My First Take: It is Hard to Save $$$ at a Rolls-Royce Dealership

A recent article looked at a crucial issue –trying to deliver “best care at lower cost” (Inflamm Bowel Dis 2014; 20: 946-51).  “The goal of this report is to answer the primary question: What are implementable strategies and exploratory considerations for cost-efficient anti-TNF use while maintaining the highest quality of IBD care?”

The strategies that are discussed include the following:

  • Reduce costs of avoidable dose intensification of class switching by eliminating episodic anti-TNF use and improving patient education
  • Reduce over-utilization costs by accurately determining indication for escalating anti-TNF use
  • Reduce nondrug infliximab costs through shortened infusion times after initial safety is clearly established

Exploratory considerations:

  • Self-injectable anti-TNFs
  • Combination therapy
  • Monitoring anti-TNF drug levels and autoantibodies
  • Assessing mucosal healing as a clinical endpoint

The authors discuss both the exploratory issues and the strategies.  Some of each could easily increase costs, at least in the short-term, rather than reduce them.  The authors also make note of the development of an infliximab biosimilar (Inflecta) which could be approved in U.S. by 2015.

While the review article is a good read, in my opinion the authors fail to address in a meaningful way the larger context.  The costs for hospital-based care are enormous; pediatric hospitals are like Rolls-Royce dealerships; and by the way, if you have to ask how much it costs, you probably cannot afford it.  With regard to charges/costs, there is little transparency, high variability, and little accountability.  Understanding health care costs and trying to get a good deal is much harder than buying a car.

For IBD care, as an example, the authors make note of the cost of infliximab at one pediatric tertiary care center.  At this institution, “77% of the total health care cost for each infusion encounter” was for non-drug costs.  Given how expensive the drug cost is, the expense for an infusion is very high, but probably similar to many other pediatric hospitals.

If one is interested in reducing the costs of infliximab and other infusions, the first practical step would be to consider infusion outside of a hospital-based setting, such as an infusion center.  In such a setting, the patient safety would still be excellent but the costs would be less.

In Atlanta, there have been some high-profile hospital acquisitions that have increased health care costs (When doctors sell out, hospitals cash in | www.myajc.com).  In many circumstances, when a hospital acquires a physician practice, infusion center, or endoscopy center, the charges and reimbursement increase despite no change in clinical care.  In this way and many others, the current system promotes cost-inefficient care.

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3 thoughts on “My First Take: It is Hard to Save $$$ at a Rolls-Royce Dealership

  1. Always enjoy reading your blogs. Thanks for thinking more deeply about our IBD article. To continue the interesting discussion: Transferring infliximab infusions from the pediatric med ctr to an outpatient infusion ctr likely won’t decrease non-drug costs very much. The reason (from our observations) is because much of the 77+% of non-drug costs goes to skilled nurses. Having any highly-trained personnel requirement to give a drug greatly elevates the total costs.

    I think the real question that needs to be answered is: Can a self-injectible anti-TNF (like adalimumab) be the default first-line drug (maybe except for hospitalized fulminant pan-colitis)? Previously, since there are no head-to-head trials, we assumed adalimumab vs infliximab were comparable in therapeutic efficacy. But with recent reports from Annals of Internal Medicine (meta-analysis) and Clin Gastro Hep (retrospective database) suggesting possibly a slight superiority of infliximab, the question of first-line is more difficult, esp if the argument is that complete mucosal healing has to be the preferred end-point.

  2. Pingback: What Happens with Cost Transparency in Medicine? | gutsandgrowth

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