The Deck is Stacked Against Value-based Healthcare.
Our system handsomely rewards companies that develop new medical products, drugs, and devices. It punishes organizations that bring together the great tools available to lower costs and prolong healthy lives. An add I saw on TV is a great example. It promoted Farxiga (dapagliflozin) as a new treatment for congestive heart failure and this is indeed a great story. Dapagliflozin was developed as a medication for type 2 diabetes. It lowers the blood sugar level by causing glucose to be lost in the urine.
The benefits for congestive heart failure have very little to do with glucose. Dapagliflozin reduces heart failure progression, hospitalization, and death all by about 30% by activating a master metabolic switch. It provides those benefits in patients with and without diabetes. Here is the crazy part. Spironolactone also reduces death from heart failure by about a third and it costs $4 a month ($48 a year). It is one of the most effective treatments in all of medicine. You only need to treat 9 patients to prevent a death from heart failure. Despite these benefits, it is one of the most underused medications in medical practice. Just over a third of heart failure patients receive spironolactone. Beta blockers and ACE inhibitors also cost $4 a month and are extremely beneficial for heart failure. Even these are underutilized. 75% of heart failure patients are on ACE inhibitors like lisinopril and 66% are on beta blockers like carvedilol. Fewer than 20% of patients with heart failure are on optimal medical treatment that can be had for $12 a month. It was no different in the trial to prove Farxiga benefit for congestive heart failure. Only 30% of patients were on a medication like spironolactone, and just over 20% were on optimal medical treatment.
The retail cost for Farxiga is over $600 a month ($7200 a year). The drug companies have huge promotional budgets and can buy adds on television. They can market directly to consumers. All proven optimal medical treatment medications are generic. No one benefits if they are used. No one is promoting those drugs. It is highly likely that Farxiga would have shown little benefit if as many patients as possible were on optimized doses of spironolactone, ACE inhibitors like losartan, and beta blockers like carvedilol. We all have a stake in this. Heart failure is the most expensive condition for Medicare.