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Monday, September 20, 2010

what do I mean by cost effective medicine?

It is not uncommon for comments about cost effective medicine to be met with mistrust by patients.  Saving money is fine, but not if it means that when I, personally, as a patient, am in pain or sick, will have to wait for relief, get suboptimal care or be denied a life saving treatment. I, as a doctor, am also a patient, and can fully sympathize with this opinion.

When I envision cost effective medicine, I mainly see an absence of cost ineffective medical interventions.  Without these big yellow lemons of common medical practice, there will be more time and money to provide care that is meaningful. So what are the top shelf worst and most cost ineffective practices? It would be beautiful to see a well funded study of this question, but I haven't seen such a thing, so I will dip down into my well of 25 years of medical experience and pick out several of the things that I, as a patient, don't want to happen to me. These are things that are costly, common and have very little value in terms of maximizing health or happiness.

1. I go into the emergency room with severe abdominal pain and before anyone asks me questions that might be relevant (have I ever had this before, what did I just eat, have I ever been evaluated for this and how...) an abdominal and pelvic CAT scan are ordered and I receive a radiation dose equivalent to over 300 chest x-rays and a bill for $2500.

2. I reach a ripe old age, am having significant problems with my memory, joints, digestion, plumbing and whatnot, and suddenly my heart stops while I'm sitting at a meal at the nursing home.  I am resuscitated, rushed to the hospital where I remain on life support for a couple of weeks with lines and tubes and beeping machines as my family tries to figure out whether I really would have wanted all of this. Costs for this kind of end of life care often run as much as $10,000 a day.

3. I go the the doctor for high blood pressure, and sure enough I do have high blood pressure.  He goes into the sample closet, gets me the newest anti hypertensive medication on the shelf, shown by drug company sponsored studies to have minimal side effects, and I take it, then fill the prescription which costs about $300 a month when a generic of proven track record would have worked just fine and cost $4.

4. I have chest pain and tell my doctor.  She wants to make sure she isn't sued if I have a heart attack, even though my chest pain is only with taking a deep breath and is never associated with exercise, so she orders a nuclear imaging stress test.  The radiation dose is huge and the bill is $6000. Later I get lung cancer, and cannot be at all sure that it wasn't caused by radiation.

5. I have knee pain and am overweight.  I can't get dietary counseling because my insurance doesn't cover it, but I can get an x-ray, then some arthroscopic surgery which doesn't help but costs about $30,000. I now am overweight, have knee pain and a nifty scar on my knee.

6. I am uninsured or underinsured so can't really afford to go to a primary care doctor for my cough.  It gets worse, so I go to an emergency room.  The evaluation includes a chest x-ray, breathing treatments and an expensive antibiotic and no followup or smoking cessation advice.  I didn't need the antibiotic and get antibiotic associated diarrhea and eventually require hospitalization. Total cost of this perfect storm is in the 10s of thousands of dollars.

7. I am an 80 years old man and go to my doctor  for a physical exam.  He says that I need a prostate exam and PSA testing for prostate cancer. He finds prostate cancer, I get evaluation then radiation therapy, causing me to decline to the point that I now need to be in a nursing home because of urinary and fecal incontinence. I would not have died of the prostate cancer had it gone undiagnosed.

8. I am a 40 year old woman, go in for a physical and am told to get a mammogram. The mammogram is abnormal so I get another 6 months later. It is still abnormal so I get a biopsy.  The biopsy is normal. When I get my next mammogram it is abnormal too because I have a scar.  I get an MRI of my breasts and that is equivocal.  I get another biopsy which is normal.  This process is repeated yearly until what is left of my breasts resembles the surface of the moon.

There are cost effective solutions to all of these problems which rely on adequate access to primary care physicians and good choices about when to use technology. Making medicine cost effective is about making it better. Dollars spent on health care should be in the service of health and happiness and nothing else.

