In the December 14, 2009 issue of The New Yorker magazine, Atul Gawande observed, “Cost is the specter haunting healthcare reform.” The idea (or better mantra?) of cost as central to healthcare’s reform is not new but 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
Somewhere between 4.5 and 7 million Americans have psoriasis. Approximately one-third of them do not improve optimally on topical therapy. Systemic therapy has become the next step in therapeutics and is now standard of care. The reference revealed some pricey annual costs for pharmaceuticals utilized for the treatment of psoriasis: methotrexate(Drug information on methotrexate) 7.5 mg/week ($1197) versus alefacept for a 12-week course ($27,577)!
Another treatment modality available as well as successful for psoriasis is phototherapy. Psoralen-UV-A therapy can cost $7288 per year. Acitretin(Drug information on acitretin) at higher doses (50 mg/day) could cost a patient 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(Drug information on methoxsalen) increased 316% and acitretin 157.5%. Newer agents such as the biologics efalizumab(Drug information on efalizumab) and adalimumab(Drug information on 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 to inflation or to 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.
Direct-to-consumer marketing on television constantly reminds patients of the expanding spectrum of benefit 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(Drug information on 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
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?