Making the Cost of IBD Care Sustainable

The prevalence of inflammatory bowel disease (IBD; Crohn disease and ulcerative colitis) is rising, approaching 1% in Europe and North America. According to a recent review article, alongside this increase in prevalence, health care costs associated with IBD are also rising. The authors said that increase in prevalence combined with shifts in IBD care and higher hospitalization costs is increasing the burden on health care systems. They discussed the challenges to making IBD costs sustainable and strategies toward achieving personalized, cost-effective care for IBD.

Direct and Indirect Costs Associated With IBD

Direct costs associated with IBD include ambulatory visits to gastroenterologists, emergency department visits, admissions for hospitalization or surgery, diagnostics, and medications. Although hospitalization rates have decreased, direct costs have not because of a trend toward more complex disease with greater severity, and rising costs of inpatient care. The authors cited The Lancet Gastroenterology & Hepatology Commission which estimated direct health care expenses associated with IBD are $9,000 to $12,000 per person per year in high income regions. However, they noted “these estimates do not fully account for factors such as disease severity, accessibility, and variability in health care infrastructure among regions.”

They also described the US as an “outlier” in direct health care costs. In the US, drug prices on average exceed international prices by several-fold due to a lack of nationwide price regulation, the fragmentation of the health care system, prolonged market exclusivity periods, and confidential rebates negotiated between private insurers and pharmaceutical manufacturers. “Patients seldom benefit” from these rebates, the authors added.

Indirect costs include lost wages from missing work, reduced capacity at work, early retirement, premature death, delayed workforce entry, and not achieving educational or professional potential. Despite studies attempting to quantify indirect costs, the authors wrote, “many aspects remain poorly understood, leading to an underestimation of their actual impact.”

Challenges to Achieving Cost Sustainability

Challenges the authors cited to reducing IBD costs and achieving sustainability include disparities in access, treatment affordability, underinsurance, and a lack of standardized cost-effective care guidelines. Unplanned health care utilization, for example emergency department visits, “drives much of the cost in IBD care,” they wrote, and cited research suggesting that low-income status leads to less access to timely and effective care, leading to unplanned health care utilization, which has detrimental effects on both long-term health and costs. Also, lower income patients may delay or skip treatments or diagnostics with high out-of-pocket costs.

Strategies to Make IBD Costs Sustainable

Strategies the authors recommended to reduce costs included early implementation of biologics, a focus on cost-effectiveness in settings with limited resources, and promoting the use of biosimilars. They also recommended several patient monitoring strategies, such as using telemedicine and noninvasive biomarkers of disease activity. In addition to treatment strategies, such as prescription of biosimilars when appropriate, they recommended support strategies, such as using multidisciplinary care models that provide holistic care, promoting healthy lifestyle behaviors, and recognizing barriers to care faced by vulnerable populations. Regarding settings with limited resources, they commented that there are no guidelines for de-escalating or withdrawing biologics, which could help to reduce costs if developed.

The Role of Biologics

There is a “clear benefit” for achieving remission to a top-down approach of starting biologic therapy early, the authors said. However, less than 20% of private insurance companies in the US permit biologics as a first-line therapy for IBD. They added that based on data from Canada and the Netherlands, whether cost savings from avoided hospitalizations and surgeries outweigh the costs of biologic drugs is unclear.

Biosimilars Limited by Patent Thickets and Market Dynamics

Biosimilar uptake in the US has been “relatively modest,” the authors said. One reason is patent thickets created by originator manufacturers to extend market exclusivity, which have limited market entry of biosimilars. Additionally, after market entry, reimbursement dynamics have limited biosimilar uptake, as manufacturers of originators often offer confidential discounts to payers to outcompete biosimilars.

Addressing the increasing direct and indirect costs of IBD “demands a comprehensive strategy, tackling disparities, access barriers, and cost-effectiveness of therapeutics,” the authors wrote. They added that policy reforms to improve access to IBD care will also be required: for example, reforming prior authorization processes, enhancing drug price transparency, and introducing value-based reimbursement structures.

Reference

Burisch J, Claytor J, Hernandez I, Hou JK, Kaplan GG. The cost of inflammatory bowel disease care - how to make it sustainable. Clin Gastroenterol Hepatol. 2024:S1542-3565(24)00729-8. doi:10.1016/j.cgh.2024.06.049