Saturday, September 18, 2010

JAMA commentary article suggests teaching medical students to be cost conscious

This week's JAMA presents an article by Samuel Sessions MD of Harbor UCLA Medical Center and Allan Detsky of Mount Sinai Hospital in Toronto suggesting that teaching medical students to be aware of cost when learning to treat patients.  They recognize that physicians have an ethical responsibility to pay attention to the fact that medical expenditures are increasingly threatening America's economic viability and point out that training in cost-effectiveness needs to start in medical school.

A few years ago I let my membership in the American Medical Association lapse since I felt that the did not represent me as a primary care physician and a socially responsible human being. During the debate around health care reform, they have not demonstrated leadership in helping American medicine move in the direction that will result in reducing costs and improving access for people who need medical care. They have, however, published articles in the Journal of the AMA by many thoughtful and visionary authors which have informed readers. The JAMA is a free publication, at least the print edition, to physicians, and is at least partly subsidized by advertising, as are many medical publications, and its circulation is huge. I have continued to receive it since my membership has lapsed and I am grateful for that.

Today when I decided to share this article in my blog, I attempted to access it online and found that I will have to subscribe to the online version if I want to copy and paste its text into this commentary.  I'm not ridiculously cheap, but I haven't yet decided that I want to give money to the AMA. Luckily, this article has made quite an impression in various online sources, so I will quote ScienceDaily:

"The commentary is written by Samuel Y. Sessions, MD, JD, a Los Angeles Biomedical Research Institute (LA BioMed) investigator, and Allan S. Detsky, MD, PhD, Departments of Health Policy Management and Evaluation and Medicine, University of Toronto.
"New physicians will be at the hub of the health care system throughout their careers as both patient advocates and allocators of resources," the authors write in the JAMA commentary. "Instead of considering economic forces to be extraneous, medical education should develop approaches to better equip physicians for this dual role through improved teaching of evidence-based medicine that reflects both economic and statistical realities. Good patient care and good public policy demand no less."
The commentary notes that health care spending continues to grow, reaching 17.3% of gross domestic product in 2009. It points out that physicians "play a critical role not only in the well-being of their patients but also in the nation's economic welfare" as they make choices about how to care for their patients. As a result, the commentary calls for "incorporating information about economic realities into medical education to enable physicians to make better-informed decisions for patients and for the United States."
The authors point out that physicians' diagnosis, choice of medication and course of treatment can affect spending and patient well-being for years to come. To ensure economic realities are part of the physicians' decision, the authors call for a "core, required medical school course that would consolidate and integrate elements of existing health policy, ethics, and evidence-based medicine courses and modify them to better reflect overt and covert economic influences on clinical decisions."
The authors also call for revising "the remainder of medical school and residency curricula" to incorporate economic realities so that the medical students and residents would take these into consideration in their medical decision-making.
"The primary goal of incorporating economics more directly into medical education would be to improve physicians' critical capacity to assess all factors affecting their decisions, as well as their social and ethical implications," the authors write.
This is all extremely heartening.  I was especially pleased to find the article quoted so many places, because it is all well and good to have a great idea, it is something quite different to do something about it. When many people are excited, as they seem to be, momentum may build in the direction of change.  The next step in such a thing would be to have the idea attach itself to some money--perhaps a grant to medical schools that try it.  Medicare already funds a great deal of medical education and perhaps the proper direction for this to take would be for folks in the new center for Medicare innovation (part of the health care reform bill) to notice that it is a terrific idea and stipulate that medical schools receiving funding from Medicare begin to teach a comprehensive curriculum based on cost effective care.

