How To Save Billions in Health Costs Starting Now

President Obama has stressed the importance of "bending the cost curve" in order to put the brakes on galloping health care expenses that total 2.5 trillion dollars a year and are increasing at 6% a year. The fastest way to do this is shockingly simple: carefully explain to patients the known risks and benefits of procedures.

Dr. Elliott S. Fisher, Director of Dartmouth's Center for Health Policy Research, estimates that thirty to forty percent of elective procedures are unnecessary. This includes elective angioplasty ($16,000), spinal fusion ($22,300), knee replacement ($14,400), and hip replacement ($15,700).

And it's not just costly procedures that are ballooning our health tab; the annual price for diagnostic imaging studies such at CT's and MRI's is about 100 billion dollars, roughly 35% of which is estimated to be wasted.

A prime example of an overused procedure is angioplasty, which opens up clogged arteries in the heart. Over a million are performed every year in the United States. Most patients believe it will prevent a heart attack and prolong life. But that's only true if the procedure is performed when a patient is actually showing signs of a heart attack. In elective cases which, according to the American College of Cardiology's National Cardiovascular Data Registry, account for 37% of angioplasties, it has not been shown either to prevent heart attack or prolong life. For a segment that aired last June on the CBS Evening News with Katie Couric, cardiologist Dr. Steven Nissen of the Cleveland Clinic told me, "Cardiovascular interventional procedures are big money makers for hospitals and for practitioners." For a lot of doctors, "it's tough to walk away from that."

Our fee-for-service payment system certainly creates perverse incentives for doctors, a major reason for the spiraling cost of health care. But there is another factor that is more insidious: the reluctance of physicians to accept new evidence about the medicine they practice. For example, doctors have been taught for many years that an open artery is always better than a closed one. Despite convincing data showing that this simply isn't true, many physicians remain unconvinced and refuse to change their behavior.

When I interviewed President Obama about health care in July, I asked him about unnecessary elective angioplasties and the friction between what a physician believes to be true and what is supported by evidence-based medicine. He replied, "I have enormous faith in doctors. I think they always want to do the right thing for patients. But I also think, if we're honest, doctors, right now, have disincentives to making the better choices in the situations you talked about. If you are getting paid more for the angioplasty, then that subconsciously even might make you think the angioplasty is the better route to take. And so if we're reimbursing the physician not on the basis of how many procedures you're performing but rather how are you caring for the patient overall - what are the outcomes - then I think you start seeing some different choices."

Trying to figure out which medical interventions actually work is the whole point of the so-called "comparative effectiveness" studies for which Congress has budgeted 1.1 billion dollars. There has already been good progress in this kind of research. Aside from data showing that elective angioplasties don't save lives, a recent study found that vertebroplasty, a common procedure to treat pain from back fractures, was no better than a placebo treatment with a shot to temporarily numb the area.

Ultimately, insurers will try to change behavior by refusing to cover services that have performed poorly in comparative effectiveness research. That strategy will likely take years to implement and will be complicated by the fact that medicine is both an art and a science and will never be able to be reduced to perfectly predictable algorithms. Clinical judgment and even what has recently become a politically incorrect term - intuition - will always play an important role.

So how do we save billions starting now? By doctors and patients agreeing to discuss carefully whether procedures and tests are worth it.

This will have to involve consent forms. A review of hundreds of these forms at more than 150 hospitals found them to be of "limited value."

They are loaded with confusing language, often omit specific risks and benefits, and are generally not well explained by doctors. Patients often sign the forms minutes before a procedure without even reading them. Experts such as Dr. Fisher say that 30-40% of unnecessary procedures could be eliminated through proper informed consent - what is increasing being called "informed patient choice" to emphasize that doing the suggested procedure is not a foregone conclusion.

Gerry O'Connor, PhD, Associate Dean for Health Policy and Clinical Practice at the Dartmouth Hitchcock Medical Center, has implemented a pilot program that personalizes the consent process. In the case of angioplasty, the physician collects detailed medical information about a patient, then searches a database of angiogram results to estimate individual risks and benefits by finding out what happened to similar patients who had the same procedure.

"It's not generic," he told me. "It's for people like you. If we get that right, we'll create a better informed consent."

Ultimately, electronic medical records will connect with electronic medical knowledge, including comparative effectiveness results, to give doctors and patients information - so-called "decision support" - at the moment a test or procedure is electronically ordered. But until then, and starting immediately, doctors and patients can try the low-tech solution of setting aside enough time to weigh adequately the pros and cons of medical options - not just for procedures but for other treatments and diagnostic studies. Of course, this is more easily said than done in a system that reimburses far better for doing things to patients than for communicating with them. That must change.

