UnitedHealthcare, one of the biggest insurance companies in America, is experimenting with a different way to control costs. Along with the inconvenience of multiple-pill regimens, this is a big reason generics aren’t much used. “There are recommended regimes at a lower cost than we’ve seen.”. Yes But that may be starting to change. A new first-line antiretroviral drug regimen scheduled to be introduced in public health facilities in South Africa in September has been given the thumbs up by SA scientists. HIV treatment is made up of three or more antiretroviral drugs normally combined into one pill. https://doi.org/10.1371/journal.pone.0210497.s001, https://doi.org/10.1371/journal.pone.0210497.s002, https://doi.org/10.1371/journal.pone.0210497.s003, https://doi.org/10.1371/journal.pone.0210497.s004, https://doi.org/10.1371/journal.pone.0210497.s005. We systematically reviewed publication databases for published cost data covering a large range of HIV interventions and summarised relevant unit costs (cost per person receiving a service) for each. Not enough. Across all types of unit cost, we used the same public-sector input costs to establish a common frame of reference. medicines are a big part of that. However, only 62% of papers reported some estimate of uncertainty, increasing the risk of potential reporting bias. The authors propose that South Africa could have started an ARV treatment program in 2000, covering not more than 5% of persons who needed therapy but ramping up the coverage as drugs … In its My ScriptRewards program, patients who choose the cheaper H.I.V. Because the analysis optimised interventions and intervention coverage based on cost effectiveness, the cost of services was a central input into the analysis; at the same time, the analytical framework mandated that even though interventions could be excluded if there was no evidence as to their effectiveness, they could not be excluded if data on their cost was missing, leaving us with the task of establishing the cost of each of the interventions included in the Investment Case. medicines — made by Mylan and other companies — were incorporated into treatment regimens, America could save between $3 billion and $5 billion, with about $1 billion of that savings accruing to Medicare and Medicaid. The drugs used to treat HIV are called antiretroviral drugs (ARVs). Yes Discover a faster, simpler path to publishing in a high-quality journal. One paper (2%) on the cost of NIMART purported to have used a societal perspective by summing costs from the healthcare provider and patient perspectives [12]. drug pricing is a mess because drug companies have so much sway over government policy. We included papers published in any language between 01/01/2000 and 31/12/2016 (see S1 Table for the full list of search terms). Access to antiretroviral drugs is no longer a major issue Initially, brand-name antiretroviral agents (ARVs) were prohibitively expensive for both patients and public programs in sub-Saharan Africa, costing upwards of US$10,000 per year per person Footnote 3 . Few analyses however use locally relevant cost data. A young woman who is taking H.I.V. “We should be planning in a smart way to make these switches when they become possible,” said Mark Harrington, executive director of the Treatment Action Group, which works globally to help people get medicines for H.I.V., tuberculosis and hepatitis C. “If this were a rational world, this would set in play a dynamic series of negotiations between buyers and manufacturers, trying to bid around for the lowest price,” he said. The cost of HIV treatment for first-line therapy has generally been lowest due to the availability of generic drugsdesigned for such treatment. In our full-text review we included papers containing primary cost data on at least one intervention with a mode of delivery of the intervention that was relevant to South Africa, and regardless of whether or not a comparator population or intervention had been included. “There are new options in the market,” according to Lida Etemad, who is vice president for pharmacy management services at UnitedHealthcare. All cost data taken from published estimates was updated to 2016 South African Rand (ZAR) using the South African consumer-price index published by StatsSA [28] and relevant exchange rates if the estimate was not given in ZAR. Methodology, So logic says it must cost less than $75. In the United States, pharmaceutical companies have built a system which supports high costs for H.I.V. Data from these 42 papers were abstracted using an Excel sheet which was piloted on the first 10 papers, and updated thereafter. What does it cost to make each year’s supply of that $39,000 therapy? drugs. This cost data was collected in 2003 and published in 2006. It’s good for patients — and rather unusual in the American health care system — that they needn’t worry about paying for expensive drugs. As an example, a large number of economic evaluations of antiretroviral treatment (ART) options for low- and middle-income countries have used South Africa as a case study for decisions facing international donors supporting HIV programmes in sub-Saharan Africa more generally [1–7]. Mylan also makes three-drug combos, Symfi (equivalent to Atripla, which costs $32,000) and lower-dose Symfi Lo. There are several different types and they work in different ways. Anil Soni, the head of global infectious diseases for Mylan, said that if generics and lower-cost H.I.V. Data curation, here. Recent estimates of discounted annual lifetime costs of HIV/AIDS care and treatment for sub-Saharan Africa are $200 to 1200/year with a median