What Are the Return on Investments for the Meds that Treat & Prevent COVID-19?

With two potential new medications to treat COVID19 infections on the horizon, I thought I’d do an estimate of the financial return on investment for the various treatments and compare that to the ROI for the vaccines. Here goes:

Average COVID19 Hospitalization Costs

To do the back of the envelope ROI math, we’ll need to start with what an average COVID-19 hospitalization costs for unvaccinated persons. CMS found that the Average Medicare payment per fee-for-service COVID-19 hospitalized Medicare beneficiary is $24,033 (see this COVID19 Data Snapshot Public Release). According to Fair Health, an independent nonprofit focused on enhancing price transparency in healthcare, the average charge for COVID-19 hospitalization in Arizona is $361K for complex patients and $42K for non-complex patients. To be conservative, let’s go with the number from CMS…  $24K.

Return on Investment for Regeneron

Let’s start with Regeneron, the monoclonal antibody treatment for which governor Ducey is such an enthusiast. Regeneron’s clinical trial found that their hospital-administered monoclonal antibody treatment reduces COVID-19-related hospitalization or deaths in high-risk patients by about 70%.

The federal government pays Regeneron Pharmaceuticals $2,100 per treatment course for the drug. Because it needs to be administered in a clinical setting, the actual full cost of a treatment course is about $10,000.

If Regeneron were administered to 1,000 patients at high risk of a bad outcome and it’s truly 70% effective at preventing hospitalization, Regeneron would bring down hospital costs from $24M to about $7.2M, a hospitalization savings of about $16.8M. Regeneron costs about $10M to administer to 1,000 patients… so we need to add that in to the costs too.  At 70% effectiveness, the ROI for Regeneron would be about 1.6. In other words, for every dollar we spend on Regeneron administration to patients at high risk of hospitalization we only get $1.60 back in reduced hospital costs for COVID patients.

Editorial Note: Regeneron is being over-administered in Arizona. Low-risk persons are routinely receiving treatment with Regeneron because of the financial incentives established by Governor Ducey in this Executive Order. The ADHS is reinforcing the over-administration of Regeneron by peppering their letters to hospitals (which they regulate) encouraging Regeneron administration. Because this very expensive treatment is routinely being administered to low-risk persons, the ROI for Regeneron is actually below 1.

Return on Investment for the New Antivirals

Both Merck and Pfizer have stated that they have developed antiviral pills that are about 90% effective at preventing hospitalization from a COVID-19 infection if taken early in the infection. Both companies have asked the FDA for emergency use authorization of their new medications, but neither have published their trial data in a peer-reviewed journal.

The FDA is holding a meeting of their Antimicrobial Drugs Advisory Committee Meeting today to discuss Merck’s antiviral (molnupiravir) pills for treatment of COVID-19. View the evidence published by the FDA on this application here.

The use of Merck & Pfizer antivirals haven’t been authorized yet, but the federal government has already contracted with Pfizer $529 and Merck $700 per treatment course.

Let’s assume that the materials the FDA just posted are correct, and Merck’s pills are 90% effective at preventing hospitalization or death among patients that are high-risk for hospitalization. If either of these medications were administered to 1,000 patients that would have otherwise been hospitalized (and the meds are really 90% effective) the drugs would bring down hospital costs from $24M to about $2.4M, a savings of about $21.6M.

But…  the drugs will cost an average of $600 to administer to each person ($600,000 total for 1,000 people), so at 90% effectiveness and $600 per treatment regimen, the ROI for these antivirals would be about 40 if given only to patients at high-risk for hospitalization. In other words, for every dollar we spend on the future Merck or Pfizer antiviral pills we’d get about $40 back in reduced hospital costs among high-risk COVID patients.

Return on Investment for Vaccines

The federal government’s contract with Pfizer, Moderna, and Johnson & Johnson is about $20 per vaccine dose. There’s also an administration cost for the vaccine. For example, Medicare reimburses providers $40 per COVID19 vaccine administered.

Putting those costs together, a 2-dose series of the mRNA vaccine costs the taxpayers about $120.  The mRNA vaccines are more than 95% effective at preventing hospitalization, but to be conservative, let’s say it’s just 90%.

When either of the mRNA vaccines are administered to 1,000 people who would have otherwise become infected and hospitalized (even at only at 90% effectiveness), hospital costs would go down from $24M to about $2.4M, a savings of $21.6M.

