JAMA had a great editorial perspective this week by Katherine Baicker and Amitabh Chandra on the challenge of figuring out quality and cost effiency in health care spending.
individuals in the United States may consume what appear to be similar health care services, but some of these services may actually be more intensive versions of the services consumed in other countries. For instance, patients in the United States may see specialists just as often as patients in Australia but may be more likely to see board-certified radiation oncologists relative to general oncologists, receive new immunotherapies instead of an angiogenesis inhibitor, and receive drug-eluting stents instead of bare-metal stents. It is not possible to conclude that individuals in the United States pay higher prices for these services just by observing that they spend more but have the same number of visits for cancer care, receive different medications, or use the same number of stents without having granular data about the exact type of services and products being used. The larger and more varied the health care services being compared, the larger the scope of this problem.
A related issue that is crucial to making valid spending comparisons is the role of quality differences. Quality differences not only make cross-country comparisons difficult but these differences may complicate within-country comparisons. For example, a report from the Health Care Cost Institute concluded that pharmaceutical utilization stayed constant over the past 4 years (2012-2016) and that there was substantial price growth in this sector.3 Like other research, this analysis treated the introduction of new drugs, including therapies for hepatitis C, as a pure price increase without incorporating the possibility of any quality improvement represented by these innovations.
Hep-C cures are the epitome of two very true statements.
1) They are really freaking expensive on both a per-patient basis and total spending basis
2) They are really effective and thus high value
We are going to see more and more treatments that will share those two true statements as personalized medicine and rare genetic disease cures work their way through the pipeline. ICER released a cost effectiveness report on a new hemophilia prophylatic regime on the 15th. They find that for individuals with inhibitors related to clotting factor for Hemophilia A the new treatment regime is both much more effective at preventing bleeding events and far less expensive. The projected cost of treatment for this regime is slightly less than half a million dollars per yer per patient. There are slightly less than 1,000 patients who qualify in this country.
And the drug is a bargain at half a million dollars a year:
Not just cost effective, but cost saving.
In fact, I believe ICER is saying it would remain cost saving even at $2million WAC.
good report to read on new Emicizumab for Hemophilia A with inhibitors. https://t.co/lQ6y3ew644
— Walid Gellad (@walidgellad) March 15, 2018
But I digress as the main point is that evaluating health systems on quality, quantity and price by plugging data into Excel and seeing pretty graphs will probably not tell the entire story. Better data and more sophisticated modeling to get the local context at a granular level that probably can not be easily captured in readily available claims data is needed.
Baicker K, Chandra A. Challenges in Understanding Differences in Health Care Spending Between the United States and Other High-Income Countries. JAMA. 2018;319(10):986–987. doi:10.1001/jama.2018.1152