A shift has occurred in the treatment costs of inflammatory bowel disease (IBD) and other GI conditions. Historically, the highest costs associated with treatment were related to hospitalizations. Today, much of the cost can be attributed to the increased expense of prescription drugs.
“Treatment regimens with biologics for an individual IBD patient can add up to tens of thousands of dollars in annual maintenance,” said Akbar K. Waljee, MD, assistant professor of internal medicine at the University of Michigan, Ann Arbor. Dr. Waljee was the first of four speakers to discuss the cost and cost-effectiveness of various GI drugs during an AGA symposium at Digestive Disease Week® 2016.
“Biologic therapy has proven to be effective but there is still a lot of uncertainty as to whether it is always cost effective,” Dr. Waljee said. “Different studies have looked at it and come to different conclusions.”
The good news, he noted, is that patents for biologics are expiring and biosimilars will soon be on the market, bringing treatment costs down. Until then, physicians need to be aware of the implications of treatment costs and take a more individualized approach to prescribing therapies over the long term, Dr. Waljee said.
“It’s about finding the right treatment for the right person at the right time,” he said.
A similar challenge exists in hepatitis C (HCV) therapy, according to Fasiha Kanwal, MD, MSHS, associate professor of medicine and gastroenterology at the Baylor College of Medicine, Houston, TX, who discussed the recent advent of direct-acting antiviral (DAA) drugs.
“The treatment paradigm for HCV has evolved at a rapid pace over the past several years,” she said. “For more than a decade, we treated patients with pegylated interferon and ribavirin, which would lead to a cure in less than 50 percent of patients. Now, with DAAs, we can cure more than 90 percent of patients with as little as eight weeks of treatment without any side effects. This has the potential to change the epidemiological curve of HCV infection.”
The catch, Dr. Kanwal said, is that the cost for the newest generation of DAAs is $1,000 a pill, which translates to a 12-week treatment cost of $88,000 for an individual patient. Despite the expense, analyses have shown that DAA therapy is cost effective for most patients when compared to previous treatments, Dr. Kanwal said. She attributed this to the greatly increased cure rate and the impact on HCV-associated disease burden, such as cirrhosis, liver cancer and liver transplantation.
“Recently, there have been major rebates in these expensive treatments and more discounts are expected that might make the DAA scenario even more favorable,” Dr. Kanwal said.
Louis Tripoli, MD, noted that even if a drug is deemed cost effective, that doesn’t necessarily mean it is affordable, or that it will be covered by commercial insurance plans.
“Access to a drug or a treatment is generally regulated in several ways: through benefits, rules and cost sharing,” said Dr. Tripoli, chief physician and medical director of MedImpact Healthcare Systems, Inc., a pharmacy benefit management company in San Diego, CA. “When we talk about benefits, for example, if a drug is not covered, a patient can’t get it at any price unless they want to pay for it 100 percent out of pocket.”
Because of the high cost and lack of coverage of certain drugs, the only option for some patients is to finance their care. But the financing mechanisms in the U.S. health system have not evolved in step with some of the increasing costs, Dr. Tripoli said.
“The answer may be to amortize care for patients over time,” he said. “That amortization could also be a source of long-term investment for managed-care companies that would take over that amortization when they take over a patient.”
In the Veterans Health Administration (VA), the majority of access and pricing problems are ameliorated by the VA’s purchasing power, according to Jason Dominitz, MD, MHS, FASGE, chief of gastroenterology at the VA Puget Sound Health Care System, Seattle, WA.
“How we deal with pharmaceutical costs is very different from the fee-for-service model and very different from Medicare, which by law is not allowed to negotiate drug prices,” Dr. Dominitz said. One of the keys to the VA’s pricing power, he said, is the fact that approximately 70 percent of physicians in the U.S. are trained in VA hospitals and clinics.
“The pharmaceutical companies know this and they also know that what you’re trained to prescribe is what you’ll prescribe after you get out of training,” Dr. Dominitz said. “So if you’re a drug company and your competitor’s drug is being prescribed at the VA, there is an incentive to having your drug available at the VA as well. That means they have to play ball with us and lower their prices if they want to have access to our trainees.”