Follow the Money Trail

An interesting report in the recent ASH2009 conference dealt with the cost of taking care of patients after they had completed Campath therapy.  Even if you have gold plated insurance coverage and your carrier pays all your medical bills without a single protest, this paper is still important because it highlights the real life implications of the possible adverse effects that are associated with Campath.  Notice one of  the authors is an industry representative from GlaxoSmithCline.  What makes it interesting is that GSK does not own rights to Campath, that privilege belongs to Genzyme.

Costs to Medicare of Treating Chronic Lymphocytic Leukemia Patients with Alemtuzumab

 Marie-Hélène Lafeuille, MA1*, Francis Vekeman, MA1*, Matthew Kerrigan, PhD2*, Si-Tien Wang3* and Mei Duh, MPH, ScD3

1Groupe d’analyse, Ltée, Montréal, QC, Canada

2US Health Outcomes, GlaxoSmithKline, Philadelphia, PA

3Analysis Group, Inc., Boston, MA

Background: Chronic lymphocytic leukemia (CLL) is the most common form of adult leukemia in the Western world, comprising over one-third of all new leukemia cases. Alemtuzumab is a humanized monoclonal antibody targeted to lymphocytes through the CD52 receptor that has been demonstrated to reduce the amount of malignant lymphocytes in patients with CLL. Alemtuzumab is, however, associated with various adverse events (AEs) including cytopenia, infections, and cardiac dysfunction. The current study aimed to quantify the incremental cost to Medicare of treating CLL patients with alemtuzumab.

Methods: An analysis of patients’ electronic health insurance claims records (1999-2007) from the Medicare 5% national sample was conducted. Patients with continuous enrollment for 3 or more months prior to their first observed claim with a CLL diagnosis, no more than two malignancies (by ICD-9 diagnostic codes associated with claims), and 1 or more claim for alemtuzumab were included in the analysis. Patients who had HMO coverage under Medicare were excluded from the analysis to ensure data completeness. A pre-post design was used to quantify the incremental costs associated with alemtuzumab by calculating health care costs within 6 months after alemtuzumab initiation relative to the 6-month period before alemtuzumab initiation. Mean monthly (per-patient per-month, PPPM) costs were calculated and were grouped by sites of care, service type, tests and procedures, treatment and drugs, and by AEs. To estimate the costs of AEs, claims with ICD-9 diagnostic codes for the AE of interest were grouped and mean PPPM costs were calculated for those groups. These groups were not mutually exclusive: claims could be associated with more than one diagnostic code. Statistical comparisons between the pre- and post-treatment periods were based on paired Student t-tests.

Results: A total of81 CLL patients treated with alemtuzumab formed the study population. The mean age (SD) was 75.2 (7.5) years and females represented 38.3% of the cohort. Patients were observed for an average of 50 months and mean time between the first observed CLL diagnosis and initiation of alemtuzumab treatment was 36 months. After alemtuzumab initiation, mean total healthcare costs increased from $4,272 to $10,385 PPPM (cost difference: $6,113, P<0.0001). Patients had a mean of 11.8 claims for alemtuzumab and the mean cost (SD) for alemtuzumab was $4,006 ($3,277) PPPM in the post-alemtuzumab period or 39% of total costs. Costs associated with diagnostic codes for cytopenia were $1,658 pre-alemtuzumab compared with $4,114 post-alemtuzumab (P<0.0001). In the pre- alemtuzumab period, costs with infection-related diagnostic codes were $107 PPPM compared with $841 in the post-alemtuzumab period (P=0.0005). Costs associated with cardiac dysfunction diagnostic codes were $766 PPPM in the pre-alemtuzumab period and $1,692 in the post-alemtuzumab period (P=0.0172) (Table 1). Note that these cost categories are not mutually exclusive.

Conclusions: Amongst a cohort of Medicare fee-for-service patients with CLL, alemtuzumab was associated with a significant increase in healthcare costs in the 6 months after initiation of therapy of which the costs of alemtuzumab, oncology services, cytopenias, infections, and cardiac dysfunctions were large components.

Editorial

Below is the table from the abstract, cleaned up a bit for easy reading.

The chart lists the average monthly cost per patient.  I have highlighted in red the cost differences that are statistically significant.  The total cost of taking care of patients before and after Campath therapy is broken down into three major categories. 

  • The first one is cytopenias.  We know by now that Campath can cause significant drop in the counts of all the other cell lines besides the CLL cells we want to see get killed!  Anemia, neutropenia and thrombocytopenia (drops in red blood cells, neutrophils and platelets respectively) are common and it costs money to take care of the fallout from these issues.  Think of growth factors such as Procrit, Neupogen, possible transfusions in refractory cases.  None of this stuff is cheap.
  • The second category is infections.  Frankly I am surprised the difference is as small as this report suggests.  Anecdotal stories are dime a dozen but based on what I have heard from patients I would have thought the difference would be higher because of potential for hospitalizations after Campath therapy. Viral reactivations are a well known risk factor for this powerful drug. This relatively small difference suggests we are getting better at protecting patients with prophylactic medications against bacterial and viral infections and that is good news indeed.
  • The last category is bit of a surprise.  Did you know Campath therapy increased the cost of taking care of post treatment heart disease? 

Who knew heart disease is yet another risk factor of Campath therapy?  I wonder if they screen patients for their general cardiac health prior to approving them for Campath therapy.  If you are a patient that has been through Campath therapy, do comment and let us know if your physicians asked about your cardiac health history prior to treating you with this monoclonal antibody. Studies such as this are useful because they highlight the real cost of therapy.  As you and I know, the story does not end once the nurse has removed the infusion needle from your arm and tells you to go home.  We keep paying for months after, both in terms of medical co-pays and health issues that linger.

Cost of health-care is much in the news.  Tempers flare and peoples’ perspectives are often colored by their political persuasion.  I try hard to report on this  and other interesting studies without so much as dipping my toes in the murky waters of partisan politics.   CLL is a non-discriminatory cancer.  People of all political stripes are stricken by this disease and our support goes to each and everyone of them. I hope you feel the same way and your comments reflect that solidarity with your fellow CLL patients.