Wednesday, September 15, 2010

Treatment of Sleep Apnea--the cost of a good night sleep

Obstructive sleep apnea (OSA), that is snoring with episodes of not breathing, probably affects more than 1 in 20 people.  It is most common in older men, though certainly not limited to this group. Risk factors include obesity, large neck size and limited room for air passage in the back of the throat.  When a person has OSA he or she may wake up hundreds of times a night as breathing is stopped by floppy tissue in the airway and the drive to breathe arouses them enough to take an effective breath.  This loud irregular snoring and snorting also interrupts the sleep of a partner in the same bed. People with sleep apnea have a lousy quality of sleep, rarely reaching the lower sleep levels and are less productive during the day than healthy sleepers and often fall asleep in meetings, movies and while driving. Years ago we discovered that application of a mask to the nose which applies a constant air pressure to the breathing passages can improve nighttime breathing and nighttime sleep. These are called CPAP (constant positive airway pressure) devices and are now commonly used in the treatment of OSA. People who use these devices have better oxygen levels during sleep, which benefits their hearts and brains, and usually feel more rested during the day.

This sounds really good so far. Treatment of sleep apnea is a success of modern medicine. Using CPAP is pretty easy, causes no major side effects and relieves suffering. A slam dunk. Unfortunately the process of getting tested for sleep apnea plus the CPAP machine and supplies is tremendously expensive. In order for an insurance company to cover their bit of the CPAP equipment, a sleep study must be completed and if OSA is diagnosed, another sleep study must be done to see what settings to use for optimal treatment.  This involves the patient spending the night in the hospital while hooked up to a machine that measures brain waves, limb movements and oxygen levels. At our hospital a sleep study costs over $2500, the physicians reading of the data costs nearly $600 and those costs are usually multiplied by 2.  The evaluation can be done with one night and that is a bit cheaper but still no great deal.  At our local durable medical supplier the CPAP machine and supplies cost close to $2000 and some of those supplies need to be replaced several times a year. With good evaluation and a good medical equipment supplier who follows up regularly, about half of the people who are diagnosed with sleep apnea can tolerate CPAP.

There is another option, though, that appears to work for some people.  A device that is quite a bit like a boxer's mouth guard can be made which places the lower jaw in a jutted position and improves breathing without the mask and tubes and such.  These oral appliances are carefully fitted and are amazingly expensive.  One of these things costs around $1200-$5000.  Why? All I can figure out is that the cost is competitive with CPAP and is the only viable option for people who can't stand a tight mask on their faces. Why doesn't someone make one that seriously undercuts the rest? I'm not sure. Perhaps because the market is small.  It sure seems like an insurer or an uninsured consumer could take a look at this not very complex piece of rubber and refuse to pay more than it is actually worth. Apparently that is not how things work.

It is definitely true that people feel better with better sleep. It is wonderful that the treatment of sleep apnea is such an active field, but none of this stuff needs to be this expensive.  This is yet another case of the free market system not acting to lower costs because the actual consumer rarely pays for the product. Insurers pay for most of these costs, and why they agree to do so is beyond me. A sleep study should not cost $3000. In fact, most people who have sleep apnea have really pretty classic symptoms and could get by with a test called an autotitration, in which the CPAP device is set up to adjust itself and a less expensive data set is gathered by a simple device that measures oxygen levels.  I asked the durable medical supplier how much they charge for an autotitration and they said that there is no charge.

What about the machines themselves? Many people with sleep apnea eventually quit using their CPAP machines because they are too uncomfortable or too inconvenient, or because they lose weight or die.  What happens to these expensive machines? Usually they go to a garage or basement somewhere and become a home for spiders. Because they are regulated as a medication would be, they cannot be sold without a doctor's prescription and durable medical suppliers do not refurbish them.  E-bay doesn't sell them, but there are companies that refurbish old ones and sell them online.  These machines can cost as little as $100-$200. I'm not sure how these companies get around these regulations.  Occasionally a person can pick up one of these things at a garage sale or Goodwill, but this is illegal and it is not straightforward to adjust them. Certainly a motivated medical profession could manage to make use of all of these wasted machines.

A reasonable conservative estimate of the number of treated patients with sleep apnea in the US would be about half a million, and the cost to treat per person at the very least $6000 each.  If the cost of evaluation were reduced to the cost of a heavily discounted CPAP machine which could do an autotitration for diagnosis (we will call this cost $1000 for simplicity sake) the cost savings without sacrificing quality would be over $2 billion.