The vaccines cost an average of $120 to administer to each person ($120,000 total for 1,000 people), so at 90% effectiveness and $120 per full vaccination the ROI for the mRNA vaccines would be about 180. In other words, for every dollar we spend on vaccinating folks with the mRNA vaccines we’d get $180 back in reduced hospital costs for COVID patients. (Note: the ROI is actually higher than 180 because vaccines not only prevent bad outcomes but also reduce community spread).

Editorial Note: Vaccines are far and away the most cost-effective way to save lives and reduce healthcare costs. The President is doing what he can to implement policies that will drive up vaccination rates via the new OSHA and CMS regulations. Governor Ducey and Attorney General Brnovich, on the other hand, are doing what they can to stop the White House proposals and are actively taking steps to prevent vaccination requirements.

A true fiscal conservative would look at the 180+ ROI for vaccines, compare that to the 1.6 ROI for Regeneron and do everything he or she could to get more people vaccinated.

Omicron Highlights the Importance of International Vaccine Equity

The Omicron variant highlights the importance of international vaccine equity. Until we get a critical mass of the world vaccinated the SARS CoV2 virus will have ample opportunities to create new more transmissible variants, perhaps even a variant that evades previously acquired immunity from vaccines and infection. We don’t know for sure whether Omicron is either of those things yet- but it might be. The answer to preventing new variants is and always has been international vaccine equity.

At an early stage during this pandemic, it quickly became apparent that to end this global crisis we don’t just need COVID-19 vaccines, we also need to ensure that everyone in the world has access to them. This triggered global leaders to call for a solution that would accelerate the development and manufacture of COVID-19 vaccines, as well as diagnostics and treatments, and guarantee rapid, fair and equitable access to them for people in all countries.

AzPHA COVAX Presentation November 29 2021

That organization is called COVAX. Up until January 2021 (after President Biden took office) the U.S. was not a member of COVAX, but we did join the organization on the first day of the Biden Administration.  Extraordinary, don’t you think?  The country with the highest GDP in the world and a leading democracy wasn’t a member? Well, that changed on 1/21/21 along with the U.S. rejoining the World Health Organization.

COVAX brings together governments, global health organizations, manufacturers, scientists, private sector, civil society and philanthropy, to provide equitable access to COVID-19 vaccines. It is the only truly global solution to this pandemic because it is the only effort to ensure that people in all corners of the world will get access to COVID-19 vaccines once they are available, regardless of their wealth.

For lower-income funded nations, who would otherwise be unable to afford these vaccines COVAX is the only viable way in which their citizens will get access to COVID-19 vaccines. Ninety-two low- and middle-income economies are eligible to participate in receiving vaccine through COVAX AMC… here is the list of countries authorized to receive vaccine under the program.

Many changes including more finding, donations and release of intellectual property need to happen before COVAX can live up to their mission. Visit this AzPHA PowerPoint for more details:

AzPHA COVAX Presentation November 29 2021

Arizona Child Fatality Review Program | Twenty-Eighth Annual Report

Arizona Child Fatality Review Program | Twenty-Eighth Annual Report

Firearm Deaths up 41%; Arizona’s Pediatric COVID19 Death Rate 250% Higher Than the National Average

Back in the mid 1990’s the AZ State Legislature established the Arizona Child Fatality Review Program to evaluate every child death and provide evidence-based policy recommendations to prevent child deaths.

Over the years many policy and operational interventions came out of these reports, from safe sleep to new seat belt laws for kids. The goal of each year’s report by conducting a comprehensive review of all child deaths and make policy recommendations to prevent as many as possible.

The Arizona Child Fatality Review Program published their 28th annual report last week. In 2020, 838 children died in Arizona, an increase from the 777 deaths in 2019. The leading causes of death were prematurity, congenital anomalies, motor vehicle crashes, poisonings, and firearm injuries. Prematurity was the most common cause of death for neonates (infants less than 28 days old) while suffocation was the common cause of death among infants 28 days to less than 1 year of age.

The accidental injury death rate increased 31% from 2019 to 2020. The top causes of accidental death were car crashes, poisonings, and suffocation. A child protective services history with the family, substance use, and poverty were the most common risk factors.

