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  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 . 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 .
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% . The findings of a cross-sectional study in Kuwait in 2018 showed that 89% of the medical cost was allocated to medications .
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 .
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 . 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 . 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 . The annual cost incurred divided with mild, moderate and severe levels of disease were 1998.05, 3280.30 and $2856.25, respectively .
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 .
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.
The most important limitation of this study was the lack of access to specific separate prescription and cost data for MS patients in Iran. This problem was largely eliminated by adapting prescriptions to graphs, diagnostic tests, and MS specific drugs for all IHIO prescriptions with the help of clinical specialists. Another point was the lack of access to data from other insurance organizations, including social security insurance, which, considering the sample size of approximately 50% of IHIO data, tried to make a relatively accurate estimate of whole Iran. Another Important limitation was the loose of related data from who were not register in national Plan and IHIO which leads to under estimate of cost calculations.
Regarding rehabilitation services, as mentioned, due to the lack of centralization of registration and the lack of insurance coverage of major services in Iran, the data are probably limited in the number of cases referred to private centers, which does not seem to have a significant share. In this study, lost production cost and non-medical direct cost are not estimated. In future studies, with access to appropriate data, this part of the cost will be calculated, which in addition to the medical cost calculated in this study can provide a more comprehensive picture of the economic burden of MS in Iran.