Fighting for Better Health Care: Beyond the government's simplistic battle
Recently, not for the first (or I am sure the last) time, I was berated by a cardiologist. This is what he said after I suggested in a facebook conversation with a friend that cardiology interventions were of low value much of the time and cardiologists were being over-paid to perform such interventions: “Andy Lazris seems like you're really pissed about not making as much money as the specialists. Maybe should've trained more (you probably could not get into a qualified cardiology training program) or make more money to make your life less miserable. Not everyone thinks like you and not everyone practices based on reimbursement.” Wow, that’s harsh!
I wrote an op-ed in The Hill discussing the new Paul Ryan health care plan, pointing out that it (much like President Obama’s ACA) had missed the point. To save our health care delivery system, to instigate reductions in premiums that would enable more people to afford insurance, to ensure the viability of Medicare and Medicaid, we cannot be devising convoluted tax breaks and subsidies to help people purchase high-priced insurance. Rather, we have to focus on why insurance costs so much money. Why is the price-tag of medical care in this county so much higher than in any other country, and why are the outcomes of that care so much worse? How can we possibly have health care for all until we figure out (and then fix) why medical care is so expensive? As I mention in my article, it is estimated that $750 billion in health care dollars is squandered needlessly on interventions that do not help patients and in many cases hurt patients. I also point out that it is estimated that 40-50% of medical interventions are of low value: they either instill no benefit or actually inflict harm. Such interventions could be medicines, tests, doctor visits, procedures, hospitalizations, ect. But without a doubt, that $750 billion is not just disappearing; it is falling into the pockets of many people and organizations that profit from our dysfunctional health care system. And those are the people who are most resistant to sensible health care reform, such as the irate cardiologist who accused me of petty jealously.
Certainly, many cardiologists are thoughtful and well-meaning physicians, but we cannot simply ignore the facts. In the past decade or so cardiovascular outcomes have not improved; just as many people die of cardiovascular disease now as died 10-15 years ago. Yet, according to an eye-opening analysis by Andurs and Welch at Dartmouth, the cost of cardiovascular disease (adjusted for inflation) has increased from $227 billion to $324 billion during that same period despite the fact that outcomes are flat . Revascularization alone (stents and bypass surgery) costs at least $50 billion, and the amount that cardiologists bill Medicare per 1000 patients has increased from $181,000 to $231,000 (adjusted for inflation) between 1999 and 2008. Stent placement increased modestly during that time (10/1000 to 12.3/1000), and groups, such as Bloomberg, have cited that the amount of money squandered on unnecessary stents is measured in the billions of dollars. A recent article in the Journal of the American College of Cardiology suggested that half of all stents put in are not necessary or helpful. Although stents placed during heart attacks and put into people who have intractable heart symptoms are certainly beneficial, far too many stents are put in in people who have no or few symptoms, many of whom have blockages discovered by screening stress tests. The benefits of such stents measured in absolute terms: 0/1000 have their lives saved or heart attacks averted when compared to just using inexpensive medicines, while 20/1000 suffer serious harm; thus we are paying billions of dollars for a procedure that hurts more people than it helps, but that enriches not only the person putting in the stent (the cardiologist) but also the hospital and stent manufacturer, among others. Talk about perverse incentives to do the wrong thing! And what a great example this is of low value care that is being paid for by insurances like Medicare at much higher rates than they are worth to the patient or the system, when that money can help thousands of people get care to avoid heart disease if allocated more sensibly.
But with cardiologists, the questionable value of what they do does not end there. The fact that this group of doctors accounts for such a large amount of Medicare’s spending without generating concomitant improvement in outcome has also to do with the testing they perform, much of which they do in their offices and for which Medicare pays very well. In my community, many cardiologists perform stress tests and echocardiograms on patients every year, even though there is no evidence that such testing helps people live longer or avoid heart attacks, and even though there is ample evidence that stress tests done in people without symptoms cause more harm than benefit, including increasing the incidence of heart attack and stroke. And yet, cardiologists keep performing these tests and Medicare keeps paying, while unsuspecting patients, who are privy to none of the actual data, think they are being taken care of by well-meaning doctors. In the Dartmouth study cited above, during the 10-year period, the number of echocardiograms performed by cardiologists who billed Medicare increased from 320/1000 to 610/1000, and the number of nuclear stress tests increased from 68/1000 to 218/1000. Again, if these tests had been demonstrated to help patients, if they had led to improved cardiac outcome during that time period, then perhaps they could be justified. But that is not the case. These are low-value tests that enrich those who perform them and drive up the cost of health care without improving outcome.
My friend’s facebook buddy, who is so upset that I dare question the current system, only knows that I am challenging his assumptions and the value of his care. Actually, that is exactly what I am doing. In fact, for us to fix our health care mess, for us to achieve either the single payer Medicare-for-all system that many liberals want, or the private-sector low cost insurance option that many conservatives want, we need to drive down the cost of care in such circumstances where that cost produces low value. Doctors should not be paid high reimbursement to perform low-value interventions, they should not be incentivized to do the wrong thing. Until we really get to the bottom of this reality, until we have the courage to challenge people like the cardiologist who was so angry at me, the hospitals that cost the system so much, the pharmaceutical and device manufacturers that encourage the use of expensive and low-value medicines and devices, then we will just keep spinning our wheels, putting band-aides on the gushing wounds of health care delivery while many people needlessly suffer and costs continue to climb. There is a better way, but it requires us to open our eyes, it requires us to speak the truth even if a few people will be offended, and it requires the consumers of health care to be privy to the facts rather than being led down precarious roads upon the clouds of myths and misinformation.
I’ll make the same pitch I’ve made for a long time. Join the Right Care Alliance. It is the one group I’ve seen that is fighting hard to make the system better for everyone. And it is led by a cardiologist!