 

Comments

[Martin 27514]

Preventing chronic Western diseases (DP Burkitt, 1971) will save much pain and suffering (and trillions of dollars). Please avoid "comparative effectiveness studies at $1.1 billion)

The mechanisms have been elusive but recent publications suggest they operate through the autonomic nervous system - those nerves that supply your organs. Persistent straining during defecation and during labour injure these nerves - as does surgery. Drugs, tobacco, alcohol, infection, etc exacerbate the problems. T1DM may simply result from bowel problems associated with early weaning and injuries ot the autonomic nerves to your pancreas.
http://www.ncbi.nlm.nih.gov/pubmed/19850417?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=1

Adjustments to diet, bowel habit, exercise, childbirth, posture and gait will prevent most ill-health. Avoid meds as most of the major classes have effects on your autonomic nerves. Avoid tobacco and alcohol.

Acknowledgements.

John Robbins. Santa Cruz, CA www.healthyat100.org Author. Son of Baskin-Robbins ice cream seller
Tom Harkins, (D-Iowa) www.harkin.senate.gov Farmer. Now D-Iowa
Professor Jane Plant www.janeplant.com Geologist. Long term breast ca survivor
Peter Egoscue www.egoscue.com US Marine. Injured in Vietnam. Does posture.

[Martin 27514]

Absolutely correct.

In relation to unnecessary cardiovascular procedures; angioplasty is one problem, another is "ablation of abnormal myocardial pathways".

The chaotic growth of new nerves is a common observation in the myocardium (Chen, Fishbein, et al. UCLA) though its source and significance are unknown. Destroying these nerves may be helpful if they are contributing to continuing arrhythmias but the first thing that happens is that new nerves start to grow from the point of injury. There are no prolonged follow-up studies to help.

Where do these new nerves come from ? Some non-cardiologists suggest straining in the bathroom, straining in labor or ..... persistent and recurrent surgery.

[medicare4all]

W should TAX THE RICH back to what they were paying when Reagan came along (35% over what they got over 4-5 million dollars, a decent living). If they don't like it, we ratchet it back to what it was when Eisenhower was president (90 % of what they made over 4-5 million dollars, a fair living then, if you ask me --back when we had a solid middle class, the 1950s). What isn't taught in school today is how the rich paid more then than they do today. Reason being that they used our TAXPAYER-funded military, highways, schools, police, firefighters, clean air and clean water to an extent that justified their paying more, because we were the owners, and they could afford it, as their FAIR SHARE, and the corporatists were using more than their fair share of the "commons" (military, roads, etc.)

Restoring the rich paying their fair share of taxes is the ONLY way to save our democracy. Democracy means OF THE PEOPLE, BY THE PEOPLE, FOR THE PEOPLE. Not rule by the rich, or the corporations, for their SOLE BENEFIT.

[Averal]

A simple question if I may?

Do any of our elected officials actually read any of these articles or the comments that follow?

There are literally hundreds of good suggestions on how to reduce the cost of our current health care system (if you can call it that). So why is it that every proposal before congress is going to cost at least 80 Billion MORE a year? Somehow we need to get the message across that the American people want REAL REFORM.

C'mon congresspeople, for once in your lives do the right thing. Create a legacy that we the people can be proud of. Work for the guys that voted you into office, instead of the corporations that pay you millions of dollars in dirty money to keep what they got at our expense.

It's a hard choice, but it's the right one.

[medicare4all]

bravo, Averal.

[Martin 27514]

Yes. They do read them.

Senator Harkins has the best track record on "prevention and wellness"

[tilted windmill]

Don't expect your legislators to come looking for good ideas. There aren't enough hours in a day to search out all media in case there is a helpful suggestion somewhere. Write to them and tell them what you want them to do. Help them craft a bill that meets our needs instead of meeting the insurance companies' greeds.

[themainpoint]

Prevention. Great. Yes. But that's hardly the biggest elephant in the health care cost room.

If Americans want to save substantially on health care and no longer want to accept being overcharged more than twice the going rate, then the large health care interests must compete for a living like the rest of us.

Just a couple of examples: Insurance has an anti-American anti-trust exemption and big drug (thanks to Congress) overcharges Americans more than anybody else in the world for the same drugs.

The health care industry players have secret meetings with the President and lobby Congress to be able to charge more than the going rate for their products and services and that needs to stop or we'll be in an even worse boat each year.

We need to get rid of the giveaways and subsidies and makes sure that health care interests charge the going rate like other businesses and employees do.

No more rigging health care prices for the benefit of a few and at the expense of the health and wealth of our country.

[SESERMAN]

To save billions in health care , the medical establishment need to remember that the PREVENTION is the cheapest way to treat the ill people before they get sick. Second after prevention is to use the natural, holistic , alternative remedies ,that are used from thousand of years around the world ,without side effect. The civilized country that have a better health and less cost of health, are used cheap Homeopathic remedies, and supplements ,that our FDA, dis consider and some time interdict , persecute the doctors or revoke their license. If Health Care Reform will change the medical policy that now is a monopole of Pharmaceutical- Allopathist medicine and will legalize the Alternative medicine, the huge cost will go dawn similar that in Canada, France, Germany, Japan, etc

[Liberal2]

First of all, the surgeries you call "elective" stun me. When does someone walk into a hospital and say, "Gee, I'd like an angioplasty." As for spinal fusions, I can understand the demand for one. I can have back pain so severe that I can't breathe for 30 seconds and have to plan 20 minutes ahead to start getting out of bed to go to the bathroom. I discovered ten years ago I have a congenital condition in my neck too. Two vertebrae never developed properly, fused from birth, and the disks above and below are blown. If I sneeze, the pain is so sudden and intense my legs buckle.

