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Expensive ConditionsTo the Editor:Benjamin Druss and colleagues (July/Aug 02) use data from the 1996 Medical Expenditure Panel Survey (MEPS) to rank the fifteen most expensive disease conditions by cost and disability. Their results are considerably at odds with previous cost-of-illness studies.1 In particular, diabetes is ranked quite low, only one cancer type makes the list, and Alzheimer’s disease doesn’t even appear. Previous literature indicates that cancer is second in total disease costs, Alzheimer’s is third, and diabetes is fourth.2 The discrepancy is explained by the fact that the economic costs of premature mortality and unpaid caregiver support, considered to be the most important societal costs of disease, are simply excluded from their MEPS data analysis. This excludes two-thirds of the costs of Alzheimer’s disease and a large portion of the costs for many other diseases. The MEPS data also exclude institutionalized patients, thereby leaving out most medical costs for Alzheimer’s patients and large costs for other diseases, particularly mental disorders. The authors use an inaccurate measure of disease burden and thus add little to the health care spending debate. Comparing accurately measured disease spending rankings to treatment cost-effectiveness rankings (rather than to the flawed Oregon plan rankings) provides a better assessment of current problems.3 Accurate disease burden estimates can be helpful in setting policy, but medically appropriate and cost-effective interventions should be used for all diseases and all patients, not just for the most burdensome. For example, aspirin, statins, beta-blockers, and angiotensin converting enzyme (ACE) inhibitor therapy (soon available generically for less than $3 billion annually for the U.S. at-risk population) could prevent more than two-thirds of cardiovascular disease, which is ranked number one in mortality and disease burden.4 Cardiovascular disease patients greatly underuse these drugs. Meanwhile, billions of dollars are spent on sophisticated coronary diagnosis, bypass, and angioplasty procedures to correct problems that are mostly preventable with lifestyle and drug interventions. The problem is not cost-effectiveness analysis; it is the inability of the U.S. health care system to take such analysis seriously.
University of Southern California, Los Angeles, California
The authors respond: Hay’s letter raises several important issues. First, because single-disease studies vary greatly in their methods and sources, they are problematic for making comparisons across conditions. The estimates on which Hay bases his alternative rankings (Note 2 above) are drawn from an advocacy group’s Web site and from two papers that use divergent techniques and data that are more than a decade old for calculating costs. These problems underline the importance of using a single source of data and consistent methods when developing such rankings. Second, it is essential to carefully consider the types of costs to include in a particular analysis. We chose to exclude indirect costs such as caregiver burden because we were examining the association between resource allocation (direct costs) and disability burden. Finally, we agree that cost-effectiveness analysis has an important role in priority setting. However, we argue that cost-of-illness and burden-of-disease estimates complement this technique by balancing aggregate estimates of costs and benefits with a focus on how those costs and benefits are distributed in the population.
Yale University, New Haven, Connecticut
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