Administrative Report
Hemophilia: Cost Considerations for Prescribing Therapeutic Materials D. R. LINNEY A N D J. LAZERSON From the Greut LoXe.s Hemophilia Foundation, the Depurtrnent of' Pediutrics. Mivlicd Collcge of' Wisconsin. und tltc, M i l n w A e i , Children's Hospital. Miliiuukci~.Wisconsin
Costs for therapeutic products utilized in treating hemophilia can be prohibitive to patients. The costs can be effectively reduced by understanding the elements comprising the total cost of these products. By calculating appropriate dosage schedules, avoiding indiscriminate purchasing practices, and monitoring costs to patients, physicians can help reduce the total financial burden to patients and third party payers.
HEMOPHILIA is an expensive lifelong disorder.*S6 Treatment is usually funded by either the patient or his family, a federal or state agency or an insurance company. Because of the need to reduce costs for the patients as well as third party payers, an analysis was undertaken to determine how cost factors of therapeutic products can be modified to reduce costs. This article defines the financial ramifications of prescribing the least expensive quality materials. Materials and Methods Twenty-nine patients with severe hemophilia A (factor VIlI activity of less than 1%) without evidence of inhibitor and on a home infusion treatment program were evaluated as to their age, weight and number of infusions (obtained from monthly calendar reports) for 1976. Patients were excluded from the study who incurred costs related to a rehabilitative medical program, surgery or surgically related procedure. All patients at the time of interview were being reintroduced into a comprehensive care hemophilia program. They had been part of a large group of hemophilia patients trained in home care management of hemophilia, but had not necessarily been involved in a routine compreReceived for publication September 29. 1977; accepted April 24. 1978. Supported in part by DHEW Grant No. MC-B5550001-01-0. the Faye McBeath Foundation Grant, and the Great Lakes Hemophilia Foundation.
hensive care program as presently defined by DHEW hemophilia center standards.3 Patients utilized a factor VIII dosage per infusion intended to raise their factor VIII activity to 50 per cent of normal immediately following transfusion ( p . g . , 25 units of factor VIII per kilogram per infusion). Calculations were performed as to cost per infusion, based on the existing cost rate for factor VIII materials provided by the Milwaukee Blood Center. Cryoprecipitate was priced at $7.00 per bag or an equivalent of 7e per unit of factor VIII. Studies had indicated an average of 100 to 105 units of factor VIII per bag. The commercial concentrate being used was priced at IOe per factor VIII unit. For comparative purposes, three other factor VIII commercially available concentrates ~ unit were used in cost difpriced at 8 % per ference calculations. All commercially prepared concentrates were biologically equivalent and comparable as to ease of reconstitution and use. The actual cost to the patient was cited.
Results Table 1 indicates the number of patients, their average weight, and age range. The average number of infusions per age group was used to calculate the average cost per infusion and per year for use of cryoprecipitate and two differently priced commercial factor VIII concentrates. By comparing the differences of total cost per year, a minimum of $800 could be saved by use of the least expensive commercially available concentrate ($5,223 bw-sus $4,441) as well as approximately an additional $800 per year by using cryoprecipitate ($4,441 w r s u s $3,657). A maximum cost savings greater than $3,200 per year could be realized by the use of cryoprecipitate rather than the most expensive product ($10,800 I'crsus $7,550). Table 2 outlines the cost of ancillary materials essential to infusion of either cryoprecipitate or a commercial concentrate. While the supply cost comprised but a small
0041-1 132/79/0100/0057$00.65 0 J. B. Lippincott Co. Trdnsfu~lon January-Fcbmary 1979
57
Volume 19 Number I
Transfusion January-Febmary 1979
LlNNEY AND LAZERSON
Table 1. Comparison of Costs for Cryoprecipitate and Commercial Concentrates Avg. Cost ($)/Year
Avg. Cost ($)/Infusion
Age (YW
Patient No.
Avg. Weight (kg4
5-10 11-19 >20
5 12 12
29.6 53.8 69.1
Commercial Concentrate
Commercial Concentrate
Avg. No. Infusions (per year)
Cryo.
A
B
Cryo.
