Statins Remain Cost Effective, Not Cost Saving

Today’s Managing Health Care Costs Indicator is $169,549

Click on image to enlarge.  Source below

Statins are enormously effective drugs that, along with a decrease in cigarette smoking, have been responsible for a huge decrease in the incidence of cardiac death, especially in young men.    Statins were shown to be effective  at lowering mortality in 1994  in the 4S study (Scandinavian Simvastatin Survival Study).   This study was reevaluated in 1996 to look at changes in hospital costs, and the saved hospitalizations in the treatment group covered 88% of the cost of simvastatin in the high risk group.  

Simvastatin has been a generic medication for a few years, and atorvastatin (Lipitor) is going generic this coming month. Have we finally reached a point where the use of statins is not merely cost-effective, but is actually cost-saving?

Even with dramatic declines in the acquisition cost of the statin medications, though, treatment in this simulation done in BMJ this past March was not cost-saving in any cohort.  The cost of a Quality Adjusted Life Year for a 55 year old man with a 5% ten year risk of a heart attack was 125,544 euros (or  almost $170K)

Harvard Link

Non-Harvard Link  

As you can see from the graphic – the cost to save lives with simvastatin was actually quite modest in many instances - especially over the longer time horizons. For instance, it cost only 5394 Euros for each QALY for 55 year old men at a 30% risk for a vascular event over the following 10 years. Still, not a single simulated group gained QALYs with LOWER costs. 

We don’t save money by using even generic statins for primary prevention of heart of vascular disease.   We only gain good health outcomes for a reasonable cost -- which doesn’t seem to me to be a bad outcome at all.

Read More

Generic Medications Make Prevention More Cost-Effective

Today’s Managing Health Care Costs Indicator is 98%

 Click to enlarge. Source 

Prevention saves lives – but it’s often stated that preventing disease can save money.   It’s intuitive – a mammogram costs far less than treatment of metastatic breast cancer, and a statin medication costs far less than bypass surgery or a stroke.

However, there are historically few medical interventions that are cost saving.  Childhood vaccinations save more money than they cost.  Preventing medical errors can certainly improve care and lower cost, although this is an internal quality improvement as opposed to a new medical procedure. 

But most prevention efforts can improve health care quality and lengthen life – but often at a considerable cost.

Researchers in this month’s Health Affairs reanalyze earlier research on cost-effectiveness, substituting current generic prices for the brand name prices used in past years when there were fewer effective generic medications available.

The good news – the cost per quality adjusted life year in this new analysis goes down between 58% and 98%.   Although the title of the article implies cost-saving, there are no “negative” costs for Quality Adjusted Life Years (QALYs);  a QALY can be purchased in some instances for as little $1022.

Further good news is that there are a number of “blockbuster” drugs going generic in the next few years.

Click to enlarge. Source above. See also article in today's Boston Globe. 

There are still challenges, though.  Many states have less effective laws promoting generic use, leading to higher use of more expensive brand name medicines when they offer little incremental benefit.   Many physicians still object to generic drugs, although laws limiting and/or disclosing pharmaceutical company gifts might change this over time.  Patients aren’t sure, either, and the different colors and shapes of generic medicines diminish their acceptability. 

We need to push hard for the most cost-effective approaches, so that we can better use our limited health care dollars.  This article shows the importance of promoting use of generic medications.

Past relevant  Managing Health Care Cost Posts:

Cost savings with generics, March, 2011

Senators Try to Undermine Generic Bioequivalents  January, 2011

Read More

Individualized Evidence Based Medicine

Today’s Managing Health Care Costs Indicator is  $340,000

The early July Annals of Internal Medicine  has a fascinating simulation which suggests that there isn’t a single “rule” about who should get mammograms.  This isn’t surprising; we’ve been thinking about individualized medicine for some time. But this throws into doubt much of the quality reporting we’ve been putting in place over the last 20 years – we’re going to have to go way beyond the percentage of women between 50 and 65 who got a mammogram each year to determine if a provider group is delivering  the best possible care!

For starters, this simulation shows that annual mammography is so costly that it costs more than $340,000 per quality adjusted life year to perform annual mammography instead of biennial for all women at any level of risk.  Annual mammograms would not be recommended for any women by value-based purchasing guidelines.

Click to enlarge.  Source 

But this is not all about costs –the rate of false positives is strikingly high.  And false positives don’t just cost money – they take an enormous emotional toll on women and their families.  This simulation considered the potential negative quality of life for the brief period of time between a false positive screening mammogram and a negative biopsy – and even if that is very small, it still has a big impact on the “value” of mammographic screening.

Click to enlarge. Density by BI-RAD methodology (see article for details)

The value of mammography is highly dependent upon two well-accepted factors:  family history and previous biopsy. Breast density is such an important risk factor for breast cancer that this alone could be a reason to recommend different screening intervals.

This is a simulation study – performed with robust sensitivity analysis – and the accompanying editorial warns that we should not change our current mammography practice based on this paper alone. The simulation assumed we would do a screening mammogram to determine breast density at the beginning of each 10 year period, and required a host of assumptions any of which could be disputed.

This paper elegantly demonstrates that we need to start thinking about evidence based therapy based on highly individualized considerations. These considerations will involve genetics, previous medical history, and individual patient preference. It’s going to be harder to effectively develop evidence-based insurance plans – since what is medically necessary for me is different than what is medically necessary for you based on criteria not likely to be found in claims  It will also be harder to effectively practice medicine without decision algorithms built into electronic medical records. Neither a simple rule nor a physician’s intuition will be adequate to give us the best medical care.

Read More

Illusory Promises of Future Health Care Cost Savings (and Increased Profits for Osteoporosis Screening Now!)

Click on image to enlarge it. Source 

The Boston Globe today has an excellent exploration of how lobbyists inserted language in the health care reform bill to effectively double payment for bone densitometry.   Medicare recognized that it was overpaying for osteoporosis screening tests, and cut prices.  Lobbyists for the scan manufacturers, physicians who perform scanning, and drug companies which sell osteoporosis medication cried "foul." As a result of a $3 million lobbying effort,  the price for a scan will go up from $50 to $97.


Here are two comments from (Democratic) legislators who got campaign contributions from the scanning industry and inserted this language into the health reform bill:


Representative Shelley Berkley (D-Nevada)

“You have to view these things through common sense. And it doesn’t take a genius to figure out that providing bone density tests for elderly Americans will save this country billions of dollars,’’ said  Berkley. “In addition to saving taxpayers money, it will prevent suffering that people with osteoporosis have.’’


Senator Blanche Lincoln (D- Arkansas)
“Part of her effort to strengthen and improve Medicare includes recognizing when a particular test with enormous potential to prevent health problems and significant promise of cost-savings is being taken out of doctors’ offices because providers can’t afford it,’’ said Lincoln spokeswoman Marni Goldberg. “That’s a flaw in the system that needs to be addressed.’’


The article notes that the cost of osteoporosis-related fractures is $19 billion per year. 


Both of these representatives are just plain wrong.   We should screen women at risk for osteoporosis - so that we can prevent fractures, prevent premature death, and give these women (and some men too) more Quality Adjusted Life Years (QALYs).   


However, when we make screening more available it costs more money.  It does not save money. In fact, depending on the analysis, each QALY saved by screening costs between $55,000 and $450,000.   Nothing wrong with doing screening.  But we should not offer false hope that this screening will save billions of dollars. 

Read More