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
Alteration by Disease
Medical progress and insurers
Death
Clinical
Treshold
u
o
C
Birth
e
s
r
of
s
i
d
e
s
ea
Lifetime
2
Medical progress and insurers
Munich Re
Current trends–
as exemplified by coronary heart
disease (CHD)
3
Medical progress and insurers
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 €
4
Medical progress and insurers
Munich Re
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
Medical progress and insurers
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 €
6
Munich Re
Medical progress and insurers
Alteration by Disease
Coronary Heart Disease
s?
s
re
g
ro ?
P
l ts
a
s
c
i
o
d
C
Me
Clinical
Treshold
se
r
u
o
C
Birth
se
i
d
f
o
Death
e
s
a
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
–Bypass –PTCA
–84
–85
–86
–87
year
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
–Bypass –PTCA
–84
–85
–86
–87
year
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
8000
Costs
4000
7000
100000
6000
3000
80000
5000
4000
60000
2000
0.97 Bill. €
3000
40000
2000
8000
7000
6000
1000
5000
4000
8000
20000
1000
3000
7000
6000
5000
2000
4000
3000
1000
00
2000
1000
–0
–00
79
79
79
80
80
81
81
80
82
82
Bypass
Bypass
83
81 PTCA
83
PTCA
84
84
82
85
85
86
86
83
87
87
84
85
86
87
Bypass
PTCA
7979 80 81 8082 83 84
98 99 00
81 85 86
82 87 88 8389 90 91
84 92 93
85 94 95 8696 97 87
Bypass PTCA
PTCA
Bypass
year
12
Medical progress and insurers
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)
13
Medical progress and insurers
Munich Re
Nonmedical reasons of the expansion
– Unchecked technology
– Supplier-induced demand
– Different disciplines (Internists/Surgeons)
– Amortisation pressure
– Legal safeguards for the doctors
14
Medical progress and insurers
Munich Re
Will prevention and screening
provide the solution?
15
Medical progress and insurers
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)
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
Alteration by Disease
Colon Cancer
Intervention
Target group
Treatment (surgery
+
& chemotherapy)
Intervention
Preventive medicine
(colonoscopy
screening)
Target group
Clinical
Treshold
Intervention
Risk factors / Life style
Birth
Target group
+++
+++
Outcome
dubious
Outcome
lo
o
C
Death
Outcome
Problem
er
c
n
dependent
of Many treatments in
a
C
n extent cancer vain
Problem
of
e compliance
sPoor
r
u Large number to screen
o
C
effective
Problem
Change life style
Risk awareness low
Lifetime
18
Medical progress and insurers
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!
19
Munich Re
Medical progress and insurers
Genetic causes of Colorectal Cancer (CRC)
Hereditary nonpolyposis
colorectoral cancer
(HNPCC) (3% - 4%)
Familial adenomatous
polyposis (FAP)
(<1%)
Rare CRC syndromes
(<0.1%)
Sporadic
(approx. 95%)
20
Medical progress and insurers
Munich Re
Sporadic colon cancer
needs several mutations
21
Munich Re
Medical progress and insurers
DN
A
or
s
Tu
m
...ACGTA
TATT...
...ACGTGTATT...
...TGCACATAA...
...TGCAT
ATAA...
mutant
normal
up
pr
es
re
so
pa
r
ir
Ki
na
se
s
Ph
os
p
Co hata
se
nta
s
ct
inh
ibi
tor
s
The future: All risk DNA-chip for colon cancer
DNA-Chip
MSH2
MLH1
HNPCC3
APC...
22
Medical progress and insurers
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
23
Munich Re
Medical progress and insurers
Risk adjustment by genetic testing
100 %
6% get CC, i.e. have a 100% risk
CC risk %
100% have a 6% risk
94% do net get CC, i.e. have a 0% risk
0%
population %
100 %
24
Munich Re
Medical progress and insurers
Risk adjustment by genetic testing
100 %
6% get CC, i.e. have a 100% risk
An ideal test depicts reality
exactly
CC risk %
100% have a 6% risk
94% do not get CC, i.e. have a 0% risk
0%
population %
100 %
25
Munich Re
Medical progress and insurers
Risk adjustment by genetic testing
100 %
10%
high
CC risk %
20%
medium
70%
low
0%
population %
100 %
26
Munich Re
Medical progress and insurers
Genetic testing might save colonoscopies
population
10%
20%
70%
cancer risk
high
medium
low
frequent
normal
no
colonoscopy
⇒ 19.2 Mio colonoscopies could be saved ⇒ 2.9 bio. €
27
Medical progress and insurers
Munich Re
Chance by genetic tests
28
Munich Re
Medical progress and insurers
Alteration by Disease
Colon Cancer
se
r
u
o
C
Clinical
Treshold
of
on
l
Co
er
c
n
a
C
Death
w
Ne tics
ne
Ge
Birth
New
Genetics
Lifetime
29
Munich Re
Medical progress and insurers
Further benefits of genetic testing
Predictive genetic testing
Pharmacogenetic
testing
(reduction of adverse
effects)
Diagnostic
genetic testing
(avoidance of
over treatment
Drug discovery
(new treatment
target/principles)
Monitoring of
treatment
(better compliance)
30
Medical progress and insurers
Munich Re
Conclusions
31
Medical progress and insurers
Munich Re
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