A
B
80.8 80.27 30.25
51.80 94.06 120.89
74.00 134.50 172.70
62.90 114.22 146.80
4,185 7.550 3.657
5,979 10,800 5.223
5,082 9.168 4,441
A = 10clunit. B = 81helunit.
part of the total infusion costs for the commercial concentrates, they add significantly to the cost of infusion of cryoprecipitate. As such, the true total cost per infusion for cryoprecipitate per year may be increased by as much as $800 and thereby negate the saving alluded to previously. The average cost per year of cryoprecipitate would be corrected to $5,015, $8,365, and $3,965 for each age group. The increase for use of the commercial concentrate would amount to $35 to 90 per year, depending on the number of transfusions. Table 3 compares the total cost per infusion per age group for cryoprecipitate and two differently priced commercial concentrates. Again, the major difference in costs per infusion is that of the more highly priced product.
Discussion
Physicians prescribing derivatives of plasma for the treatment of hemophilia Table 2. Comparison of Supply Costs for Cryoprecipitate and Commercial Concentrates Commercial Concentrate Infusion Supplies
Cry0 ($)
($1
~
Syringe (50cc) Straight Needle Vacuum Bottle Transfer Set Recipient Set Salinee Butterfly Needle Miscellaneous (bandaids, gauze, sponge, swab) Totals
.52
must be aware of their cost to the patients. It is a well recognized fact that patient compliance in the use of a drug is frequently affected by the cost of the d r ~ g Even . ~ if personal (out of pocket) expenses are low, patients neglect treatment in order to avoid using an expensive therapeutic product. With the development of hemophilia comprehensive care centers for diagnostic evaluation, treatment, and long-term monitoring of patient care, it has been demonstrated that patients who do not treat hemorrhagic episodes early and aggressively develop progressive degenerative joint disease and increasing long-term disability.' If patients are to adhere to an effective treatment regimen, the cost of therapeutic products must be kept to a minimum. The physician prescribing these products independently, under the direction of a comprehensive care center for hemophilia, or a blood center must be aware not only of the products available to their patients, but also their costs. A number of considerations emerged from this study. Cryoprecipitate is considered to be the least expensive product available from most blood centers, it was used as the base line cost (7e per unit) for
.52 .06 2.53 .84 1.57 4.04 .61
.61
Table 3. Comparison of Total Costsllnfusion
.10
.10
10.27
1.23
Commercial Concentrates Age (yrs)
~
15 ml of saline required per bag of cryoprecipitate. Saline supplied as 150 ml vials at $2.02/vial. Average adult utilizing cryoprecipitate requires more than 10 bagshnfusion,therefore two vials were needed.
Cryoprecipitate
(A)
~~~~
(B) ~
5-10 11-19 >20
$ 62.07 104.33 131.16
$ 75.23 135.73 183.93
$ 64.13 115.45 148.03
Volume 19 Number 1
59
HEMOPHILIA: COST CONSIDERATIONS
comparative purposes. Implicit in this cost comparison is the quality of factor VIII cryoprecipitate produced (average factor VIII concentrations of 100 units per bag). Usual billing procedures by most blood centers consist of charging per bag of cryoprecipitate rather than per unit of factor VIII. It is important, therefore, to know the average units of factor VIII per bag in order to calculate the exact price per unit of factor VIII. Although cryoprecipitate must be kept frozen and is somewhat cumbersome to useScompared with the commercially available factor VIII concentrates, our experience suggests that product cost is of greater importance in patient compliance than whether or not the product is convenient to use. Another factor became obvious was that by simply calculating the dosage schedules (25 units/kilogram) and utilizing newer to determine dosage schedule per type of hemorrhagic episode, an additional savings could be realized. Exactly how far this latter aspect, reduction to 10 units/kilogram/infusion,can be extended remains to be assessed. It appears, however, that except for a central nervous system hemorrhage, the need to exceed 20 units/kilogram/dose is limited, and therefore, at least a 20 per cent saving in unitage and cost can be achieved. Hopefully as patients are introduced to the comprehensive care concept at a young age, and are trained and educated as to early aggressive infusion therapy treatment regim e n ~ , ~the * ' ~total cost per infusion and per year will be decreased for patients not requiring rehabilitative procedures or surgery. The physician faced with deciding which product to be used must take into account the total financial cost per unit of factor VIII as well as the expediency of administration of any given product. If one product is priced considerably lower than the other, the decision should be an easy one, as long as the quality of the product is uniform. A commercial concentrate, comparably priced or even slightly higher than cryopre-
cipitate, may be a more logical choice if this material is easier to administer. The present study delineates that by observance of factors necessary to reduce costs, considerable savings in total cost per year for patients with hemophilia, their third party payers, federal or state agencies can be achieved. Acknowledgments We wish to thank Drs. Richard Aster and Peter A. Tomasulo for their helpful comments in preparation. and Ms. Robin Coven and Ms. Julie Harmon for their assistance in the typing of this manuscript.
