America's economic picture remains bleak. Employment numbers, industrial output, housing starts all continue to languish. It seems that the only economic measure still rising is one we don't want -- the ever-increasing cost of health care. The Kaiser Family Foundation recently reported that the average health insurance premium for employer sponsored family policies rose 9% in 2010 to $15,073. Our medical costs are taking larger and larger pieces out of a smaller and smaller economic pie and damaging our chances for recovery. Unless health care expenses are controlled so that Medicare and Medicaid budgets can be contained, attempting to balance state and federal budgets will be futile.
Meanwhile, debates over health care reform center around legal challenges to the Affordable Health Care Act, a ponderous Democratic sponsored document with measures that are mostly irrelevant to providing either affordable or quality care. These challenges have been mounted primarily from political conservatives who express an almost religious belief that the market forces that got us into our health care mess somehow miraculously, if left alone, will get us out of it. The difficult, but needed, health care reforms remain largely ignored by both parties. With such bipartisan ineffectiveness, it is easy to find hopelessness and despair sneaking into our thoughts.
Sometimes, though, only desperation can push people into making the hard, necessary decisions. As Winston Churchill correctly observed, "You can always count on the Americans to do the right thing -- after they have tried everything else." Perhaps, with no other options, Americans can finally face what needs to be be done: to require cost-effective considerations as a guide to high-quality, economically responsible medical care.
Cost-effective analysis helps determine clinical decisions in all other developed countries besides the US -- every one of which has better health care systems than ours. In Great Britain, for example, the National Institute for Health and Clinical Excellence (NICE) periodically releases recommendations in diverse areas of medical care. Their recommendations are based on high quality medical studies and, although clinical outcome is the major factor, cost is also considered. The U.S. similarly has organizations that release recommendations for medical care, like the Joint National Commission (JNC), the United States Preventive Service Task Force (USPSTF), various medical specialty organizations, and advocacy groups. Practice recommendations from the specialty organizations and advocacy groups often represent their institution's special interests and, although widely followed, lack objectivity and all these organizations lack the influence and the power for shaping health policy that NICE has. Witness the USPSTF recommendations on breast cancer screening in 2009 and how that group was vilified in the press for making objective, evidence based guidelines.
As a practicing doctor, I find the recommendations from NICE well thought out and helpful and I try to incorporate their guidelines for quality, cost-effective medicine into my own medical practice. For example, recently NICE published recommendations for the treatment of hypertension which differs substantially from the last recommendations by the JNC. Based on a careful analysis of recent medical studies, NICE recommended easing blood pressure requirements for those older than 80, and accepting BPs up to 150/90 as normal for that population. They proposed that the upper limit of BP for all other people should be 140/90. Their recommendations also mentioned how frequently patients without hypertension become excessively nervous in the doctor's office causing their blood pressure to rise. These people, with so-called "white coat syndrome," can be incorrectly labeled as hypertensive and be destined to take a lifetime of BP medications. The NICE panel suggested that the diagnosis of high blood pressure be confirmed by ambulatory blood pressure monitoring in practically all patients. With ambulatory blood pressure monitoring, a device is connected to the patient which measures blood pressure every fifteen minutes for 24 hours as the patient carries out normal activity. These measurements give the physician a clearer understanding of whether there is actually a blood pressure problem. NICE has determined that the slight added expense of ambulatory monitoring is cost-effective and more than offset by the savings from avoiding the overtreatment of people with "white coat syndrome." With their higher allowable blood pressure values and their more cautious determination of who actually has hypertension, the NICE recommendations will exclude many Americans who are now receiving BP medications.
American medical practice needs to be directed by guidelines such as these, guidelines that are the result of a careful review of medical data with consideration to cost. Incentives need to be developed to encourage physicians to follow such recommendations. For the sake of our entire economy, America must act now to contain health care costs while, at the same time, improving the quality of care.
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