Now that I’m starting on my third biological treatment for rheumatoid arthritis – Enbrel, Cimzia, now Humira, I began thinking about the high costs of these treatments, whether or not they are “worth it”, and how this information influences those who make decisions about treating RA. Most of these complex medications cost $1,200-$2,000 per month. None of the treatments, including the oldest-Enbrel, have cheaper generic equivalents due to the fact that the government gives pharmaceutical companies longer copyrights on biological medicines. The argument is that the companies need to recoup hefty research and development investments needed to create, test, and market the treatments. But are these treatments cost effective? An investigation into the scientific literature revealed that cost-benefit arguments of medical treatments are widely studied.
When considering cost-benefit analyses, some standard definitions are required in order to measure “quality of life” (QOL). Aspects of QOL include disability, social perspectives, loss of productivity, and overall general feelings of wellness. Since 1994, disabilities have cost over $300 billion in health care and lost production in the United States and according to the Centers for Disease Control, arthritis is the #1 cause of disability. [i] [ii] Slowing or stopping the impact of arthritis is beneficial not only for the individual, but also for society in general.
In order to make comparisons across studies, economists developed the Quality Adjusted Life Year (QALY). Here is a definition.
A year of life adjusted for its quality or its value. A year in perfect health is considered equal to 1.0 QALY. The value of a year in ill health would be discounted. For example, a year bedridden might have a value equal to 0.5 QALY.[iii]
Some argue that QALY could even be negative if the person felt life was not worth living…like in a terminal cancer patient. It is generally agreed that treatments are worthwhile if they cost below $50,000 to $100,000 per quality-adjusted life-year (QALY) gained.[iv]
Since biological treatments for RA are so expensive, I conducted a brief search of the medical economic literature to determine how they fared on the QALY continuum. One large meta-analysis (a study of many studies) of biological treatments in Medicare patients found that Enbrel and Humira fell in the range of $50,000/QALY. Remicade was found to be less cost effective.[v] Other studies demonstrated the cost effectiveness of Enbrel.[vi] At this point, these expensive treatments for RA appear to fall within acceptable, yet high, ranges for impacting patient’s quality of life.
Studies like these are sure to influence decision makers when it comes to RA treatments. Decision makers may include doctors and their professional societies (like the America College of Rheumatology), insurance companies, and governmental agencies. At this point, expensive biological treatments are covered by insurance after certain criteria are met.
Some researchers in Europe argued that cheaper treatments should be tried first before moving to the more expensive biological treatments.[vii] In countries with nationalized healthcare, such as the United Kingdom, “Treatments that don’t justify their high cost are nixed or limited—rationed, by another name.”.[viii] I’ve heard of the UK’s National Institute for Clinical Excellence (NICE) system rejecting biological treatments for RA due to high costs (read Pollyanna Penguin’s blog). Systems in the United States are not at this level of government decision-making regarding medical treatments…yet. Time will tell if the newly approved healthcare reform bills will lead us in that direction.
In the meantime, we continue to be able to use expensive biological treatments because of their impact on quality of life. I’m fortunate that my insurance plan covers such treatments with modest copays ($25 a month for Humira). But, the personal impact of Humira on my symptoms remains unknown as I just started a few days ago. So far, no change in my QOL.
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