Pharmaceuticals reduce the societal burden of cardiovascular disease

February is American Heart Month—a month dedicated to raising awareness around heart disease. Throughout the month, organizations educate the public about heart disease and its risk factors, promote checkups, encourage healthy behaviors, teach CPR, and support research for heart disease prevention. We want to contribute to these efforts by raising awareness around the societal burden of cardiovascular disease, the societal impacts of treatments for cardiovascular disease, and the need to ensure adequate incentives exist for future innovation in cardiovascular disease.  

SAD BUT TRUE

Cardiovascular disease is the leading cause of death in the United States. One in three US adults receive healthcare for either a cardiovascular disease risk factor (e.g., hypercholesterolemia, diabetes, hypertension) or a cardiovascular condition (e.g., stroke, heart failure, atrial fibrillation, coronary heart disease). 

The economic burden of cardiovascular disease is enormous. In 2020, the healthcare costs for cardiovascular disease risk factors were $400 billion and the healthcare costs for cardiovascular conditions exceeded $390 billion. 

The economic burden of cardiovascular disease extends far beyond the healthcare system. In addition to these healthcare costs, cardiovascular disease has a massive impact on productivity. In 2020, annual productivity losses due to cardiovascular disease were $234 billion, with $17 billion resulting from lost productivity from morbidity of the condition (missed workdays or inability to work due to the condition) and $217 billion resulting from premature mortality (productivity missed from dying early from the condition).

The productivity losses due to cardiovascular disease are greater than the healthcare costs due to cardiovascular disease for people less than 65 years of age. Cardiovascular disease is a necessary target for future pharmaceutical innovation to reduce healthcare spending and improve productivity. 

I JUST WANT TO CELEBRATE 

Pharmaceuticals for cardiovascular disease have had a huge impact on reducing medical costs, improving health outcomes, increasing labor productivity, and promoting health system efficiency. 

Pharmaceuticals on Medical Costs

From 1992 to 2004, per capita healthcare spending increased linearly for the Medicare population. But around the year 2005, the growth of healthcare spending started to slow down for this population. Check out Exhibit 1 in this article and you can see the slope of the line representing per capita healthcare spending starts to markedly decrease around the year 2005.

What caused this spending slowdown? Reduced growth in spending for cardiovascular risk factors and disease was the largest contributor (accounting for 56%) of this spending slowdown. While you have that article open, make sure to also check out Exhibit 2. 

What caused this reduced growth in spending for cardiovascular risk factors and disease? The increased use of cardiovascular pharmaceuticals (e.g., lipid-lowering, antihypertensive, and antidiabetic medications) was the largest contributor (accounted for at least 51%) to this reduced growth in spending on cardiovascular risk factors and disease. Greater use of pharmaceuticals resulted in greater risk factor control and a lower rate of acute cardiovascular events. 

Pharmaceuticals can reduce medical costs.

Pharmaceuticals on Health Outcomes

Between 1990 and 2015, the life expectancy for someone in the United States increased 3.3 years—from 75.5 years in 1990 to 78.8 years in 2015. 

What caused this increase in life expectancy? The reduction in mortality from cardiovascular conditions was the largest contributor (accounting for 63%) of this increase in life expectancy. Improvements in ischemic heart disease and cerebrovascular diseases accounted for 2.09 of the 3.3 added years of life expectancy. 

What caused these reductions in mortality from cardiovascular conditions? Pharmaceutical treatments for ischemic heart disease and cerebrovascular disease were the largest contributors (accounting for 53%) to the reductions in mortality from cardiovascular conditions. Of the 2.09 years that were added to the US life expectancy from reductions in mortality from cardiovascular conditions, 1.11 of the years were attributed to pharmaceutical treatments for ischemic heart disease and cerebrovascular diseases.  

Pharmaceuticals can improve survival.

Pharmaceuticals on Productivity 

Health conditions impact sectors beyond the healthcare system. Poor health translates into lost productivity. Eighteen million adults between the ages of 19 and 64 years old are unemployed because of their health. Fortunately, pharmaceuticals have resulted in substantial gains in productivity—both by reducing morbidity to increase the ability to work and by reducing premature mortality to prolong the number of productive years an individual is able to have. 

