Their findings indicate that an insurance program that provided coverage of all three treatments-primary, secondary, and tertiary- has the largest overall impact on population health and is cost-effective relative to the status quo of non-coverage. The challenge, of course, is financing such a large increase in coverage. This is especially true in countries like India which currently spends relatively little on healthcare as a percentage of GDP. If providing full coverage is unattainable for the country given the initial high cost and resources needed, providing less is still more cost-effective than the status quo. The authors recommend providing primary prevention and tertiary care.
“The findings from this study show that providing universal coverage for cardiac care will not only save lives but is also good value for money even in resource constrained environments,” said Sood, who is also the Vice Dean for Research at the USC Sol Price School of Public Policy.
Why Look at Cardiovascular Disease in India?
The treatment of cardiovascular disease factors has improved dramatically in higher-income countries as better treatments options and pharmaceutical therapies have been introduced. Yet, low- and middle- income countries are experiencing a growing rate of cardiovascular disease. Furthermore, outcomes from these disease events are worse in comparison to high-income countries.
This has lead policymakers and experts to consider the expansion of government health insurance coverage to include treatment for cardiovascular risk factors and events. Yet, the cost burden of the additional health care coverage remains a burden for these government programs.
Arecent community-based evaluation
of a social insurance program providing tertiary care in India by Sood and his colleagues showed significant reductions in cardiovascular mortality among patients receiving the coverage in comparison to the individuals in regions without coverage. Though several low- and middle-income countries offer government coverage for tertiary care to mitigate its high costs for low-income individuals, it is unclear if this is the best strategy.
Is Providing Cardiovascular Disease Coverage in India Cost-Effective?
Sood and his coauthors used simulation modeling to predict the health and economic implications of different coverage scenarios among Indian adults. They presented their results in terms of disability adjusted life years (DALYs) which measure the overall disease burden expressed as the number of years lost due to ill health, disability or early death. They looked at number of DALYs averted in the population and the relative cost per capita of various combinations of primary, secondary and tertiary coverage to find the most cost effective solution to coverage.
The researchers found that a national insurance program that provided comprehensive coverage –all three levels of care- would be most cost effective, even taking into account plausible scenarios of coverage effectiveness and adherence to therapy. This scenario would avert 6.8 million DALYs per year at a cost of roughly $1,300 per DALY averted versus the status quo of no coverage. But despite the cost effective label, covering all three cardiovascular treatments will be costly: in India, a fully universal plan would generate a total societal cost of $13.6 billion Rs, which is far larger than the current $4 billion government healthcare budget in place currently.
In cases like this one, the authors offer an alternative: coverage of primary prevention only. In fact, according to the results, coverage of primary prevention should be foundation of any policy for universal health coverage for cardiovascular disease. They found that coverage of primary prevention remained cost effective even if adherence to therapy was low and coverage did not result in significant access to care.
What are the Policy Implications?
These results provide evidence to support the expansion of government social insurance programs in low- and middle-income countries like India. The findings of cost-effectiveness substantially inform policy conversations for countries looking into expanding coverage strategies and show the benefits of such expansions on the overall economy.
Given the high rates of return, Sood and his colleagues note that, “primary prevention alone is only sensible in environments where coverage of all three treatments is simply unaffordable.”
Said Sood, “India needs to improve the health of its citizens and providing universal coverage for cardiac and possibly other diseases is an important step in this direction.”