New Research Highlights

Section Editor: George Papadopoulos, BSc(Hons), GradDipEpi, Lucid Health Consulting and University of New South Wales, Sydney, NSW, Australia

Guest Contributor: Aakash Bipin Gandhi, BPharm, ISPOR Student Network Chair, 2019-2020, University of Maryland, Baltimore, MD, USA

Welcome back to Research Roundup as we tackle the area of aging. We present recent research that highlights what aging contributes to healthcare costs; the importance of coordinated health and social systems to address the challenges of aging; what can be saved in morbidity, mortality, and costs; policy implications; and lastly, the impact of recent advances in the treatment of Alzheimer’s disease and the challenges and implications. As always, we trust that you enjoy delving into the research of aging presented in this section and we look forward to highlighting new research in the next edition.

Actualizing Better Health and Healthcare for Older Adults
Fulmer T, Reuben DB, Auerbach J, Fick DM, Galambos C, Johnson KS. Health Affairs. 2021;40:(2) 219-225. https://doi.org/10.1377/hlthaff.2020.01470

Summary
By 2030, more people in the United States will be aged 65 and older than those aged 5 and younger. Our healthcare system is unprepared for the complexity of caring for a heterogenous population of older adults—a problem that has been magnified by the COVID-19 pandemic. Here, as part of the “National Academy of Medicine’s Vital Directions for Health and Healthcare: Priorities for 2021” initiative, the authors identify 6 vital directions to improve the care and quality of life for all older Americans. The next administration must create an adequately prepared workforce; strengthen the role of public health; remediate disparities and inequities; develop, evaluate, and implement new approaches to care delivery; allocate resources to achieve patient-centered care and outcomes, including palliative and end-of-life care; and redesign the structure and financing of long-term services and supports. If these priorities are addressed proactively, an infrastructure can be created that promotes better health and equitable, goal-directed care that recognizes the preferences and needs of older adults. The paper makes 6 recommendations: (1) create an adequately prepared workforce; (2) strengthen the role of public health; (3) remediate disparities and inequities; (4) develop new approaches to care delivery; (5) allocate resources to palliative and end-of-life care; (6) redesign long-term services and supports.

Relevance
The authors propose a concerted, coordinated effort to advance 6 vital directions. Despite long-standing barriers to their adoption, the next administration and Congress—in partnership with state and local government entities—should tackle them with new vigor.

What Can Economics Say About Alzheimer’s Disease?
Chandra A, Coile C, Mommaerts C. National Bureau of Economic Research. Working Paper No. 27760. Published August 2020. https://www.nber.org/papers/w27760

Summary
Alzheimer’s disease affects 1 in 10 people aged 65 or older and is the most expensive disease in the United States. The authors describe the central economic questions raised by Alzheimer’s disease. While there is overlap with the economics of aging, the defining features of the “economics of Alzheimer’s disease” is an emphasis on cognitive decline, choice by cognitively impaired patients, and a host of issues where dynamic contracts between patients and caregivers are hard to enforce. There is enormous scope for economists to contribute to our understanding of Alzheimer’s-related issues, including drug development, efficient care delivery, dynamic contracting within the family and with care providers, long-term care risk, financial decision making, and public programs for Alzheimer’s disease.

Relevance
This National Bureau of Economic Research working paper discussion proposes that the “economics of Alzheimer’s disease” overlaps with a number of areas of economics: health economics; public finance; behavioral economics; experimental economics; family economics; mechanism design; and the economics of innovation, suggesting that the topic should attract almost all economists.

Aducanumab for Alzheimer’s Disease: Effectiveness and Value: Evidence Report
Lin GA, Whittington MD, Synnott PG, McKenna A, Campbell J, Pearson SD, Rind DM. Institute for Clinical and Economic Review. Published June 30, 2021. https://icer.org/wp-content/uploads/ 2020/10/ICER_ALZ_Revised_Evidence_Report_06302021.pdf

Summary
The Institute for Clinical and Economic Review (ICER) revised an Evidence Report assessing the comparative clinical effectiveness and value of aducanumab (Aduhelm™, Biogen) for the treatment of Alzheimer’s disease. This updated version reflects changes made based on the breadth of the US Food and Drug Administration (FDA) label, the treatment’s announced price, and comments received from the manufacturer, patient groups, clinicians, and other stakeholders. While the evidence suggests that aducanumab’s side effects are both common and potentially serious, the 2 phase III clinical trials produced contradictory results as to whether aducanumab slows the progression of the disease or improves cognition. ICER has determined the evidence is “insufficient” to show a net health benefit for patients with mild cognitive impairment due to Alzheimer’s disease, as well as for patients with mild Alzheimer’s disease. ICER’s health benefit price benchmark range for aducanumab is $3000 to $8400 per year for patients with early Alzheimer’s disease. This range was slightly higher than what was included in ICER’s preliminary draft report, and the change is largely due to the FDA requiring fewer MRIs than what patients received during the clinical trials. ICER also calculated what a fair price would be for a hypothetical chronic maintenance therapy that halted the progression of dementia in people with Alzheimer’s disease.