References 1. Aledort, L. M.: Hemophilia care: Its costs. I n :
Hemophilia In Children. M. W. Hilgartner, Ed. Littleton. M A , Publishing Sciences Group, 1976, p. 201. 2. Britton, M., J. Harrison, and C. F. Abildgaard: Early treatment of hemophilic hemarthroses with minimal dose of new factor VIII concentrate. J. Pediatr. 89245. 1974. 3. Federal Register: Final regulations: grants for hemophilia treatment centers. 42:(no. 204). 56248. 1977. 4. Hilgartner, M. W.: Current therapy. In: Hemophilia In Children. M. W. Hilgartner. Ed. Littleton, MA, Publishing Sciences Group, 1976.
p. 151. 5 . Lazerson. J.: The prophylactic approach to hemophilia A. Hosp. Pract. 6%. 1971. : Hemophilia home transfusion program: 6. Analysis of cost data. J. Pediatr. 83:623, 1973. 7. Levine, P. H.: Efficacy of self-therapy in hemophilia. N. Engl. J. Med. 291:1381, 1974.
8. Penner, J. A., and P. E. Kelly: Lower doses of factor VIlI for hemophilia. N. Engl. J. Med. 297401. 1977. 9. Schindell, S.. J. C. Salloway. and C. M. Oberembt:
A Coursebook in Health Care Delivery. New York, Appleton-Century Crofts, 1977, p. 18. 10. van Eys, J., D. P. Agle, M. W. Hilgartner, and J. Lazerson: Home therapy for hemophilia, a physician's manual. Med. Sci. Advisory Counc. Hemophilia. National Hemophilia Foundation, 1977.
David Linney B.A., Financial Aides Officer, Great Lakes Hemophilia Foundation, 1701 West Wisconsin Avenue, Milwaukee, Wisconsin 53233. Jack Lazerson, M.D., Associate Professor of Pediatrics, Medical College of Wisconsin, and Medical Director of Great Lakes Hemophilia Foundation. 1700 West Wisconsin Avenue, Milwaukee. Wisconsin 53233.
Hemophilia: Cost Considerations for Prescribing Therapeutic Materials D. R. LINNEY A N D J. LAZERSON From the Greut LoXe.s Hemophilia Foundation, the Depurtrnent of' Pediutrics. Mivlicd Collcge of' Wisconsin. und tltc, M i l n w A e i , Children's Hospital. Miliiuukci~.Wisconsin
Costs for therapeutic products utilized in treating hemophilia can be prohibitive to patients. The costs can be effectively reduced by understanding the elements comprising the total cost of these products. By calculating appropriate dosage schedules, avoiding indiscriminate purchasing practices, and monitoring costs to patients, physicians can help reduce the total financial burden to patients and third party payers.
HEMOPHILIA is an expensive lifelong disorder.*S6 Treatment is usually funded by either the patient or his family, a federal or state agency or an insurance company. Because of the need to reduce costs for the patients as well as third party payers, an analysis was undertaken to determine how cost factors of therapeutic products can be modified to reduce costs. This article defines the financial ramifications of prescribing the least expensive quality materials. Materials and Methods Twenty-nine patients with severe hemophilia A (factor VIlI activity of less than 1%) without evidence of inhibitor and on a home infusion treatment program were evaluated as to their age, weight and number of infusions (obtained from monthly calendar reports) for 1976. Patients were excluded from the study who incurred costs related to a rehabilitative medical program, surgery or surgically related procedure. All patients at the time of interview were being reintroduced into a comprehensive care hemophilia program. They had been part of a large group of hemophilia patients trained in home care management of hemophilia, but had not necessarily been involved in a routine compreReceived for publication September 29. 1977; accepted April 24. 1978. Supported in part by DHEW Grant No. MC-B5550001-01-0. the Faye McBeath Foundation Grant, and the Great Lakes Hemophilia Foundation.
hensive care program as presently defined by DHEW hemophilia center standards.3 Patients utilized a factor VIII dosage per infusion intended to raise their factor VIII activity to 50 per cent of normal immediately following transfusion ( p . g . , 25 units of factor VIII per kilogram per infusion). Calculations were performed as to cost per infusion, based on the existing cost rate for factor VIII materials provided by the Milwaukee Blood Center. Cryoprecipitate was priced at $7.00 per bag or an equivalent of 7e per unit of factor VIII. Studies had indicated an average of 100 to 105 units of factor VIII per bag. The commercial concentrate being used was priced at IOe per factor VIII unit. For comparative purposes, three other factor VIII commercially available concentrates ~ unit were used in cost difpriced at 8 % per ference calculations. All commercially prepared concentrates were biologically equivalent and comparable as to ease of reconstitution and use. The actual cost to the patient was cited.
