Estimation the medical cost of multiple sclerosis in Iran; 2019–2020

Multiple sclerosis (MS) is an inflammatory disease of the central nervous system. MS has an unknown etiology and is therefore classified as a complex disease [1]. It is the most common neurological disease among young adults [2], and according to latest studies, as of 2020, 43.95 per 100,000 population worldwide were affected by this disease [3]. In Iran, the prevalence of MS in 2017 was estimated 62,000 populations and age-standardized rate per was 69.5 per 100,000 population [4].

MS clinically divided into several subgroups, that the most important of which are Relapsing-Remitting (RR) [5], primary progressive (PP) [6] and secondary progressive (SP) [7]. According to available statistics, about 85% of MS cases in the world are relapsing-remitting [8]. The most common type of MS in Iran, which accounts for approximately 88% of cases, also is the RR type. RRMS may become a SPMS type after 10 to 15 years [9].

The disease affects a wide range of men and women, mainly young people, such that the average age of disease onset is estimated to be about 30 years old [10]. There are also various evidences in terms of mortality and disability of MS patients. According to the latest review studies in 2016, 18,932 people worldwide died due to MS, and the number of disability-adjusted life years (DALYs) was estimated [11] at 115,148 units [12]. In Iran DALYs was estimated at 29.1 per 100,000 population in 2017 [4].

There are variety of interventions are used to treat MS patients and includes preventive and supportive cares, rehabilitation and symptoms management [11, 13]. The use of disease modifying therapies (DMTs) is a common type of interventions. These Medications are used to change the course of the disease, treat relapses, and manage symptoms [14]. In addition to these interventions, rehabilitation services also ultimately leads to reducing fatigue and improving the patients’ quality of life.

Due to the debilitating nature of this chronic and progressive disease which affects people during his productive life years, the economic burden of MS is considerable [15], which a large part of this economic burden is borne by the patients themselves [11]. Based on latest studies the catastrophic health expenditure of MS patients in North-west of Iran was estimated at 54 and 44% of household with MS patients experienced poverty because of out of pocket payments (OOP) [16].

It also has high economic cost for society, the health care system and the family. This cost share is especially important for insurance companies. Since nearly 80% of the medications used in Iran are covered by insurance organizations, it increases the financial burden imposed on insurance organizations. Many special patients, including MS (90%), are exempt from the deductible. Therefore, this type of disease puts more financial pressure on insurance organizations and the country’s health system. In addition to the increase in the covered population, increase in the average number of visits, increase in drug prices, gradual elimination of drug subsidies, the entry of new medications into the market and the use of expensive drugs and lack of strict control of prescriptions should be considered. This indicates a double burden on insurance companies to cost reimbursement [17].

The economic burden of diseases is a valuable indicators in health systems, so the economic burden studies is very necessary and important to identifying the economic dimensions of the disease current situation in order to applying the best strategies. Based on the explanations provided regarding the various dimensions of the issue, and considering that a comprehensive study on estimating the costs and economic burden of MS in Iran has not been conducted, the present study aimed to measuring the total MS medical cost divided to different sectors and investigating OOP and insurance share of MS medications in Iran in 2019–2020 based on comprehensive national data. Considering the major share of medical cost in total MS economic burden and calculating different of its dimensions, present study can provide good evidence to understand the overall dimensions of the issue and also identification the best strategy to control the effects of the disease in the future. Also, considering that the country’s health system and insurance organizations are directly affected by this issue, results of present study can be effective in applying more detailed rules and guidelines to promote efficiency and equity in this regard.

Findings from calculations of the medical cost of MS patients in Iran for 2019–20 are presented in the form of 3 separate sections including the cost of MS medications, the cost of determining and diagnosing the risk of disease and the cost of rehabilitation services.

We aimed to estimate the medical cost of MS in Iran using comprehensive national data of 2019–2020. Findings of the study showed that in general, in the study year, the medical cost of MS, which accounted for the largest share of the total economic burden of the disease [21] was estimated at $238,124,160.1 (10,001 Billion IR Rial), which is a significant figure.

According to the findings, the largest share of the economic burden of MS was allocated to the medications, followed by rehabilitation cost and the cost of determining and diagnosing the MS risk. Blahova et al. (2012) estimated the total annual cost of MS in the Czech Republic in 2012 at around €12,272, which direct medical cost accounting for more than 50% of the total economic burden [22]. In return, Blozik et al. (2017) reported an estimated cost of MS patients in Switzerland of $4 million in 2010, of which 38% was direct medical cost and 67% was non-medical direct cost [23].

The cost of medications used to treat MS was estimated at about 80% of the total medical cost of the disease. Among the 9 specific and general MS medications studied in this study, the highest share of cost with amount equivalent to $112,560 thousand was allocated to beta-interferon 1A and 1B, which were very different from other drugs in this regard. Cyclophosphamide, on the other hand, had the lowest share of the cost at just $12.7 thousand.