By now, you all know I love using economic models to extrapolate and synthesize evidence to understand the impact pharmaceuticals have on societal outcomes, so I built a model to estimate the productivity impact of the 1.11 additional years in US life expectancy that was attributed to pharmaceutical treatments for ischemic heart disease and cerebrovascular diseases. 

What did I find? The increase in life extension of 1.11 years for the US population could result in $1.4 trillion of increased labor productivity and $9 trillion of increased total productivity (including labor and non-labor production such as household production, non-household production, and volunteering). 

On a per person basis, this 1.11 years of added life extension that was attributed to pharmaceutical treatments for ischemic heart disease and cerebrovascular disease is estimated to generate 1,510 hours of total additional productivity per person, with 1,014 hours in additional household production, 97 hours of non-household production, 236 hours of labor production, and 163 hours of volunteering production. 

How did I estimate this? I used formulas reported by Drs. Jiao and Basu to estimate the added productivity associated with now living to 78.8 years (as compared to living to 75.5 years) based on the life expectancy extension from 1990 to 2015 as reported in this study. I used a quality of life estimate of 0.811 based on the estimates reported in this study and assumed 46% of the population had a disability based on this source. I multiplied the total productivity gains over the 3.3 year period (78.8 years minus 75.5 years) by 33.6% to account for the percent of the life extension (1.11 years divided by 3.3 years) that was attributed to pharmaceuticals for ischemic heart disease and cerebrovascular disease. 

Multiplying these estimates by the US population in 2015 (320,000,000 people) to estimate the total added productivity among the population and then by the average hourly wage for an elderly worker ($18.73 per hour) generates numbers in the trillions of dollars. 

Pharmaceuticals can improve productivity. 

Pharmaceuticals on Health System Efficiency

The pharmaceuticals evaluated in the studies summarized above largely include antihypertensives, statins, and warfarin. Lisinopril, a commonly used hypertensive, is now $0.10 a pill ($38 per year) from the Mark Cuban Cost Plus Drug Company. Rosuvastatin, a commonly used statin, is now $0.12 a pill ($42 per year). Warfarin, a commonly used blood thinner, is now $0.11 a pill ($40 a year). 

Pharmaceuticals targeting cardiovascular risk factors and conditions can now be bought for pennies per day now that their patents have expired and generic competition has entered the market. The impact that these innovations have had on patient health and non-health outcomes (like productivity) have extended (and will continue to extend) far beyond their branded periods when they might have had a “high” price.

Pharmaceuticals can improve health system efficiency

SO WHAT 

Cardiovascular disease remains the leading killer of Americans and unfortunately the health burden of cardiovascular disease is expected to dramatically increase over the next few years due to an increasing prevalence of risk factors (e.g., diabetes, uncontrolled blood pressure) and an aging population. The economic burden associated with cardiovascular disease is expected to triple by 2050. Despite the tremendous pharmaceutical advancements in the last few decades, we need ongoing pharmaceutical innovation to address the ongoing health and economic burden of cardiovascular disease. 

However, policies such as the Inflation Reduction Act (IRA) could disincentivize innovations for cardiovascular disease. Seven of the ten drugs selected for the first round of Medicare drug price negotiation were treatments for cardiovascular risk factors or conditions. Further, the cardiovascular pharmaceuticals that were summarized in the section above are all small molecules. In the IRA, small molecules are eligible for negotiation four years earlier than biologics. This disparity is expected to disincentivize the development of some new small molecules. 

What does this mean for future innovation in cardiovascular disease? Read Dr. Tomas Philipson’s recent article on the implications of the IRA on small molecule development. He states, “Since the IRA was introduced, investment in small-molecule drug development has dropped by 70%. Research from our center at the University of Chicago estimates that over the next two decades, we’ll lose out on 79 potential new small-molecule drugs — medications that could have helped prevent heart attacks, slowed the progression of Alzheimer’s, or better treated depression.”

Pharmaceutical innovation can continue to play a crucial role in addressing the increasing health and economic burden of cardiovascular risk factors and conditions if adequate incentives to innovate exist. Creating parity between small molecules and biologics as it relates to the time to Medicare drug price negotiation (i.e., changing when small molecules can be subject to negotiation to match that of biologics) is one opportunity to promote the ongoing innovation of small molecules for cardiovascular disease.