Managing Healthcare Costs: statins

Today’s Managing Health Care Costs Indicator is $169,549

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Statins are enormously effective drugs that, along with a decrease in cigarette smoking, have been responsible for a huge decrease in the incidence of cardiac death, especially in young men. Statins were shown to be effective at lowering mortality in 1994 in the 4S study (Scandinavian Simvastatin Survival Study). This study was reevaluated in 1996 to look at changes in hospital costs, and the saved hospitalizations in the treatment group covered 88% of the cost of simvastatin in the high risk group.

Simvastatin has been a generic medication for a few years, and atorvastatin (Lipitor) is going generic this coming month. Have we finally reached a point where the use of statins is not merely cost-effective, but is actually cost-saving?

Even with dramatic declines in the acquisition cost of the statin medications, though, treatment in this simulation done in BMJ this past March was not cost-saving in any cohort. The cost of a Quality Adjusted Life Year for a 55 year old man with a 5% ten year risk of a heart attack was 125,544 euros (or almost $170K)

Harvard Link

Non-Harvard Link

As you can see from the graphic – the cost to save lives with simvastatin was actually quite modest in many instances - especially over the longer time horizons. For instance, it cost only 5394 Euros for each QALY for 55 year old men at a 30% risk for a vascular event over the following 10 years. Still, not a single simulated group gained QALYs with LOWER costs.

We don’t save money by using even generic statins for primary prevention of heart of vascular disease. We only gain good health outcomes for a reasonable cost -- which doesn’t seem to me to be a bad outcome at all.

Today’s Managing Health Care Costs Indicator is $6.8 billion

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The Archives of Internal Medicine published a report this weekend of researchers who reviewed data from two standard national databases to ascertain how often physicians offered the top overused clinical activities in primary care. They then extrapolated the incremental cost of this low-value care across the entire population.

A disturbing percentage of office visits included inappropriate care. Blood counts were not indicated more than half of the time they were performed, and four in ten kids prescribed antibiotics for sore throats probably didn’t need them. A third of the time physicians prescribed expensive brand name statins when generics would have saved substantial money. How much money? I’ve truncated the ‘y’ axis here – the brand name statin use is responsible $5.8 billion in excess cost, for the overwhelming majority of excess cost in this study.

The researchers used the Medicare fee schedule and drugstore.com prices, so this underestimates the actual cost of excess office-based care and overestimates drug costs, as pharmacy benefit managers get lower prices. This is a study based on claims only. Researchers did not review charts to find subtle reasons for these clinical activities, so this could overstate excess care.

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The $6.8 billion in excess cost is nothing to sneeze at – but removing all of these costs wouldn’t make much of a dent in our $2.3 trillion total health bill. The generic statin issue will be largely solved, as Lipitor becomes available generically as early as next month and will presumable drop dramatically in price by mid 2012. The resource cost to do an extra blood count, blood chemistry, or EKG is only a tiny fraction of the allowable charge.

There is a lot of room to improve clinical practice in this country. However, we continue to face mainly a price issue – and eliminating all the overutilization identified in this study would only lower the cost of health care by a quarter of a percent.

Thanks to Eyal Zimlichman, MD for pointing out this article.