Medical Progress and New Genetics Facing Another Cost Explosion? - - - PowerPoint PPT Presentation

Medical Progress and New Genetics – Facing Another Cost Explosion?

• A Plea for an Impartial Approach to Genetic Testing
• Dr. Achim Regenauer

IAAHS Colloquium 2004 April 28 – 29, 2004, Dresden

Münchener Rück Munich Re Group CENTRE OF COMPETENCE BIOSCIENCES

Medical progress and insurers 2 Munich Re

Birth Lifetime Alteration by Disease

Clinical Treshold

Course of disease

Death

Medical progress and insurers 3 Munich Re

Current trends– as exemplified by coronary heart disease (CHD)

Medical progress and insurers 4 Munich Re

Coronary heart disease – Symptomatic expression of atherosclerosis – Start in young adulthood – Symptomatic in middle age – Germany : > 80,000 !/year (10% of all deaths) – Estimated costs for the health system: 8 billion €

Medical progress and insurers 5 Munich Re

– Introduced at the end of the 60s Aortocoronary bypass – Operative “bypass” of vessel

• cclusions

– Difficult and complicated

• peration

– Relatively high risk for the patients (1.3% mortality, 6% neurological complications) – Average cost: 15,000 €

Medical progress and insurers 6 Munich Re

Balloon dilation (PTCA) – Introduced at the end of the 70s – Dilation of occlusions through a catheter – Comparatively simple, low cost procedure – Low risk for the patient – Average cost: 3,300 €

Medical progress and insurers 7 Munich Re

Coronary Heart Disease

Birth Lifetime Alteration by Disease

Clinical Treshold Course of disease

Death

Medical Progress? Costs?

Medical progress and insurers 8 Munich Re

Bypass PTCA

?

Coronary interventions – What has been expected?

Medical progress and insurers 9 Munich Re

Bypass PTCA – Bypass surgery by PTCA – Possibly a few more PTCA’s due to more liberal indication Coronary interventions – What had been expected?

Medical progress and insurers 10 Munich Re

–0 –1000 –2000 –3000 –4000 –5000 –6000 –7000 –8000 –79 –80 –81 –82 –83 –84 –85 –86 –87 –Bypass –PTCA

?

year

Coronary interventions – What had been expected? Costs? Bypass? PTCA?

Medical progress and insurers 11 Munich Re

Coronary interventions – What happened in reality?

–0 –1000 –2000 –3000 –4000 –5000 –6000 –7000 –8000 –79 –80 –81 –82 –83 –84 –85 –86 –87 –Bypass –PTCA

year

Reality?

Medical progress and insurers 12 Munich Re

Coronary interventions – What happened in reality?

–0 1000 2000 3000 4000 5000 6000 7000 8000 79 80 81 82 83 84 85 86 87 Bypass PTCA

1000 2000 3000 4000 5000 6000 7000 8000 79 80 81 82 83 84 85 86 87 Bypass PTCA

20000 40000 60000 80000 100000 120000 140000 160000 180000 200000 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 Bypass PTCA

year

0.97 Bill. € 2.75 Bill. €

Costs

Medical progress and insurers 13 Munich Re

Medical reasons of the expansion – Increasing age of the population – Expansion of both procedures to treat new patients (e.g. higher age, milder forms of CHD) – PTCA often requires repeat procedures (1/3 short-term)

Medical progress and insurers 14 Munich Re

Nonmedical reasons of the expansion – Unchecked technology – Supplier-induced demand – Different disciplines (Internists/Surgeons) – Amortisation pressure – Legal safeguards for the doctors

Medical progress and insurers 15 Munich Re

Will prevention and screening provide the solution?