Relevance
We will continue to read a lot more about the cost-effectiveness of aducanumab and indeed future treatments for Alzheimer’s disease, including engagement with a variety of stakeholders in a discussion of how we should reflect Alzheimer’s disease value to patients and families, especially when there is uncertainty around a product’s effectiveness, its price, and the scale of its potential use in the community.

The Economic Value of Targeting Aging
Scott, AJ, Ellison M, Sinclair DA. Nat Aging. Published July 5, 2021. https://doi.org/10.1038/s43587-021-00080-0

Summary
In this article, the authors argue that although the life expectancy for older adults may have improved over the past century, not all years of life gained may be healthy. Hence, healthcare planners may need to focus on improving aging by compressing morbidity (maximizing a healthy life span and minimizing time spent sick or disabled) as compared to extending life. The authors evaluate the economic value of targeting healthy aging as compared to increasing life expectancy for individuals by using the value of statistical life methodology. Specifically, this methodology allows investigators to determine the monetary value attributable to gains from increased life expectancy and improved health by evaluating an individual’s willingness to pay to decrease the risk of death. The study was conducted from a US perspective. Information on number of deaths and years lost to illness were identified from the Global Burden of Disease dataset. Population-related birth estimates were identified from the US Census Bureau data. The authors found that compressing morbidity may offer higher economic gains to healthcare systems as compared to efforts focused on increasing life expectancy or eradicating individual diseases. For example, the authors found that focusing efforts on promoting healthy aging that can increase life expectancy by a year can result in economic gains worth $38 trillion. Similarly, focusing on efforts that promote healthy aging and consequently increasing life expectancy by 10 years can result in economic gains as high as $367 trillion.

Relevance
Healthcare planners or policy makers may benefit from designing interventions that target healthy aging, which in turn can lead to increased life expectancy, improved quality of life, and cost savings in the future.

Comparison of Healthcare Spending by Age in 8 High-Income Countries
Papanicolas I, Marino A, Lorenzoni L, Jha A. JAMA Netw Open. 2020;3(8):e2014688. doi:10.1001/jamanetworkopen.2020.14688

Summary
While it is well established that the United States has the highest healthcare expenditure globally, it is unclear how this healthcare spending differs across age groups and compares to populations of other high-income countries that have more homogeneous healthcare financing schemes. This cross-sectional study utilized data from the Organization for Economic Co-operation and Development to evaluate healthcare spending per capita by different age groups across 8 countries. This included the United States, Australia, Canada, Germany, Japan, The Netherlands, Switzerland, and the United Kingdom. All estimates were standardized and expressed in terms of absolute US dollars. Expectedly, the mean per capita spending for the United States was $9524 (1.9 times higher) than the mean per capita spending for the 7 comparator countries. Importantly, in term of age groups, this difference was the higher among individuals 65 years and older, especially among individuals in the 80- to 84-year age group ($18,645). Additionally, Medicare-eligible beneficiaries in the United States had a 100% higher per capita spend on healthcare as compared to older adults in the comparator countries. Several factors could explain these findings, including differences in health status, prices of healthcare services, and breadth of covered services across the United States and the 7 comparator countries. Limitations of the study include the descriptive nature of the analysis that did not allow for control of differences inherent in the healthcare systems across the countries.

Relevance
This study improves our understanding of differences in healthcare spending across the United States and other high-income countries by age group. Importantly, the findings related to the Medicare-eligible population in the study suggest that shifting to a Medicare-for-all healthcare system in the United States may not be the ideal solution to reduce substantial healthcare costs.

The FDA’s Approval of Aduhelm: Potential Implications Across a Wide Range of Health Policy Issues and Stakeholders
Health Affairs Blog. Published June 10, 2021. doi10.1377/hblog20210609.921363

Summary
On June 7, 2021, Aduhelm^™ was approved by the FDA for treating Alzheimer’s disease based on its ability to reduce amyloid plaques (a surrogate endpoint). This occurred despite a majority vote by the FDA’s own drug advisory committee against aducanumab’s approval due to lack of evidence surrounding its clinical efficacy. Further, the broad FDA-approved drug label indicates that the drug can be used to treat Alzheimer’s disease. This does not give any additional guidance on managing Alzheimer’s disease among key clinical subgroups that were excluded from the trial.

In addition to this controversy, this decision also has several economic implications. Aduhelm has been priced at $56,000 for an annual course of treatment, which can increase Medicare spending by $10 to $100 billion dollars, annually. Hence, Aduhelm adds to the list of drugs that are subject to a drug pricing debate in the country. On one side, while heavy investments in drug research and innovation may justify high prices, access to these medications may be endangered, particularly for seniors, due to high premiums set by insurance companies to offset these costs.

Relevance
Aduhelm represents the FDA’s first Alzheimer’s disease-related drug approval in over 20 years. Despite the controversy regarding its efficacy, the approval of Aduhelm also has far-reaching economic consequences for patients given its high list price. These mainly include barriers to treatment access and elevated premiums that would help payers offset high costs.