare, including a study showing that eliminating drug co-payments for heart attack victims significantly reduced the chance that they would suffer another major cardiovascular event.
The 2012 meeting, held in Los Angeles, included several dual presentations with companion studies on the economic impact of a drug or therapy as well as its safety and effectiveness.
"We have an unsustainable economic model in healthcare delivery in the U.S.," said Dr Elliott Antman, professor of medicine at Harvard Medical School and chairman of the AHA Scientific Sessions Committee. "We all have to be conscious of ways we can be more cost efficient, and that includes understanding what the big breakthroughs mean in terms of cost."
Difference in follow-up cost
Heart disease accounts for one of every four deaths in the U.S., according to the Centers for Disease Control and Prevention.
It also is very expensive. AHA estimates that annual U.S. medical costs of cardiovascular disease will reach $800 billion by 2030 - nearly triple the $272 billion spent in 2010.
"Rising costs of medical care make it very pertinent for us to assess value," said Dr Mark Hlatky, director of the cardiovascular outcomes research center at Stanford University.
President Barack Obama's Affordable Care Act, which has now survived a challenge in the Supreme Court and a presidential election, is structured to reward quality of care, not the traditional fee-for-service model that can result in unnecessary treatment.
But the equation is not always simple.
One study presented at the AHA meeting showed that diabetics with diseased arteries not only fared better if they underwent bypass surgery rather than a less expensive stent procedure, but the surgery was also more cost effective.
Researchers, funded by the National Institutes of Health, found that up-front costs for bypass surgery and hospitalisation were about $8 600 higher than costs for stent patients. But more stent patients either died or needed repeat artery revascularization, while those who had surgery lived longer, higher-quality lives, resulting in lower, long-term healthcare spending for them.
Another study found that angioplasty to clear blocked arteries costs more at hospitals not equipped for emergency heart surgery, due mainly to follow-up costs. Elective angioplasty is becoming increasingly common at hospitals that do not conduct more complicated heart procedures.
"Surprisingly, there was no difference in procedure cost," said Dr Eric Eisenstein, lead author of the study and assistant professor of medicine at Duke University Medical School in North Carolina. "We did find a difference in follow-up cost."
New research paid for by Johnson & Johnson, one of the makers of the new anti-clotting drug rivaroxaban (Xarelto), showed that the costs of a heart attack, angina, or chest pain go well beyond actual hospital care.
The study, led by Robert Page, a clinical specialist in the division of cardiology at the University of Colorado School of Pharmacy in Aurora, Colorado, found that every short-term disability claim for acute coronary syndrome cost employers nearly $8 000, and each long-term claim carried a price tag of more than $52 000.
Annual healthcare costs for each worker, including out-of-pocket expenses, totalled nearly $8 200 during the four-year period studied.
About half of all patients with acute coronary syndrome are working adults under the age of 65, Page said. That means the burden for their care will more likely fall on employers and employee co-payments rather than on the Medicare system.
The AHA estimates the rate of coronary heart disease in the United States will increase by 16% between 2010 and 2030.
Xarelto is one of three new blood-thinners that offer potential advantages over older drugs to prevent strokes and other conditions caused by blood clots.
"These drugs are expensive. They cost more than warfarin, which is relatively cheap to use," said Dr Stuart Connolly, director of the cardiology division at McMaster University in Ontario, Canada. "Cost-effectiveness studies have been favourable. The reason is that even though purchase of the drug is not cheap, there are savings from preventing ischemic strokes."
Even so, physicians can face significant hurdles to secure insurance coverage for patients they think need to be on a new, more expensive drug.
"It is a cost firewall," Dr Antman said, explaining that it can take considerable time for him to talk to insurance telephone operators, claims supervisors and, eventually, medical directors to secure coverage for a patient.
(Reuters Health, November 2012)
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