Sounds like Dr LaPook needs to suffer a little pain to understand certain realities.

On another matter, Dr. LaPook should actually be more concerned with the impact of Baby Boomer retirements, the 100 trillion dollar cost, and coming medical advances that will add 20-40 years to life, only if one can afford the medical treatment. No combination of Medicare and private insurance will be able to cover 76 million retirees.

But as I've tried to present to several HuffPost reporters, there is a solution.

[Peter007]

I have spinal stenosis. It knocked me to my knees for years until I had a laminectomy. That was 12 years ago and I fell great today. Without it I'd be disabled and unable to work.

[Indon]

Sounds like they need to add a byline to the hipocratic oath to mention frivolous or ineffective medicine.

[Appleblossom]

Eliminating fee for service would solve some of the costs.
Stop focusing on technology and more on what the body actually does during healing would be another.

[FreeNemo]

The real fix would be to place the decision and responsibility to spend money where it belongs: the patient. The Atlantic had an excellent article about all these problems we are discussing ... and how to fix them. It's the only proposal I've read yet that really makes sense.

http://www.theatlantic.com/doc/200909/health-care/1

[no body]

The Atlantic article brings up many good points. This article also brings up many good points. But the correct solution to address costs and medical errors is a public-private Healthcare IT process that actually incorporates both articles. Done correctly it could even tell if you washed your hands using a camera.

[lobear00]

The best way to cut the outrages cost, one. gather all CEOs in healthcare industry and throw them out of the country for good. two. get rid of the insurance companies, go strictly government, its people in government who are bad, just as it is in the "Private Sector' . When people are caught defrauding the system, don't throw them in prison , throw them out of the country for good.

[medicare4all]

Or, lobear, tax them their fair share Tax them their fair share when they come back from their tax havens. Tax them, tax them, tax them. It's not a dirty word. It's the only way we can overcome.

[Maxiesid]

To save money on healthcare the first most important thing that needs done is the removal of the insurance corporation's middlemen. You cannot achieve any savings as long as they are involved because their fees and costs are the only thing that is considered in every healthcare decision. If you reduce services and declare procedures unnecessary, then they just use that to increase their costs and deny reimbursement for those services, without reducing any of the fees they demand. Once you have them out of the equation altogether, then you can start to reasonably discuss what services are 'unnecessary' and how people can change their lifestyles in order remain healthy.
Anything other than their total removal from the system will end up just being a way to increase their profits on the backs of the people they are supposedly serving.

[menlopian]

Dr. Elliott S. Fisher, Director of Dartmouth's Center for Health Policy Research, estimates that thirty to forty percent of elective procedures are unnecessary. This includes elective angioplasty ($16,000), spinal fusion ($22,300), knee replacement ($14,400), and hip replacement ($15,700)....

Well this about tells it all right here. So we'll just let the senior hobble around on a bad knee because it is "unnecessary" (read: too costly) to pay the $14,000? Unnecessary is a judgment call in many cases; in this case synonymous with "rationing."

And part of the reason we are spending so much on imaging services is because (a) for years the government's fee for service reimbursement created massive incentive for radiologists to set up referral networks from their buddies to imaging centers in strip malls, and (b) defensive medicine to avoid malpractice lawsuits.

[MillinMn]

If you're already at the hospital, the context and impetus makes it highly likely you'll do the procedure. I speculate that if people were sent the consent contracts at their home days beforehand, more thought and research could go into the decision. When you're bare-ass in a hospital bed, you're not dressed to negotiate wisely

[blue53]

Self-referral is one of the main cause overused CT, MRI etc. Dr.'s make money on procedures--not visits. There is no incentive not to overuse. Physicians are the largest consumers of health care. They are not paying.
Hospital infections and medical errors kill 200,000 people a year. A report on these issues in 2000 reads pretty much the same in 2007. The increased hospital stays, drugs, Rehab, procedures and visits caused by these errors and infections alone, would save millions.
Medicare and Medicaid are the victims of fraud. It does not commit the fraud. Physicians, drug companies, medical suppliers, therapists etc. ---are the criminals. A search in Google for, Medicare, fraud, settlements yields millions of dollars in fines, and gives you an idea of who is involved.
Check out the Cochrane Review site. This is what “evidence based medicine” means. Looking at the research, -was the sample size large enough, was the correct criteria meet. Search any disease or condition. This is what you find--"needs more study", because of “methodological shortcomings we can not recommend" "no evidence to support the use of". While you are at it take a look at the drug studies. Blood pressure medication may drop your BP 4-5- points, --but take it the rest of your life, other meds like some injectables--no idea of the mechanism by which they work, studies structured so poorly, no consistent endpoints, and tons of research paid for by the drug companies.