CLINICAL
NEWS
American College of Cardiology Extended Learning
ACCEL interviews and topical summaries of cardiology’s
most interesting research areas
The Conundrum of Cost-effective but
Unaffordable Care:
The Plight of High-tech New Interventional Therapies
W
e’re not #1! At least when it comes to
health expenditures, the U.S. per capita
rate of $9,146 is third (third!!) to Norway’s lead at $9,715 and Switzerland’s per capita
rate of $9,276. (The World Bank lists the data [in
U.S. dollars] from the World Health Organization
Global Health Expenditure database: data.worldbank.org/indicator/SH.XPD.PCAP ) Granted, these
are much smaller countries.
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.
To listen to an
reduced amenable mortality to
interview with
the average rate achieved in the
David J. Cohen,
three top-performing countries
MD, on the costs of
new interventional
(France, Japan, and Australia),
therapies, scan the
then the U.S. would have realcode. The interview
ized 101,000 fewer deaths per
was conducted by
Deepak L. Bhatt, MD.
year by the end of the study
period.
CONUNDRUM
This brings us to what has
been called the current crisis
in technology: cost-effective
26 CardioSource WorldNews
(based on historical measures) yet unaffordable
care. Here 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 left atrial appendage occlusion (LAAO), based on PROTECT-AF,
the applicable annual cost for expanding use would
TABLE
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.
International Comparison of Spending on Health (2013)
Per capita total healthcare
expenditure
Health expenditure as a % of GDP
United
States
Australia
Canada
France
Germany
Japan
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
Data: The World Bank and the World Health Organization
All figures are $U.S. dollars.
GDP = gross domestic product
be $13 billion. Throw in more patients receiving
drug-eluting stents (DES; an extra $2.4 billion
based on SIRIUS) and a wider use of transcatheter
aortic valve replacement (PARTNER data and an additional cost of $3 billion), then these four interventional therapies would add $33.4 billion to annual
healthcare 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 statinintolerant), 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,
LAAO, 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
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
• Costs for health care continue to increase but,
on a per capita basis, the United States is no
longer the most expensive place in the world
for healthcare 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.
May 2016