The firearm injury mortality rate increased 41% while car crash death rate increased 54%. The most common risk factor contributing to a firearm injury death was access to firearms. Eighty-six (86%) of firearm deaths involved a pistol (with the child’s parent often being the owner of the pistol).

Most of the Sudden Unexpected Infant Deaths (SUIDs) were due to unsafe sleep environments. Unsafe sleep environment was a factor in 100% of these deaths while objects in sleep environment was a factor in 92% of SUIDs.

The death rate from COVID19 among kids was 250% higher in Arizona than the rest of the country (due to Governor Ducey and former Director Christ’s hostility toward evidence-based COVID19 mitigation measures). The direct COVID-19 mortality rate in Arizona was 0.73 deaths per 100,000 children while the national direct COVID-19 mortality rate was 0.27 per 100,000 children.

The most important parts of the report are the policy and operational recommendations that begin on Page 82 of the report.

We encourage every public health professional to review the recommendations before the legislative session and bookmark this report- as this is a must-have document for public health professionals committed to evidence-based policy.

Dr. Joe Gerald’s Weekly Epidemiology & Hospital Occupancy Report

Dr. Joe Gerald’s Weekly Epidemiology & Hospital Occupancy Report

From Dr. Gerald:

“Bad news continues to compound. Cases, hospitalizations, and deaths continue to increase locally. Interestingly, our current case rates our identical to those of the same calendar week last year. While transmission is expected to rise for the remainder of the holidays, let’s hope it is not as brisk as last year. In a small glimmer of good news, transmission is shifted just a bit towards children and away from adults. Also, influenza cases in Arizona trail historical averages, so no evidence of a ‘twindemic’ yet.

Unfortunately, the WHO named another Variant of Concern this week, the Omicron variant. Identified by South African authorities it has multiple mutations to its spike and domain binding proteins which gives rise to concerns about increased transmissibility and immune escape. 

Currently, there is not enough information to understand what impact it is going to have on the pandemic’s trajectory. Anyway, we’ve got our hands full in Arizona with the Delta variant. What’s needed hasn’t changed a bit: get vaccinated, get tested, wear a mask, and avoid high risk exposures (e.g., prolonged indoor exposure where others aren’t masked). I’ve upgraded from cloth to KN-95’s myself and got my third shot booster! Hopefully, others will do the same.”

View the Full Weekly Report

Navajo Nation Goes Smoke Free- Even the Casinos

From Navajo Nation President Nez:

In case you haven’t heard, the Navajo Nation recently banned all commercial tobacco use, including smoking and vaping, in enclosed and indoor areas on the Navajo Nation, including casinos

Patricia Nez Henderson (our incoming President) was instrumental in passage of this legislation, as were other SRNT members and many members of the Navajo Nation. It is another great example of science, advocacy, and public policy working together to advance public health.

For additional information on the new law, here are a few links:

Congratulations to the Navajo Nation and thank you to all of those who worked for years to make this happen!

Have a Happy & Safe Thanksgiving Everybody! 

As Hospitals Enter Contingency Standards of Care, Brnovich Tries to Undermine CMS Vaccine Requirements

Twelve states including Arizona have filed a lawsuit in a federal district court in Louisiana challenging the Centers for Medicare & Medicaid Services interim final rule that mandates COVID-19 vaccines for workers at Medicare/Medicaid participating facilities by January 4.

Attorney General Brnovich argues that the CMS rule exceeds their statutory authority, violates the Tenth Amendment, and that the rule is arbitrary and capricious. For once, the suit doesn’t blame refugees and immigrants.

This lawsuit follows the complaint filed last week by a different group of states in a U.S. district court in Missouri also challenging the CMS interim final rule on similar grounds. For more information about the CMS rule, please refer to AzHHA’s Summary and CMS’s FAQs.

Contingency & Crisis Standards of Care: A Refresher

As pressure continues to mount in Arizona’s hospital system, I thought it would be good to provide a little summary in plain language about what those words mean.

Hospitals generally operate under conventional standards of care. That just really means that they’re providing patient care without any change in daily practice.  Every cold and flu season hospitals face surges in demand (like the week after Christmas and off and on during January and February in Arizona). But hospitals are still operating under conventional care standards.

They juggle space and staffing and may temporarily ask ambulances to go to alternate facilities or accelerate the discharge of healthy patients. Staff may be asked to work in a different part of the hospital than they’re used to (for example a surgeon might be asked to work in the ER) but everyone is still working in their bounds of expertise, under normal staffing ratios, and following standard protocols.

