American College of Cardiology Extended Learning

If you ’ re feeling competitive or miss no longer being first in per capita health care expenditures , then you will be happy to know that , among major countries , we remain # 1 in total health expenditure as a percent of gross domestic product ( GDP ) ( TABLE ). However , we miss being # 1 among all nations , beat out by tiny Tuvalu ( formerly known as the Ellice Islands ), a Polynesian island nation located midway between Hawaii and Australia . There you will find health care expenditures that are 19.7 % of their GDP .

You probably have seen older graphics showing the U . S . as a resounding # 1 in both categories , which certainly was the case . Our descent to # 3 is a recent phenomenon ; as of 2010 , the U . S . was spending more per capita than either Norway or Switzerland — or anyone else , for that matter . And that had been the case since about 1980 .

Also , you likely have seen the trends in deaths considered amenable to health care in people younger than 75 years . In an analysis of the U . S . and 18 other industrialized countries , investigators reported such deaths account , on average , for 23 % of total mortality in this age group among males and 32 % among females . The decline in amenable mortality in all countries averaged 16 % between 1997 – 98 and 2002 – 03 . The U . S . was an outlier , with a decline of only 4 %. Had the U . S . reduced amenable mortality to the average rate achieved in the

To listen to the interview with David J . Cohen , MD , visit the CSWN YouTube channel or scan the QR . Interview conducted by Deepak L . Bhatt , MD , MPH . three top-performing countries ( France , Japan , and Australia ), then the U . S . would have realized 101,000 fewer deaths per year by the end of the study period .

CONUNDRUM This brings us to what has been called the current crisis in technology : cost-effective ( based on historical measures ) yet unaffordable care . Here

TABLE International Comparison of Spending on Health ( 2013 )

Per capita total health care expenditure

Health expenditure as a % of GDP

Data : The World Bank and the World Health Organization All figures are $ U . S . dollars . GDP = gross domestic product

are some numbers : if ICDs were used in patients shown to benefit in MADIT-II , the price-tag would be $ 15 billion per year . For LAA occlusion ( based on PROTECT-AF ), the applicable annual cost for expanding its use would be $ 13 billion . Throw in more patients receiving DES ( an extra $ 2.4 billion based on SIRIUS ) and a wider use of TAVR ( PART- NER data and an additional cost of $ 3 billion ), then these four interventional therapies would add $ 33.4 billion to annual health care costs .

These numbers apply to expanding established interventional technologies , but this problem is not confined to high-tech devices . Consider the new lipid-lowering agents , known as PCSK9 inhibitors : with approximately 2.6 million U . S . individuals who could potentially receive a PCSK9 inhibitor over the next 5 years , the total budgetary impact over that time period would be $ 19 billion ( for those with familial hypercholesterolemia ), $ 15 billion ( for those who have CVD but are statin-intolerant ), and $ 74 billion ( if used for individuals with CVD but not at their low-density lipoprotein cholesterol target ).

According to David J . Cohen , MD , director of cardiovascular research at Saint Luke ’ s Mid America Heart Institute , Kansas City , KS , there is already informal rationing in cardiovascular care , including limiting use of LV assist devices , carotid stenting , and transcatheter heart valves . Coming soon , he said , you might see limits placed on the use of PCI in stable coronary artery disease , renal stenting , LAA occlusion , and perhaps others .

From a public health standpoint , there are data to support further expansion of spending on health care over many other areas , but there is a need for continued education of the public regarding the true “ value ” of medical technology . Dr . Cohen also noted that even the current economic environment will continue to support innovation over iteration : technologies that provide substantial benefit and fill truly unmet clinical needs are most likely to be covered and reimbursed .

He added that study designs should emphasize clinical benefit and focus on identification of optimal populations . Also , there should be a demonstration of economic value through “ real world ” studies that focus on outcomes that are relevant to patients and payers ( survival , QOL , and lower costs of care ).

Dr . Cohen added that treatments are not “ cost effective ” unless they are truly effective . And for truly transformative technologies , the true value may not be immediately apparent . ■

REFERENCES : 1 . Nolte E , McKee CM . Health Aff ( Millwood ). 2008 ; 27:58-71 .

Take-aways

United Kingdom

$ 9,146 $ 6,110 $ 5,718 $ 4,864 $ 5,006 $ 3,966 $ 3,598

17.1 9.4 10.9 11.7 11.3 10.3 9.1

• Costs for health care continue to increase but , on a per capita basis , the U . S . is no longer the most expensive place in the world for health care expenditures .

• In interventional cardiology , there are a number of cost-effective but unaffordable technologies that has led to an informal rationing of care that will likely expand .

• There is a great need to understand the true “ value ” of medical technology — which may require changes in how clinical trials are designed and evaluated — so that technologies can be demonstrated to provide substantial benefit and fill truly unmet clinical needs based on outcomes relevant to patients and payers .

ACC . org / CSWNInterventions CardioSource WorldNews : Interventions

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