Who doesn’t like the idea of a successful treatment that saves medical dollars? A 2019 report revealed that U.S. healthcare spending is projected to grow faster than the economy over the coming eight years, increasing from 17.9% of gross domestic product in 2017 to 19.4% in 2027.[i] This includes all public and private spending. We are at a point where best value matters more than ever, so we love treatments that work while being kind to the economy.
We love these treatments even more when they restore quality of life (QOL). Now that’s value! Harvard’s Milton Weinstein, an expert on cost-effectiveness in medicine, remarked in an interview:
“Cost-effectiveness looks at technologies and drugs and treatments through an economic lens. How much do they cost? What do they cost compared to alternatives? And not only what do they cost, but is it worth the cost?
For example, we developed a concept called the quality-adjusted life year, or QALY. It reflects how many years of high-quality life a patient gains with a particular intervention. Another number that we use to measure value is the cost-effectiveness ratio. Basically, it tells us the “price” of buying more healthy years with a new treatment compared with the standard treatment, and whether it’s a good value.”[ii]
Comparing ET treatment costs
How does one evaluate whether one treatment for a certain disease or disorder is a better value than another for the same condition? A collaborative team from Stanford University and University of Pennsylvania did a cost-effectiveness analysis of MRI-guided Focused Ultrasound (MRgFUS or simply FUS) compared to the two other major neurosurgical procedures for essential tremor (ET): Deep Brain Stimulation (DBS) and gamma knife (stereotactic radiosurgery). All three procedures are intended to interrupt the brain’s ET signals at an area called the thalamus.
To determine the dollar cost of each treatment, the team used Medicare reimbursement figures for DBS and gamma knife. However, at the time of their study, Medicare did not yet have such figures for FUS, so the authors used the cost of gamma knife as a proxy figure. But remember, they were not comparing dollar amounts, but the impact of each treatment on a patient’s quality of life (QOL).
Determining value in terms of QOL
It is no overstatement to say that ET can crush a person’s QOL. Not only do tremors impair the ability to accomplish even the simplest daily tasks, it gradually starts to isolate people as uncontrollably shaking hands, head or voice becomes a source of embarrassment, frustration and depression. There are, in fact, specialized tremor questionnaires that put a numerical score on how badly tremors have harmed QOL. These scores are reported in published clinical studies to give an objective before-and-after “snapshot” of how much each treatment’s success contributes to improving QOL.
The team reviewed 32 published studies that reported these before-and-after scores. Among them there were 83 FUS cases, 615 DBS cases, and 260 gamma knife cases. (Since FUS was the most recent new technology, there were the least number of individuals who had that treatment for their tremors.)
Results of the comparison favor FUS
The authors used the scores to calculate the percent change in functional disability, that is, how much better the patients could function when their tremors in one hand (or both, in some cases) were under control. Again, this is based not only on observation, but on patients completing the same questionnaires or tests after treatment as before. They concluded:
Magnetic resonance-guided focused ultrasound thalamotomy resulted in significantly higher utility [QOL] scores compared with DBS … or stereotactic radiosurgery… Projected costs of magnetic resonance-guided focused ultrasound thalamotomy were significantly less than DBS but not significantly different from radiosurgery.[iii]
Magnetic resonance-guided focused ultrasound thalamotomy is cost-effective for tremor compared with DBS and stereotactic radiosurgery and more effective than both.[iv]
I’m certain that, as the number of persons with ET who choose FUS continues to grow, similar articles will be written. Medical professionals and patients alike are very concerned with the proportion of the economy occupied by medical costs. In the case of ET, a condition that most frequently appears with aging, I anticipate we’ll see more cases among the wave of Baby Boomers who now make up what economists call the silver tsunami. I believe that FUS will be seen by many people older than 65 as more acceptable than invasive DBS surgery with its attendant risks, and that the same generation that were taught to fear the atomic bomb as children are more “radiation averse” toward gamma knife than younger generations.
It’s hard to argue with proven cost-effectiveness: in addition to saving medical dollars over DBS, FUS offers the benefits of an outpatient procedure, immediate tremor control, durable change, and a return to quality of life that for many feels nearly miraculous—all without drilling holes, implanting electrodes, or exposure to radiation. Now, that’s what I call value.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you have health concerns or questions of a personal medical nature.
[ii] “Can Cost-Effective Healthcare = Better Healthcare?” Harvard T. H. Chan/School of Public Health, Winter 2010. https://www.hsph.harvard.edu/news/magazine/winter10assessment/
[iii] Ravikumar VK, Parker JJ, Hornbeck TS, Santini VE et al. Cost-effectiveness of focused ultrasound, radiosurgery, and DBS for essential tremor. Mov Disord. 2017 Aug;32(8):1165-1173.