Perspective on the prevalence of pulmonary hypertension and pulmonary arterial hypertension from the payer standpoint, as well as overall economic burden.
Derek van Amerongen, MD, MS, FACOG: When you think about the economic impact of PH [pulmonary hypertension] and PAH [pulmonary arterial hypertension] on the health plan, it certainly is small and that’s driven by prevalence. The top 3 areas of cost and utilization for just about every health plan in the country are going to be cancer, diabetes, and heart disease. Those affect millions of people. They generate enormous use of resources, both medical and pharmacy. PAH and PH are much smaller in prevalence and incidence. I would say, however, that for these individual members, they are typically quite high in cost. When I review high cost claims lists with employers, which I do on a regular basis, if a member with PAH is on that list, that will certainly jump out and provoke a lot of questions as to why this 1 individual is spending so much money. But from a plan-wide basis, it’s usually going to cost fractions of a penny per member per month.
In terms of area of focus for a health plan, PAH is typically going to be in the top 50. It’s not that the individuals with PAH and PH don’t have very significant medical needs and significant utilization, it’s more that they’re being crowded out by the enormous costs and utilization in diabetes, heart disease, and cancer. It seems that every month, we have another $300,000 oncology agent coming to market. Because of the dynamics of all of the other conditions, especially those that continue to grow in prevalence, PAH tends to be pushed to the edge of the radar screen.
We spend, as does every large health plan in the country, a lot of time and energy trying to understand the treatment paradigms and up-to-date treatments for conditions like PAH and PH. I think the understanding of the treatment course and the potential implications of the condition are well understood by health plans. At the end of the day, and I always want to emphasize this, the ultimate treatment decisions need to be made by clinicians based on the particular characteristics of a patient and the dynamics of that particular clinical scenario. Our job is to provide coverage and access to the standard of care and to make sure that those tools and resources are being used appropriately.
The economic burden of PAH and PH is very significant on the individual. Those individuals are typically identified as high cost members: in other words, usually spending above $25,000 to $50,000 per year. From a plan-wide basis, those members are going to have very minimal impact on the overall budget because of the prevalence. The direct costs of PAH and PH are of course what we’re focused on from the plan perspective because that represents the direct use of medical resources and utilization. Indirect costs are certainly important to individuals, and they’re important from a societal standpoint. Indirect costs include things like absenteeism, presenteeism, or a spouse who has to leave his or her job to take care of the individual. While those costs are real—they impact the family, they might impact the employer, and they impact society—they’re not direct medical costs that the health plan is responsible for.