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Excerpt
Dr. Merrill: Over the past 2 years in the managed care sector, overall costs and costs per patient-year have reached a steady state. We have seen stabilization of hospital days and relatively inconsequential increases in cost per patient-year. Drug costs continue to rise, and laboratory costs have risen slightly.
Dr. Wong: We’ve all noted an inexplicable increase in costs of care during 1998 and 1999. Costs for first-line regimens are at a steady state. When you begin looking at more complicated second-and third-line regimens, especially those that use four or more drugs, there is a cost increase. I agree with Dr. Merrill that decreased hospitalization costs have offset the increased cost of drugs so far. Regardless of the type of analysis we do, our results all indicate that it’s likely that costs will start to rise again. When considering the costs of initiating therapy, the costs of PIs and nonnucleoside analog reverse transcriptase inhibitors are about the same. But the observational data we have show that PIs provide durable results, so we need to consider efficacy as well as cost when deciding which drug regimen to use.
Dr. Keiser: I agree that costs have reached a plateau for the time being, but there is concern that costs will continue to rise. It is important to look at individual pricing for drugs in a given regimen. At our clinic, we have looked at the effect of some of the nonnucleoside analog reverse transcriptase inhibitors on impact of total cost and could not find any difference between using them and PIs. The cost differential between those two drug categories and its impact on overall costs is small.
Dr. Palella: As highly active antiretroviral therapy (HAART) regimens become more complex, with more agents used per regimen to treat patients who have already been exposed to treatment, rising antiretroviral costs are unavoidable. At this point, these costs are still more than offset by the avoidance of inpatient hospital days, high-tech nursing, and home health care costs, which would otherwise be incurred among patients with advancing illness.
For several reasons, it is difficult to predict when or how HAART treatment costs will rise again in the future. First, we don’t know whether newer, more effective drugs will allow us to reduce the number of agents currently used in HAART therapy. Also, it seems likely that the costs of monitoring patients receiving HAART will increase. Currently, we routinely undertake assays of viral genotypic and phenotypic susceptibility. It seems likely that soon we will also be routinely measuring antiretroviral drug levels (therapeutic drug monitoring) and more frequently assessing for metabolic disturbances, all of which can significantly add to the cost of care.
Have the cost offsets identified after the initial introduction of antiretroviral therapy continued to control the cost of human immunodeficiency virus (HIV) care? Examples of cost offsets include hospitalization, nonantiretroviral pharmacy, physician care, and home care. What has happened to total cost per HIV patient from 1998 to 2000?
Dr. Keiser: I don’t know whether the plateau in costs that we’ve seen in the last few years will last. My guess is that, as more patients fail on drug therapy and use more intensive regimens, their costs will continue to rise slowly. It is interesting, however, that although Dr.
