“Hope.” That’s what the 74-year-old veteran told me when he was approved to receive lecanemab, a groundbreaking new therapy for Alzheimer’s disease. “I feel like I have it again.” As a neurologist and founding member of the San Francisco VA’s Advanced Alzheimer’s Therapeutics group, I’ve found that moments like this capture both the promise and peril medical innovations bring to my patients.
With the advent of these therapies, I can finally offer something essential to my patients: optimism. These treatments aren’t perfect — the data is nuanced, and the side effects can be significant — but for the first time, we may be able to slow cognitive decline in individuals with Alzheimer’s disease. In neurology, where degenerative conditions like ALS and Parkinson’s often feel like battles fought by the inches, this advance is nothing short of revolutionary. In some ways, these therapies mark a chance to redefine the very nature of aging itself.
But this progress comes at an enormous expense. These drugs will cost Medicare $3.5 billion in 2025 alone, a figure that is only expected to rise in subsequent years. How will our fragmented health care system absorb such an influx of spending and resource utilization? And most controversially, who “deserves” access to these treatments? These questions have only become more pressing under an administration threatening to slash Medicare funding.
A growing tension is now developing between my responsibility as a neurologist — focused on the individual — and my duty to consider the broader public welfare. There’s no simple resolution to this conflict, but ignoring the complex interplay between these drugs and our rapidly evolving health care system risks compromising their potential.
Conversations With Patients
We recently studied patients considering lecanemab, and their willingness to take the drug often surprised us. Despite the burdensome monitoring requirements (MRIs, PET scans, blood work) and potentially dangerous side effects (brain bleeds, brain swelling), many patients see these treatments as the best chance to hold on to their autonomy for just a little while longer.
One patient told me, “If I get to spend a few more meaningful months with family before my brain goes kaput, it’s worth the risk.” Another said, simply, “I’m worth saving.” In turn, this desire to ease my patients’ suffering often overrides my ability to think about the bigger picture.
However, the numbers are hard to ignore. Each MRI, PET scan, genetic test, clinic, and infusion visit amounts to nearly $82,500 annually. Adding the cost of the drug itself pushes the total to well over $100,000 annually. This doesn’t even account for the additional costs tied to the cascade of diagnostic tests and treatments needed if a patient develops side effects or co-morbidities, such as atrial fibrillation, that can no longer be managed with conventional approaches.
These dilemmas make me question whether prescribing the drug is justified. On one side, I have a desperate patient whose brain is deteriorating, and on the other side, I have a strained health care system that may collapse under the weight of these innovations.
Beyond Alzheimer’s
The questions raised by these therapies extend far beyond neurology and even medicine itself — they cut to the heart of how we value health and allocate resources in society. With 70% of health care spending in the U.S. tied to a doctor’s signature, physicians are gatekeepers to an increasingly expensive and complex health care system. Every new technology, every revolutionary drug, forces us to reckon with the same core tension: Who gets access, and at what cost?
On one end, we can lean into regulation, building something akin to the organ transplant network, where decisions are meticulously governed by ethical frameworks and public accountability. For instance, countries with more centralized health care systems, such as England and Australia, have chosen not to include lecanemab in their national formularies, citing cost-effectiveness and safety concerns.
On the other end, we can embrace a more market-driven approach, leaving these decisions in the hands of individual patients and their physicians.
Personally, I believe there is a middle path. Rather than flooding an unprepared system or severely restricting access, we can take a phased approach, prioritizing patients most likely to benefit while building the infrastructure to support them. This would help control both supply and cost while we wait for a cheaper biosimilar to enter the market in ten to fifteen years. Supply control is controversial but isn’t new. We saw it with hepatitis C treatments like sofosbuvir, where access was initially limited due to cost and capacity then expanded as prices dropped. With Medicare now facing funding cuts under the Trump administration, this kind of strategy is more important than ever.
Whichever option we choose, it is essential that physicians continue to play a central role in the decision-making process, whether at the FDA, CMS, or NIH. Without our firsthand insights, policy decisions risk being detached from the realities of clinical practice.
For now, I’ll keep offering these drugs to my patients. I’ll keep seeing how they perform in the real world. And I’ll keep giving hope to those who need it. But a reckoning is coming to the industry, and only through an honest appraisal of both our immense innovative power and vulnerabilities will we be able to sustain this rapidly evolving health sector.
How do you weigh patient hope against system-wide cost and access in your own clinical decisions? Share in the comments.
Dr. Naveen Reddy is a neurologist at the San Francisco VA medical center and NCSP fellow at UCSF.
Dr. Sachin Shah is an assistant professor at Massachusetts General Hospital.
Image by Fanatic Studio / Getty Images