value of $612 [11,. According to the article, Cipla was offering to sell the AIDS cocktail for $350 a year per patient, or roughly $1 a day, as compared to Western prices of between $10,000 and $15,000 a … in the United States have achieved that. The majority of papers (62%) reported results as a point estimate only, without giving a range. The South African Investment Case followed the Investment Case framework used by UNAIDS to a certain extent [27] but additionally introduced the category of technical efficiency factor. Other papers detailed the costs of HCT, MMC, palliative and inpatient care; no papers were found on the costs of PrEP, social and behaviour change communication, and PMTCT. But in the United States, virtually no one on antiretrovirals has to pay for them. Steve Cohen’s time on this study was funded by the South African National AIDS Council (SANAC). medicine, Atripla, off its list of covered drugs. Beginning this fall, it will encourage patients it covers to choose a less expensive H.I.V. Formal analysis, That’s not only way below countries like Britain and France; it’s worse than Zimbabwe, Kenya and Malawi. here. Writing – review & editing, Roles Click through the PLOS taxonomy to find articles in your field. Roles Where no data was found in the literature, we constructed unit costs either based on available information regarding ingredients and relevant public-sector prices, or based on expenditure records. Tina Rosenberg won a Pulitzer Prize for her book “The Haunted Land: Facing Europe’s Ghosts After Communism.” She is a former editorial writer for The Times and the author, most recently, of “Join the Club: How Peer Pressure Can Transform the World” and the World War II spy story e-book “D for Deception.”. Super-organized, savvy patient groups all over the world banded together to make H.I.V. No other disease has such a program. The crazy system exists because until very recently, there has been virtually no price competition in H.I.V. Finally, for selected interventions for which no published data on either unit cost or ingredients was available, we used information from budgets or expenditure records. “They really do help to subsidize a lot of H.I.V. “There’s a complex patchwork in place. We are grateful for the support of the members of the South African HIV Investment Case Steering Committee and Technical Task Team for their help in sourcing expenditure data and reviewing results. Generic medicines don’t normally come with co-pay assistance. medicine, Atripla, off its list of covered drugs, government’s survey of what pharmacies pay, greatly reduced patient pressure for lower prices, The Haunted Land: Facing Europe’s Ghosts After Communism, Join the Club: How Peer Pressure Can Transform the World. While planned simplification of HIV service delivery promises to reduce expenditure, the drug cost of ART provision consumes the bulk of most HIV programme We want to make sure everybody continues to have access to prescription drugs and services.”. “But the first-line regimens recommended still favor the absolute best — and often most expensive — drugs available. In economic analyses of HIV interventions, South Africa is often used as a case in point, due to both the size of its HIV-positive population and the number of people in need of and receiving services as well as the availability of good data on the course of its HIV epidemic and the outcomes of interventions. We searched Pubmed for publications on the cost of each of the interventions, using a combination of MeSH and manually set search terms describing the intervention as well combinations of “economics”, “cost”, “cost analysis”, “costing”, “financial”, “budget” or “resource use”, at the level of title or abstract, as well as “South Africa” at the level of the text. per patient year) of a sample of service recipients during the intervention, and multiplying the resource use by the cost of each resource from the same period as the resources were used. For example: Medicare is not allowed to negotiate with drug companies on price — although 92 percent of Americans think it should. To receive email alerts for Fixes columns, sign up here. It’s smart business — small payments that increase sales of very expensive drugs. We did not find any cost papers reporting primary cost data relevant for South Africa on PMTCT, pre-exposure prophylaxis (PrEP), condom use, social and behaviour change communication (SBCC), or post-exposure prophylaxis (PEP). South Africa is one of the countries most severely affected by HIV/AIDS. S2 Table summarises the definition of each parameter collected from the included papers. The United States is infamous for its high cost of health care — and H.I.V. What’s new about Mylan’s Cimduo is that it combines two medicines available in generic form: tenofovir and lamivudine. That’s true even for Medicare and Medicaid, where tax dollars pay the bills. The fact that antiretroviral medicines were priced beyond the reach of most people who needed them in Africa had long been an international concern: at the International AIDS Conference in Stockholm in 1988 there was debate about how to ensure people in the developing world could access the treatment of that time - zidovudine monotherapy - which was marketed at a price of US$8000 per year . The principal summary measures that we collected were the mean or median cost estimate with ranges, cost year, currency, and where relevant, exchange rate between the reported currency and USD in the cost year. Strategic Development Consultants, Pietermaritzburg, South Africa. These resource costs are then summed to calculate the unit cost of the