As hospitals transition to contingency standards of care (where AZ is operating right now) hospitals change their practices and do everything they can to maintain the standard level of care. 

For example, under contingency care hospitals may repurpose rooms of the hospital for different kinds of clinical care than usual, like converting surgical rooms for emergency services or using recovery rooms as a makeshift intensive care unit. Doctors, nurses, and respiratory therapists make different decisions about what therapies to use because of resource shortages too. Staffing rations may be altered, with nurses on general ward and ICU floors managing more than the standard number of patients.

Practitioners may start conserving supplies by, for example, not providing precautionary oxygen to patients who under normal circumstances would receive it, but who can survive and recover without it.

Patients are transferred between hospitals as they try to level out patient loads when they have periods of time. Some hospital systems like Banner are large enough to do interfacility transfers using their own resources and data. Others will need to contact the ADHS Surge Line, where transfers can be facilitated.

Hospitals restrict non-emergency procedures. This isn’t something hospitals like to do because patients really need these important procedures and because general surgery and elective procedures contribute much to the financial bottom-line. Nevertheless, these procedures will begin to be postponed or canceled. 

Hospitals change their admission decisions. For example, persons presenting in the emergency department may be sent home when, under normal circumstances, they would be admitted. Likewise, a patient that would normally be admitted to an Intensive Care Unit (with robust staffing rations) might instead be placed on a general ward bed.

Hospitals change their discharge decisions. People that have been admitted and who would normally stay for a couple more days will be discharged rather than observed. In some cases, persons that are in the ICU may be discharged directly to home rather than admitted to a general ward bed. Others will be discharged to a skilled nursing facility rather than a general ward hospital bed.

When the system becomes totally saturated, as may be the case at some point in December, hospitals will ask the ADHS to allow them to operate under Crisis Standards of Care

Crisis Standards of Care” is basically a protocol for making healthcare decisions when the system can’t provide all of the care that everybody needs because the needs outstrip the resources. Ethics panel discussions will be held to make difficult decisions regarding who will get care and who will not.

Under Crisis standards hospitals need to make even more substantial changes to the way they provide care. For example, staff are asked to practice outside of the scope of their usual expertise. Supplies are reused and recycled. In some circumstances, resources may become completely exhausted.

Core strategies that get used under Crisis standards include substitution, adaptation, conservation, reuse, and reallocation in the areas of for oxygen, medication administration, IV fluids, mechanical ventilation, nutrition, and staffing.

The Crisis Standards of Care also provides a protocol to help healthcare providers objectively decide who gets care when resources don’t allow everyone to get treatment.  These blog posts flesh it out:

Here’s a link to the ADHS Crisis Standards of Care Planning Document. It’s 141 pages, but the real heady stuff is on pages 29 through 38 where it discusses the scoring system to prioritize which patients will get treatment and which will not and how to ration care to all patients when resources are outstripped by demand.

The ADHS also has an Addendum to the report called Arizona Crisis Standards of Care Addendum April 2021.

The Arizona Crisis Standards of Care Addendum is COVID specific and outlines specific triage protocols that hospitals should use to decide who gets care and who doesn’t. Once we get to Crisis Standards of Care (likely to happen sometime in December) doctors will be using this document to decide who gets for example the last extracorporeal membrane oxygenation (ECMO) machine or who needs to be pulled off an ECMO to make room for a patient more likely to survive.

Pretty grizzly stuff… but it will probably become a reality again this December due to the decisions that Governor Ducey made last summer to refuse to use policy interventions to encourage vaccination and universal indoor masking.

Arizona Hospital Bed Availability At It’s Lowest Point During the Pandemic

View Dr. Joe Gerald’s Weekly Epidemiological & Hospital Occupancy Report

The situation in Arizona hospitals is becoming increasingly dire. The number of available ward beds are now at the lowest point they have been during the pandemic. Access to care will continue to be restricted in the face of staff shortages in inpatient and outpatient settings. There’s undoubtedly primary and probably secondary triage happening already, and many Arizona hospitals are likely already operating under Contingency Standards of Care.