Medical progress and insurers 16 Munich Re

Bowel cancer

– Second most frequent cause of death due to tumours – One in twenty people (5.9%) affected – 90-95% develop from benign polyps (recognisable early) – Numerous endo-genetic & exo-genetic factors " Cigarette smoking " Alcohol " Physical inactivity " Low fiber intake (vegetable, fruits)

Medical progress and insurers 17 Munich Re

Early stage (Dukes A): almost normal survival Others: 5 year survival 50% Distribution of cancer stages today 16% 84% Bowel Cancer – Prognosis

Source: Bavarian cancer registry

Medical progress and insurers 18 Munich Re

Colon Cancer

Birth Lifetime Alteration by Disease

Clinical Treshold

Course of Colon Cancer Death

Intervention Target group Outcome Problem Risk factors / Life style +++ dubious Change life style Risk awareness low Intervention Target group Outcome Problem Preventive medicine (colonoscopy screening) +++ effective Poor compliance Large number to screen

Intervention Target group Outcome Problem Treatment (surgery & chemotherapy) + dependent of extent cancer Many treatments in vain

Medical progress and insurers 19 Munich Re

Colon cancer screening: Colonoscopy –32 million Germans are entitled to free colonoscopy for colon cancer screening! –30.4 million will not get colon cancer and do not profit from colonoscopy! –How to save these 30.4 million colonoscopies, ( ≅ ≅ ≅ ≅ 4.5 billion €) ? –Preselection, based on genetic testing!

Medical progress and insurers 20 Munich Re

Genetic causes of Colorectal Cancer (CRC)

Rare CRC syndromes (<0.1%) Hereditary nonpolyposis colorectoral cancer (HNPCC) (3% - 4%) Familial adenomatous polyposis (FAP) (<1%) Sporadic (approx. 95%)

Medical progress and insurers 21 Munich Re

Sporadic colon cancer needs several mutations

Medical progress and insurers 22 Munich Re

The future: All risk DNA-chip for colon cancer

MSH2 MLH1 HNPCC3 APC... ...ACGTATATT... ...TGCATATAA... . . . T G C A C A T A A . . . . . . A C G T G T A T T . . . normal mutant Tumor suppressor Phosphatases DNA repair K i n a s e s C

• n

t a c t i n h i b i t

• r

s DNA-Chip

Medical progress and insurers 23 Munich Re

Population risk vs. individual risk – Today: your risk of getting CC is 5.9% (0-100%) – But individuals want to know whether they will get CC or not, yes or no – Tests are required that tell us

• yes or no, or at least give
• a smaller margin of uncertainty

Medical progress and insurers 24 Munich Re

Risk adjustment by genetic testing CC risk % population % 0 % 100 % 100 % 6% get CC, i.e. have a 100% risk 94% do net get CC, i.e. have a 0% risk 100% have a 6% risk

Medical progress and insurers 25 Munich Re

Risk adjustment by genetic testing CC risk % population % 0 % 100 % 100 % 6% get CC, i.e. have a 100% risk An ideal test depicts reality exactly 100% have a 6% risk 94% do not get CC, i.e. have a 0% risk

Medical progress and insurers 26 Munich Re

Risk adjustment by genetic testing CC risk % population % 0 % 100 % 100 % high 10% 20% medium 70% low

Medical progress and insurers 27 Munich Re

Genetic testing might save colonoscopies population 10% 20% 70% cancer risk high medium low colonoscopy frequent normal no

⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ 19.2 Mio colonoscopies could be saved ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ 2.9 bio. €

Medical progress and insurers 28 Munich Re

Chance by genetic tests

Medical progress and insurers 29 Munich Re

Colon Cancer

Birth Lifetime Alteration by Disease

Clinical Treshold

Course of Colon Cancer Death

New Genetics N e w G e n e t i c s

Medical progress and insurers 30 Munich Re

Predictive genetic testing Pharmacogenetic testing (reduction of adverse effects) Drug discovery (new treatment target/principles) Diagnostic genetic testing (avoidance of

• ver treatment

Monitoring of treatment (better compliance)

Further benefits of genetic testing

Medical progress and insurers 31 Munich Re

Conclusions

Medical progress and insurers 32 Munich Re

– Medical Progress: ongoing intensification of health expenses – Focus on preventive medicine – New Genetics: potential to uncover virtual causes – Preventive medicine will transform to predictive medicine – Containment of risk populations: potential cost savings? – Unembarrassed approach of insurance to genetic tests! Conclusions: New Genetics and Health Insurance