intervention. Additional abstracted data included the year of publication and first author, the country or countries where cost data had been collected, the type of economic evaluation and its objective or objectives, whether the evaluation was part of a clinical trial, the target population and any population subgroups, a description of the intervention, intervention setting and level of care, the cost analysis method (economic vs. financial, and full vs. incremental cost), the cost data collection method and time period, whether costs were discounted and whether costs and any outcome indicators came from the same setting, whether a sensitivity analysis was done, and if so, of which parameters. Current first-line regimens have performed well in real-life programmes, but have a low barrier to virological resistance and still carry toxicity that limits adherence. No, Is the Subject Area "Systematic reviews" applicable to this article? Unit costs based on ingredients are denoted as “From ingredients” in Table 2; unit costs based on literature updated by more recent input prices are denoted as “From ingredients, based on Author (year)” in Table 2. Drugs can’t solve that. What do we get from spending so much? care.”. Technical efficiency in the context of the South African Investment Case refers to the maximisation of output (for example, HIV tests done) given a set level of inputs (for example, healthcare staff). 55% of papers used a bottom-up approach to analysing resource use, 43% an ingredients or top-down approach, and one paper (2%) used both [34]. (For a definition of “technical efficiency” and other economics terms used in this paper, please see Box 1.). Formal analysis, Yes take an almost identical therapy. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and … For those estimates that did not include enough details regarding ingredients and quantities, we forward-adjusted the estimate for inflation to 2016 costs as above. The same is true for Mylan’s three-drug combos. More than 25 million people in the region are HIV positive, out of a total of 36 million worldwide, yet only a few thousand are being treated with antiretroviral drugs. During 1999–2008, South African government leadership had a both a president and a minister of health who doubted openly that HIV caused AIDS or that antiretroviral drugs were needed. For example, a commonly cited cost source is one of the very early costs of ART in an NGO-run programme years before the public-sector roll-out [9]. (Mylan is doing this, too, with its new drugs.) The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The majority of the reviewed publications included all cost categories relevant to the intervention under study, and more than half had collected data through bottom-up resource use analyses, often using large patient samples. Yes Follow The New York Times Opinion section on Facebook and Twitter (@NYTopinion), and sign up for the Opinion Today newsletter. It will exclude Atripla because there’s now another drug that is essentially identical and costs 40 percent less. Of the estimated 36.7 million individuals living with HIV worldwide in 2015, approximately 70% resided in sub-Saharan Africa (SSA) . It’s also good for everyone else: If people couldn’t afford their meds, we’d have many more deaths, huge hospital bills and an uncontrollable H.I.V. This arbitrage is very profitable. Validation, But if a patient has commercial insurance, they can bill the insurer at commercial prices. Lastly, for those interventions for which neither literature on costs nor detailed ingredients nor expenditure data were available, most often because they were either so new that cost analyses had not yet been undertaken, we used expenditure data instead (denoted as “Expenditure records from implementing agencies” in Table 2). The cost of the three generic drugs in Symfi and Symfi Lo is $12,000. It requires humans — to find people, win their trust, bring them into the health care system and help them deal with other issues (such as substance abuse) so they can handle getting tested. For those without private insurance, Medicare or Medicaid, the Ryan White AIDS Drug Assistance Program steps in. Medical costs in South Africa have not increased with general inflation over the last 15 years. medicines affordable in poor countries. Nevertheless, in contrast to most countries in Eastern and Southern Africa, Western African countries are generally facing relatively low HIV prevalence levels. https://doi.org/10.1371/journal.pone.0210497, Editor: Nicky McCreesh, London School of Hygiene and Tropical Medicine, UNITED KINGDOM, Received: August 10, 2018; Accepted: December 23, 2018; Published: February 26, 2019. Why now? Finally, we collected which cost categories had been reported as having been included in the cost analysis (costs of antiretroviral and any other drugs; laboratory, radiology, staff, consumable, overhead, capital, and transportation costs). It costs $75 a year. Similarly, drug costs, also a significant contributor to total costs, do not increase each year with inflation as the costs are negotiated through a tender process and may be fixed for a number of years, and in the past the prices tended to decrease as a result of tender negotiations. Funding: The study was funded by the United States Agency for International Development (grant AID 674-A-12-00029) (G.M.