Results Table 1 indicates the number of patients, their average weight, and age range. The average number of infusions per age group was used to calculate the average cost per infusion and per year for use of cryoprecipitate and two differently priced commercial factor VIII concentrates. By comparing the differences of total cost per year, a minimum of $800 could be saved by use of the least expensive commercially available concentrate ($5,223 bw-sus $4,441) as well as approximately an additional $800 per year by using cryoprecipitate ($4,441 w r s u s $3,657). A maximum cost savings greater than $3,200 per year could be realized by the use of cryoprecipitate rather than the most expensive product ($10,800 I'crsus $7,550). Table 2 outlines the cost of ancillary materials essential to infusion of either cryoprecipitate or a commercial concentrate. While the supply cost comprised but a small
0041-1 132/79/0100/0057$00.65 0 J. B. Lippincott Co. Trdnsfu~lon January-Fcbmary 1979
57
Volume 19 Number I
Transfusion January-Febmary 1979
LlNNEY AND LAZERSON
Table 1. Comparison of Costs for Cryoprecipitate and Commercial Concentrates Avg. Cost ($)/Year
Avg. Cost ($)/Infusion
Age (YW
Patient No.
Avg. Weight (kg4
5-10 11-19 >20
5 12 12
29.6 53.8 69.1
Commercial Concentrate
Commercial Concentrate
Avg. No. Infusions (per year)
Cryo.
A
B
Cryo.
A
B
80.8 80.27 30.25
51.80 94.06 120.89
74.00 134.50 172.70
62.90 114.22 146.80
4,185 7.550 3.657
5,979 10,800 5.223
5,082 9.168 4,441
A = 10clunit. B = 81helunit.
part of the total infusion costs for the commercial concentrates, they add significantly to the cost of infusion of cryoprecipitate. As such, the true total cost per infusion for cryoprecipitate per year may be increased by as much as $800 and thereby negate the saving alluded to previously. The average cost per year of cryoprecipitate would be corrected to $5,015, $8,365, and $3,965 for each age group. The increase for use of the commercial concentrate would amount to $35 to 90 per year, depending on the number of transfusions. Table 3 compares the total cost per infusion per age group for cryoprecipitate and two differently priced commercial concentrates. Again, the major difference in costs per infusion is that of the more highly priced product.
Discussion
Physicians prescribing derivatives of plasma for the treatment of hemophilia Table 2. Comparison of Supply Costs for Cryoprecipitate and Commercial Concentrates Commercial Concentrate Infusion Supplies
Cry0 ($)
($1
~
Syringe (50cc) Straight Needle Vacuum Bottle Transfer Set Recipient Set Salinee Butterfly Needle Miscellaneous (bandaids, gauze, sponge, swab) Totals
.52
must be aware of their cost to the patients. It is a well recognized fact that patient compliance in the use of a drug is frequently affected by the cost of the d r ~ g Even . ~ if personal (out of pocket) expenses are low, patients neglect treatment in order to avoid using an expensive therapeutic product. With the development of hemophilia comprehensive care centers for diagnostic evaluation, treatment, and long-term monitoring of patient care, it has been demonstrated that patients who do not treat hemorrhagic episodes early and aggressively develop progressive degenerative joint disease and increasing long-term disability.' If patients are to adhere to an effective treatment regimen, the cost of therapeutic products must be kept to a minimum. The physician prescribing these products independently, under the direction of a comprehensive care center for hemophilia, or a blood center must be aware not only of the products available to their patients, but also their costs. A number of considerations emerged from this study. Cryoprecipitate is considered to be the least expensive product available from most blood centers, it was used as the base line cost (7e per unit) for
.52 .06 2.53 .84 1.57 4.04 .61
.61
Table 3. Comparison of Total Costsllnfusion
.10
.10
10.27
1.23
Commercial Concentrates Age (yrs)
~
15 ml of saline required per bag of cryoprecipitate. Saline supplied as 150 ml vials at $2.02/vial. Average adult utilizing cryoprecipitate requires more than 10 bagshnfusion,therefore two vials were needed.
