Today’s Managing Health Care Costs Number is $124
Kevin Schulman and colleagues wrote last month in the New England Journal that the cost of the new PCSK9 inhibitors, injectable biologic drugs that dramatically lower LDL (bad) cholesterol, could be huge.
We estimated the magnitude of additional costs per beneficiary in a typical insurance pool by applying a 25% reduction (negotiated discount, cost sharing, or both) to the list price of alirocumab, accounting for the estimated $600 in savings due to fewer cardiovascular events, and varying clinical criteria for use of these therapies. If 5% of the estimated 27% of U.S. adults 40 to 64 years of age who have high LDL cholesterol levels were eligible for a PCSK9 inhibitor, annual insurance premiums would increase by $124 for every person in the insurance pool.
$124 is more than half as much as we pay for all primary care office visits!
The insurance pool of those with employer sponsored health insurance is about 49% of the population – or 159 million. This means the cost of these medications could be almost $20 billion. This doesn’t count the cost of PCSK9s for the Medicare population, where prevalence of hypercholesterolemia is higher.
Note that the potential savings if these medications eliminated ALL heart attacks entirely is accounted for in these figures. Even if these drugs are highly effective, they are priced at far more than their value. The Institute for Clinical and Economic Review (ICER) estimated the value of these drugs at between $3600 and $4800 annually – as opposed to the $14,000 list price.
The most recent JAMA predicts four decision errors likely to lead to vast overprescribing of PCSK9 medications
1. We will start diagnosing more people with intolerance to statins. These people will then be candidates for PCSK9 inhibitors. Muscle aches with statins are common - and most who suffer from these could simply try a different statin or even try the same statin again. Statin intolerance should be a rare reason for PCSK9 use – and then only in patients at very high risk of cardiovascular disease.
2. We’ll return to LDL targets – and many people won’t be able to achieve these with statins. These targets are likely to be chosen without nearly enough attention to “number needed to harm.”
3. PCSK9 inhibitors will be prescribed for statin “failure,” even though it’s hard to define “failure” for meds which lower (but cannot eliminate) risk.
4. PCSK9 inhibitors will be prescribed for nonadherence to statins. The new drugs are injected every week or two weeks – as opposed to taken orally daily. Keep in mind that statin adherence rates were 27% (!) in the control group of a recent study.
There is a long history of physicians warmly embracing heavily-marketed new drugs and new technologies. There is every reason to believe this new class of drugs will be overused. At best, this will buy us better outcomes at an exceptionally high price. At worst, we’ll discover that these drugs have unexpected side effects and we will have spent unnecessary billions of dollars and diminished health care quality.
