Value-based medicine needs backing of physicians for success, surgeon says

WAIKOLOA, Hawaii — The proposal of value-based medicine needs the support of physicians in order to succeed and provide the appropriate funding for the most valuable treatments, among which are treatments for age-related macular degeneration, according to a surgeon speaking here at Retina 2008, held in conjunction with Hawaiian Eye 2008.

Gary Brown, MD, explained the process of comparative effectiveness by which he predicted the United States will determine reimbursement in the future.

"Essentially, it's comparing the interventions that are out there," he said. "The key is for physicians to have a strong say in it."

Dr. Brown explained that Canada, the United Kingdom and Australia currently require cost-effectiveness and cost-utility analyses before approving a drug. The creation of a similar agency was recently proposed by U.S. legislators.

"This will be coming to the U.S. When? We don't know. But the key is that, when it comes, we want to have a major role in it - we as physicians," Dr. Brown said. "We don't want the economists doing this for us because they don't understand [medicine] like we do."

The system of value-based medicine is based on analyzing the cost-effectiveness and cost-utility of an intervention to determine its value - the associated improvements in length of life and/or quality of life, Dr. Brown explained.

Utility analysis, which is combined with quantifiable effectiveness, then quantifies quality of life, allowing people to rate their quality of life from 1.0 (perfect health) to 0.0 (death).

In a study in which Dr. Brown and colleagues surveyed both physicians and patients, they found that ophthalmologists underestimate the effect of AMD on their patients.

Mild AMD has a quality of life utility of 0.83, which is the same as leg amputation or moderate angina, Dr. Brown said. Moderate AMD has a utility of 0.6, which is the same as being on dialysis or suffering a fractured hip. Severe AMD has a utility of 0.47, which is the same as severe angina with daily crushing chest pain. Lastly, he said, very severe AMD has a utility of 0.39, which is the same as a Rankin class 5 stroke or end-stage metastatic prostate cancer with severe pain.

The patients' utility is then multiplied by length of the effect to estimate the quality-adjusted life years, Dr. Brown explained. In the United Kingdom, he said, the approval of drugs is based upon their cost per quality-adjusted life year.

"The basic overriding principle is not about cost-effectiveness," he said. "It's that patients deserve the interventions which deliver the greatest value.

"It's only when the conferred value of interventions is similar that cost actually becomes a differentiating factor," Dr. Brown said.

"Value-based medicine standardizes this comparative cost-effectiveness," he said. "As new therapies emerge, value-based medicine will demonstrate both comparative effectiveness and cost-effectiveness. It's critical that we as physicians become involved because we are the patient advocates and we are the ones that can best put in the information that's really important."