Read More About Contingency & Crisis Standards of Care

As of November 17th, 2403 (27%) of Arizona’s 8774 general ward beds were occupied by COVID-19 patients, a 14% increase from last week. Thirty-four percent (34%) of Arizona’s 1782 ICU beds are occupied by COVID-19 patients, a 12% increase from last week

COVID-19 hospital occupancy is holding steady and will likely exceed 25% of all beds in the general ward and 30% of beds in the ICU for the remainder of the year. Because ADHS uses licensed beds in the denominator of their occupancy statistics rather than staffed beds- there’s less room at the inn than meets the eye. 

Arizona also continues to experience high levels of community transmission. Test positivity also remains high reminding us that test capacity, accessibility, and/or uptake is inadequate. Increasing case rates among older, highly vaccinated groups serves as a warning that major behavioral shifts and/or waning immunity could result in future increases in not only cases but also hospitalizations.

New cases were being diagnosed at a rate of 347 cases per 100K residents per week. The rate was increasing by 13 cases per 100K residents per week. Navajo, Greenlee, and Gila counties have case rates nearing their previous pandemic highs.

Meanwhile, Governor Ducey & Interim Director Herrington continue to nonchalantly shrug their collective shoulders.

View Dr. Joe Gerald’s Complete Weekly Epidemiological & Hospital Occupancy Report

Who’s At Highest Risk for a Bad Breakthrough Case?

This study in the British Medical Journal analyzes who is at highest risk of death even after having been vaccinated

The authors of this article use a risk prediction model to stratify risk of severe covid-19 outcomes among people that are already fully vaccinated. They found that the dominant risk factors for breakthrough hospitalization and death are people with:

  • Down syndrome
  • Kidney transplantation
  • Sickle cell disease
  • Nursing home residents
  • People undergoing chemotherapy
  • People with a recent bone marrow or solid organ transplant
  • People with HIV/AIDS, dementia, Parkinson’s disease, neurological conditions, and liver cirrhosis.

Everybody in all of these categories should get a booster shot 6 months after they were fully vaccinated.

Climate Change & the Federal Build Back Better Act (BBBA)

Democratic Leadership in the House started last week with a goal of passing the BBBA and the bipartisan infrastructure bill by the weekend. They ended the week with the bipartisan infrastructure bill passed but a vote on the larger Build Back Better Act is on hold until this week or later. 

The initial regular infrastructure bipartisan bill will be signed into law this coming week, which is a good thing. This initial infrastructure bill does little to transition to U.S. to carbon free energy sources and doesn’t do anything for the human infrastructure pieces like making childcare more affordable etc.

I’ll keep my eye out for critical control points this week so we can do what we can to keep up the pressure to seal the deal on the Build Back Better Act. In short, the initial bipartisan infrastructure package that will be signed this coming week is not a climate bill! We need the BBBA bill to pass, which does have several important climate change provisions built into it.

We need to reach priority members of congress this week like Senator Sinema and Kelly to shore up support for the Build Back Better Act. I’ve had conversations with their office staff in the last couple of weeks about climate and prescription drugs.

If any of you have relationships with the staff, I urge you to make appointments and make your voice known- and make sure to mention that you are a member of AzPHA. Here’s a toolkit to reach moderate members. 

 Climate Change Talking Points to help you:

  • To fight the climate crisis, create millions of new good-paying clean energy jobs, and build the foundation of an equitable and thriving clean energy future: we need the Build Back Better Act.
  • The bipartisan infrastructure bill that just passed makes no meaningful reductions in carbon emissions, and commitments on other key environmental justice and climate issues.
  • Key parts of the bipartisan infrastructure bill (like electric vehicle charging stations, power infrastructure, and climate resilience) can only be unlocked if passed with the complementary, transformative climate investments in BBBA.
  • Climate action is the only fiscally responsible choice. Climate-fueled disasters are already costing us hundreds of billions of dollars every year—Hurricane Ida alone resulted in more than $64.5 billion in damages across the country—we can’t afford to wait to act any longer.

Senator Sinema Contact Info: @SenatorSinema

3333 E. Camelback Rd, Suite 200
Phoenix, Arizona 85018
Phone: 602-598-7327

317 Hart Senate Office Building
Washington D.C. 20510
Phone: 202-224-4521

Senator Kelly Contact Info: @SenMarkKelly

2201 E. Camelback Rd
Suite 115
Phoenix, AZ 85016
Phone:  602-671-7901

Hart Senate Office Building
Suite 516
Washington, DC 20510
Phone:  202-224-2235

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