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

CENTRE OF COMPETENCE BIOSCIENCES 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

Munich Re Medical progress and insurers Alteration by Disease Death Course of disease Clinical Treshold Birth Lifetime 2

Munich Re Medical progress and insurers Current trends– as exemplified by coronary heart disease (CHD) 3

Munich Re Medical progress and insurers 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 € 4

Munich Re Medical progress and insurers Aortocoronary bypass – Introduced at the end of the 60s – Operative “bypass” of vessel occlusions – Difficult and complicated operation – Relatively high risk for the patients (1.3% mortality, 6% neurological complications) – Average cost: 15,000 € 5

Munich Re Medical progress and insurers 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 € 6

Munich Re Medical progress and insurers Coronary Heart Disease Alteration by Disease Medical Progress? Death Costs? Course of disease Clinical Treshold Birth Lifetime 7

Munich Re Medical progress and insurers Coronary interventions – What has been expected? ? Bypass PTCA 8

Munich Re Medical progress and insurers Coronary interventions – What had been expected? – Bypass surgery by PTCA – Possibly a few more PTCA’s due to more liberal indication Bypass PTCA 9

Munich Re Medical progress and insurers Coronary interventions – What had been expected? Bypass? –8000 –7000 –6000 PTCA? –5000 –4000 Costs? –3000 ? –2000 –1000 –0 –79 –80 –81 –82 –83 –84 –85 –86 –87 year –Bypass –PTCA 10

Munich Re Medical progress and insurers Coronary interventions – What happened in reality? –8000 –7000 –6000 –5000 Reality? –4000 –3000 –2000 –1000 –0 –79 –80 –81 –82 –83 –84 –85 –86 –87 year –Bypass –PTCA 11

Munich Re Medical progress and insurers Coronary interventions – What happened in reality? 8000 200000 7000 180000 6000 160000 140000 5000 2.75 Bill. € 120000 Costs 8000 4000 7000 100000 6000 3000 80000 5000 4000 60000 0.97 Bill. € 2000 3000 40000 8000 7000 2000 6000 1000 5000 4000 8000 20000 1000 7000 3000 6000 5000 2000 4000 3000 1000 0 2000 0 1000 0 –0 79 80 81 82 83 84 85 86 87 –0 79 80 81 82 83 84 85 86 87 79 80 81 82 83 84 85 86 87 Bypass PTCA Bypass PTCA Bypass PTCA 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 79 80 81 82 83 84 85 86 87 Bypass PTCA Bypass PTCA year 12

Munich Re Medical progress and insurers 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) 13

Munich Re Medical progress and insurers Nonmedical reasons of the expansion – Unchecked technology – Supplier-induced demand – Different disciplines (Internists/Surgeons) – Amortisation pressure – Legal safeguards for the doctors 14

Munich Re Medical progress and insurers Will prevention and screening provide the solution? 15

Munich Re Medical progress and insurers 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) 16

Munich Re Medical progress and insurers Bowel Cancer – Prognosis Distribution of cancer stages today 84% Early stage (Dukes A): almost normal survival 16% Others: 5 year survival 50% Source: Bavarian cancer registry 17

Munich Re Medical progress and insurers Colon Cancer Alteration by Disease Death Course of Colon Cancer Intervention Target group Outcome Problem Treatment (surgery dependent of Many treatments in + & chemotherapy) extent cancer vain Intervention Target group Outcome Problem Preventive medicine Poor compliance (colonoscopy +++ effective Clinical Large number to screen screening) Treshold Intervention Target group Outcome Problem Change life style Risk factors / Life style +++ dubious Risk awareness low Birth Lifetime 18

Munich Re Medical progress and insurers 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! 19

Munich Re Medical progress and insurers Genetic causes of Colorectal Cancer (CRC) Hereditary nonpolyposis Familial adenomatous colorectoral cancer polyposis (FAP) (HNPCC) (3% - 4%) (<1%) Rare CRC syndromes (<0.1%) Sporadic (approx. 95%) 20

Munich Re Medical progress and insurers Sporadic colon cancer needs several mutations 21

Munich Re Medical progress and insurers The future: All risk DNA-chip for colon cancer Tumor suppressor s r o Phosphatases t i mutant normal b i DNA repair h n i . s t . ...TGCATATAA... e c . A a s a t A n . n ...ACGTATATT... o . T i . K C T A T C A A T C G G T T G . . C . A . . . DNA-Chip MSH2 MLH1 HNPCC3 APC... 22

Munich Re Medical progress and insurers 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 23

Munich Re Medical progress and insurers Risk adjustment by genetic testing 6% get CC, i.e. have a 100% risk 100 % CC risk % 100% have a 6% risk 94% do net get CC, i.e. have a 0% risk population % 0 % 100 % 24

Munich Re Medical progress and insurers Risk adjustment by genetic testing 6% get CC, i.e. have a 100% risk 100 % An ideal test depicts reality exactly CC risk % 100% have a 6% risk 94% do not get CC, i.e. have a 0% risk population % 0 % 100 % 25

Munich Re Medical progress and insurers Risk adjustment by genetic testing 100 % 10% high CC risk % 20% medium 70% low population % 0 % 100 % 26

Munich Re Medical progress and insurers 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. € ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ ⇒ 27

Munich Re Medical progress and insurers Chance by genetic tests 28

Munich Re Medical progress and insurers Colon Cancer Alteration by Disease Death Course of Colon Cancer Clinical Treshold w e s N c i t e n e G New Genetics Birth Lifetime 29

Munich Re Medical progress and insurers Further benefits of genetic testing Predictive genetic testing Diagnostic Pharmacogenetic genetic testing testing (avoidance of (reduction of adverse over treatment effects) Drug discovery Monitoring of treatment (new treatment target/principles) (better compliance) 30

Munich Re Medical progress and insurers Conclusions 31

Munich Re Medical progress and insurers Conclusions: New Genetics and Health Insurance – 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! 32