Afschin Gandjour raises an interesting point that we did not explore in our paper [1]: the discrepancy between the higher return on investment (ROI) we calculated for innovations for coronary heart disease following acute myocardial infarction, type 2 diabetes, and stroke relative to the overall ROI to Medicare for these same diseases. In his attempt to account for this inconsistency in our findings, he notes (correctly) that the cost-effectiveness analyses (CEAs) of specific treatments do not incorporate the costs of overuse, rather they consider only appropriate care. Furthermore, he suggests that substantial treatment overuse of medical care in the United States may be the main reason for its relatively lower ROI. This could be, but we do not think there is sufficient evidence to draw such an inference for the following reasons.

First, the technologies we chose to review for ROI were selected as being the major innovations over the past 20 or so years and for which CEAs had been published. So each technology was a special, high profile case in contrast to all of medical care for the diseases in question. We had no expectation that individually or collectively they would be indicative of overall medical care. Second, the ROIs for the technologies were not focused on the Medicare population of more than 65 years old. Third, whereas overuse of medical care in the elderly population undoubtedly occurs, so does underuse, including incomplete prescribing and poor adherence to medications.

Thus, we would suggest that Dr Gandjour’s comments are speculative at this point. ––Bryan R. Luce, PhD, MBA, United BioSource Corporation, Bethesda, MD, USA.

Reference
1 Luce BR, Mauskopf J, Sloan FA, et al. The return on investment in health care: from 1980 to 2000. Value Health 2006;9:146–56.