Hasnat et al. (2020) in their study, which aimed to examine the increasing cost of MS in several selected countries, reported that the share of pharmaceutical cost in the economic burden of MS was 55% [21]. The findings of a cross-sectional study in Kuwait in 2018 showed that 89% of the medical cost was allocated to medications [24].

Findings of the study on the cost of rehabilitation services showed 19% share of the total medical cost of MS patients, which is a significant amount. According to study by Svendsen et al. (2018) in Norway and Ponzio et al. (2014) in Italy, the cost of rehabilitation services for MS accounted for a significant share of total medical cost [25, 26].

Rehabilitation costs include various services such as physiotherapy, occupational therapy, speech therapy and sub-acute hospitalization, which are used intermittently in different groups of the disease severity to improve the symptoms of the disease and improve patients’ quality of life. Based on the findings of present study, it is clear that the highest cost of rehabilitation services are allocated to groups with more severe disease and patients with higher EDSS scores also create more cost due to the need to repeat more rehabilitation courses. Findings of the Ponzio study in 2014 and Imani et al. (2020) also showed that with increasing disease severity and patients’ EDSS score, the economic burden of the disease and especially rehabilitation cost increases [25, 27].

Among the MS rehabilitation services, physiotherapy services have the largest share of cost in Iran at all levels of the disease. This may be due to higher access to these services as well as the existence of insurance coverage for these services. However, speech therapy and occupational therapy, firstly, are not in optimal position in terms of accessibility and, secondly, they do not have insurance coverage. In this regard, the lack of distributive equity in access to rehabilitation services in Iran is also important.

The point about rehabilitation services is increasing the share of these services in managing the statues of MS patients during the past years, so that with the expansion of rehabilitation service centers, increased physicians’ knowledge of these services and also prove the efficacy of these interventions on improving the patients disease status, especially those with more acute conditions, had increased the use of these services. This is also confirmed by the Hasnat et al. study [21].

Regarding Iran, it should be noted that according to experts and the distribution of patients in terms of disease severity levels, about 70% of MS patients need parts of rehabilitation services in their disease periods, while according to the results of the present study, the utilization rate of rehabilitation services is lower. Accordingly, it should be noted that in case of higher access and proper utilization of these services, the cost of this sector will be much higher. On the other hand, the calculations in this study are based on public sector tariffs, while part of the services are performed in the private sector with higher cost.

Among the MS medical cost, the lowest share was allocated to the determining and diagnosing of disease risk services, including imaging cost, periodic visits and laboratory services. It accounted for about less than 1% of total medical cost. In the Hasnat study, these cost were estimated at 3% of the total direct medical cost of MS [21]. An important point in this category of cost is the share of more than 50% of MRI services among the total cost of determining and diagnosing disease risk services, which should be highly considered. This is due to the higher unit cost of MRI as well as the frequency of repetition of this service during the disease courses in patients with MS.

In general, the results of the study showed that the medical cost of MS in the country is significant and is increasing due to the spread of the disease, increased diagnosed patients and new interventions and medications. According to the the results of a study by Fattahi et al. (2021), the DALYs of MS in Iran has increased from 9098 to 26,183 unit between 1990 and 2017 [4]. On the other hand, the highest amount of these costs, as mentioned, is allocated to direct medical cost, especially medication and rehabilitation services cost, which have a significant burden on the country’s health care system and also uncovered population [15, 27]. The latest studies in Iran confirmed our results. Results of study by Imani et al. (2020) showed that the mean annual cost for MS patients in Iran with the mean EDSS score of 3.14 is $2321.94 [27]. The annual cost incurred divided with mild, moderate and severe levels of disease were 1998.05, 3280.30 and $2856.25, respectively [27].

An increasing trend in the economic burden of this disease is also predicted in the whole world. Nana et al. (2017) in their study, which simulated the epidemiological situation and economic burden of MS in Canada, estimated that by 2031 the total economic burden of MS health services will reach $2 billion [28].

Since the middle of the last decade, with the development of new MS drugs and proving the effectiveness of rehabilitation services for these patients, there have been significant advances in the effectiveness of interventions to improve patients’ quality of life. This shows that the implementation of control policies and careful planning should be done for this group of patients, which in addition to increasing the patients’ quality of life, which in itself reduces the cost of lost production, the burden on the health care system and insurance organizations should also be monitored in order to maintain and complete insurance coverage.

Results of calculating the medical cost of MS in Iran in 2019–2020 showed a significant burden on the Iranian health care system and patients, among which the medication cost had the largest share, which requires serious attention of health system policymakers in order to control the increasing cost along with paying attention to completing insurance coverage of interventions such as rehabilitation services for increase efficiency and social justice.