-R.’s, C. v. R.’s, C. C.’s, R. L.’s and L. J.’s time) and UNAIDS (grant awarded to Gesine Meyer-Rath). These medicines are by far the largest item in Medicaid’s drug budget, the third largest for the insurance exchanges and the fifth largest for commercial insurers. drugs. He was the chief of staff to the first leader of the Global Fund and later chief executive of the Clinton Health Access Initiative. But generic competition slashes prices only when there are many competitors. Yes Top-down costing starts with the total expenditure on the intervention, and uses a metric (such as allocation factors based on patient volumes per service or similar) to assign total costs to individual services. Cimduo is two pills (taken together) instead of one. Thirty-two papers (76%) presented full cost, 8 papers (19%) incremental costs, one paper (2%) reported both [32], and one paper (2%) did not give any information [33]. This isn’t an accident. Project administration, H.I.V. Ingredient-based costing is used to cost interventions for which there is no data from economic study. Supervision, At 40 percent less, the two Symfi combinations cost $19,200. But insulating patients from costs has greatly reduced patient pressure for lower prices. Micro-costing is a method of cost estimation that enumerates and costs every input needed during a health intervention. Of these 1,054 papers, 219 (21%) were duplicates, and 18 (2%) could not be found, leaving us with 817 papers for full-text screening (see Fig 1 for PRISMA diagram). patients also, perversely, benefit from high prices. drugs. No, Is the Subject Area "South Africa" applicable to this article? Citation: Meyer-Rath G, van Rensburg C, Chiu C, Leuner R, Jamieson L, Cohen S (2019) The per-patient costs of HIV services in South Africa: Systematic review and application in the South African HIV Investment Case. Our big problem in America is that too many people with H.I.V. In our review we were able to find literature detailing the results of primary cost analyses for five out of the 11 intervention categories included in the Investment Case, including for most of the HCT technical efficiency factors. No, Is the Subject Area "Health economics" applicable to this article? Prescribing those individual drugs instead of Atripla would mean taking three pills instead of one — and saving $20,000. Most important are the distorted incentives for patients. care,” he said. (The Mylan drugs are not technically generics, because they are new single-pill combinations of existing generic drugs, not exact copies of existing drugs.). https://doi.org/10.1371/journal.pone.0210497.g001, https://doi.org/10.1371/journal.pone.0210497.t001. Writing – review & editing, Affiliation (They differ in one piece of their triple therapy, but the World Health Organization and the United States government consider those drugs to be interchangeable.). We established the unit cost for each intervention using a number of methods: First, we used data from papers identified in our review without further adjustment if the cost year was recent and the service described was represented implementation of the service under the most recent guidelines, for the target population in question and at the relevant level of care. South Africa has begun rolling out a state-of-the-art antiretroviral drug in a “game-changing” bid to drastically reduce the number of people living with HIV. UnitedHealthcare is giving patients incentives to choose Mylan’s two-drug combination of Cimduo instead of its pharmacological equivalent Truvada, which costs $19,700 a year. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The unit of output can be a person, test, visit, patient year, or a whole programme, but most often it will be a person reached by the particular intervention. Writing – review & editing, Affiliation It costs $39,000 a year. In line with the impact ART has on the total cost of the HIV programme in South Africa, more than two thirds of the identified 42 papers detailed the cost of ART. This paper reviews available information on the costs for two types of services: a) Interventions: These were all biomedical or behavioural interventions for which available evidence showed a direct impact on HIV risk, transmission, morbidity and mortality; b) Technical efficiency (TE) factors: These were defined as activities that improve the technical efficiency of existing programmes, often by increasing their quality, uptake or coverage, but only affect a single intervention- in contrast to the enablers and synergies that have the potential to affect a number of interventions, possibly across different programme areas. Alternatively, we suggest searching the unit cost study repository of the Global Health Cost Consortium (https://ghcosting.org/pages/data/ucsr/app/index) which, at the time of writing, contained data from four of the papers included in our review). More primary cost analyses of non-ART interventions are needed. Because there is a smaller market for such drug treatments, patients must often … The results of both the literature review and the cost calculation exercise are presented in both ZAR and US dollars (USD), using the 2017/18 period average exchange rate of 1 USD = 13.32 South African Rand. If Cimduo is interchangeable with Truvada, then so are these drugs. In an effort to correct for outdated costs, those modelled analyses tended to inflate primary cost data over many years using general inflation indices such as the consumer price index, instead of sourcing and using more recent input prices for salaries, drug costs, etc, which skewed resulting estimates considerably, often upwards. For more information about PLOS Subject Areas, click drugs. Formal analysis, However, in our review we were able to find publications on the costs of a number of other interventions such as HCT, MMC, palliative and inpatient care. 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