Cryoprecipitate
(A)
~~~~
(B) ~
5-10 11-19 >20
$ 62.07 104.33 131.16
$ 75.23 135.73 183.93
$ 64.13 115.45 148.03
Volume 19 Number 1
59
HEMOPHILIA: COST CONSIDERATIONS
comparative purposes. Implicit in this cost comparison is the quality of factor VIII cryoprecipitate produced (average factor VIII concentrations of 100 units per bag). Usual billing procedures by most blood centers consist of charging per bag of cryoprecipitate rather than per unit of factor VIII. It is important, therefore, to know the average units of factor VIII per bag in order to calculate the exact price per unit of factor VIII. Although cryoprecipitate must be kept frozen and is somewhat cumbersome to useScompared with the commercially available factor VIII concentrates, our experience suggests that product cost is of greater importance in patient compliance than whether or not the product is convenient to use. Another factor became obvious was that by simply calculating the dosage schedules (25 units/kilogram) and utilizing newer to determine dosage schedule per type of hemorrhagic episode, an additional savings could be realized. Exactly how far this latter aspect, reduction to 10 units/kilogram/infusion,can be extended remains to be assessed. It appears, however, that except for a central nervous system hemorrhage, the need to exceed 20 units/kilogram/dose is limited, and therefore, at least a 20 per cent saving in unitage and cost can be achieved. Hopefully as patients are introduced to the comprehensive care concept at a young age, and are trained and educated as to early aggressive infusion therapy treatment regim e n ~ , ~the * ' ~total cost per infusion and per year will be decreased for patients not requiring rehabilitative procedures or surgery. The physician faced with deciding which product to be used must take into account the total financial cost per unit of factor VIII as well as the expediency of administration of any given product. If one product is priced considerably lower than the other, the decision should be an easy one, as long as the quality of the product is uniform. A commercial concentrate, comparably priced or even slightly higher than cryopre-
cipitate, may be a more logical choice if this material is easier to administer. The present study delineates that by observance of factors necessary to reduce costs, considerable savings in total cost per year for patients with hemophilia, their third party payers, federal or state agencies can be achieved. Acknowledgments We wish to thank Drs. Richard Aster and Peter A. Tomasulo for their helpful comments in preparation. and Ms. Robin Coven and Ms. Julie Harmon for their assistance in the typing of this manuscript.
References 1. Aledort, L. M.: Hemophilia care: Its costs. I n :
Hemophilia In Children. M. W. Hilgartner, Ed. Littleton. M A , Publishing Sciences Group, 1976, p. 201. 2. Britton, M., J. Harrison, and C. F. Abildgaard: Early treatment of hemophilic hemarthroses with minimal dose of new factor VIII concentrate. J. Pediatr. 89245. 1974. 3. Federal Register: Final regulations: grants for hemophilia treatment centers. 42:(no. 204). 56248. 1977. 4. Hilgartner, M. W.: Current therapy. In: Hemophilia In Children. M. W. Hilgartner. Ed. Littleton, MA, Publishing Sciences Group, 1976.
p. 151. 5 . Lazerson. J.: The prophylactic approach to hemophilia A. Hosp. Pract. 6%. 1971. : Hemophilia home transfusion program: 6. Analysis of cost data. J. Pediatr. 83:623, 1973. 7. Levine, P. H.: Efficacy of self-therapy in hemophilia. N. Engl. J. Med. 291:1381, 1974.
8. Penner, J. A., and P. E. Kelly: Lower doses of factor VIlI for hemophilia. N. Engl. J. Med. 297401. 1977. 9. Schindell, S.. J. C. Salloway. and C. M. Oberembt:
A Coursebook in Health Care Delivery. New York, Appleton-Century Crofts, 1977, p. 18. 10. van Eys, J., D. P. Agle, M. W. Hilgartner, and J. Lazerson: Home therapy for hemophilia, a physician's manual. Med. Sci. Advisory Counc. Hemophilia. National Hemophilia Foundation, 1977.
David Linney B.A., Financial Aides Officer, Great Lakes Hemophilia Foundation, 1701 West Wisconsin Avenue, Milwaukee, Wisconsin 53233. Jack Lazerson, M.D., Associate Professor of Pediatrics, Medical College of Wisconsin, and Medical Director of Great Lakes Hemophilia Foundation. 1700 West Wisconsin Avenue, Milwaukee. Wisconsin 53233.
