Skip to main content

In hospital versus out of hospital heart attacks: wow, things sure cost a lot of money!

An article from the JAMA (Journal of the American Medical Association) has been gnawing at my consciousness for the last couple of weeks. Dr. Prashant Kaul and colleagues out of the University of North Carolina reviewed records from hospitals in the state of California from 2008 through 2011, looking for patients who had been hospitalized with heart attacks. Specifically, they were looking for patients with ST elevation myocardial infarction (STEMI), which are generally the most damaging and deadly of the events generally known as heart attacks, due to the amount of damage they do to the heart muscle. The authors compared patients who were already in the hospital for another reason when they had their heart attack, versus ones who were admitted specifically for heart attacks. They found that the patients who were admitted specifically for the heart attacks were generally younger and healthier, more often male, and were much more likely to survive than the ones who were hospitalized with other illnesses at the time of their STEMI. This is not terribly surprising, since people who have some other problem bad enough to put them into the hospital and then develop a heart attack on top of it are clearly at a disadvantage, even though there are cardiologists with magical potions and procedures close at hand.

What was most interesting and disturbing to me was the sheer astounding magnitude of costs associated with these groups of patients. The patients admitted for STEMI stayed an average of 4.7 days and total costs were $129,000. About 9% of them died. The patients who were already in the hospital at the time stayed an average of 13.4 days, their costs were $245,000 and a third of them died in the hospital.

I don't think we should get jaded to numbers like this. This is real money, the kind of money that can buy a house in some places or at least a very hefty down payment, can support a person for years, and the co-pays on which can destroy a family financially. As a person is racking up such a bill, there are days of inadequate food and sleep, indignities of hospital gowns and waiting for someone to come with medication or to allow one to empty bladder or bowels, if it's not already too late. And death, in 9-30% of the people thus cared for. In a hospital. This money is not buying comfort and luxury. What costs so much? I'm not entirely sure. The interventions done on people with heart attacks include bypass operations, which are costly, but happen to very few of these people. There are the "percutaneous interventions" meaning high-tech catheters passed through arteries to place stents in clogged blood vessels in the heart, which are also terribly costly, sometimes as much as $40,000 for placing a tiny metal finger trap in a partially blocked artery. More stents are placed than need to be, per many studies, but an STEMI is definitely a good reason to place a stent and doing so is often life saving.

But why? Why so much money? There is nothing absolutely expensive about any of this. A little expensive, yes, but not hundreds of thousands of dollars. But the costs add up. The equipment is getting incrementally slightly better and is priced somewhere in the ozone. But it's not about raw materials or time or any of the resources that are truly set in stone. The costs just rise to the level that we agree to pay. The many places where money hemorrhages from the system feed our vibrant healthcare economy. We pay huge amounts of money to insurance companies who disburse it to the entities that charge this much. If there were limits on costs, or even goals for cost cutting, I'm confident we could slim down our spending. But there aren't and we don't.

Heart attacks and their treatment are just a tiny piece of the picture. There are still a few good values (a needle and syringe still costs less than $1), but generally everything that has to do with healthcare is overpriced. I learned a new computerized medical record keeping system last week and talked at length to the trainer who had been instrumental in adopting it. I complained because it was clearly clunky and lacking in the subtleties that would have made it really useful. I asked about another program I had heard about which was looked at as the best. According to her, the "best" cost about half a million dollars per hospital bed to implement. A medium sized hospital might be 200 beds. So 100 million dollars. Apparently hospitals, hoping for efficiencies, have gone bankrupt after adopting this Mercedes Benz of medical records. And the other systems aren't much cheaper. How is that even possible? There are almost no fixed costs in computer software. They charge this much entirely because they can.

There are no obvious solutions to this, while we remain attached to a non-centralized third party payment system. Payment structures are changing, but slowly, and the powerful interests who make money off of this system seem to escape ideas made to dampen profits. As individuals, though, it's important to continue to notice that things cost too much, they don't have to, and it's not OK.




Comments

dymphna said…
You lay out well the reasons that I choose to avoid robust cardiac care. I have a big DNR on my chart, but an EMT person wouldnt know that.

I do not want to die but even less do I want the 'heroic' measures that would keep me half-alive. My husband knows my feelings about this. We have discussed the technical issues - e.g., getting a notarized card to carry so 'rescuers' would know to leave me alone.

I have a pacemaker newly installed but the arterial stenosis is slowly progressing. I will NOT ever have by-pass surgery. As someone who has all (or many) of the problems associated w/ developmental PTSD (iow words, etiology dates back to preverbal stage), I often recognize my fellow sufferers -e.g., Robin Williams.

His suicide probably stemmed from the horrendous sequelae of his by-pass surgery four years previously. IMHO.

I would rather die 'naturally' than be forced down Mr. Williams' road. There really ARE worse things than dying but many doctors can't handle that.
Anonymous said…
"There really ARE worse things than dying but many doctors can't handle that." So true. We ALL will die. It is just how and if we have any dignity left when we go. If up to the medical community as a whole (this blog author is a rare exception) no one would be allowed to die with dignity. Everyone would be mutilated, exposed and drugged. Then after death cut up in to pieces to see why we died. Is nothing sacred anymore?

Popular posts from this blog

How to make your own ultrasound gel (which is also sterile and edible and environmentally friendly) **UPDATED--NEW RECIPE**

I have been doing lots of bedside ultrasound lately and realized how useful it would be in areas far off the beaten track like Haiti, for instance. With a bedside ultrasound (mine fits in my pocket) I could diagnose heart disease, kidney and gallbladder problems, various cancers as well as lung and intestinal diseases. Then I realized that I would have to take a whole bunch of ultrasound gel with me which would mean that I would have to check luggage, which is a real pain when traveling light to a place where luggage disappears. I heard that you can use water, or spit, in a pinch, or even lotion, though oil based coupling media apparently break down the surface of the transducer. Or, of course, you can just use ultrasound gel. Ultrasound requires an aqueous interface between the transducer and the skin or else all you see is black. Ultrasound gel is a clear goo, looks like hair gel or aloe vera, and is made by several companies out of various combinations of propylene glycol, glyce

Ivermectin for Covid--Does it work? We don't know.

  Lately there has been quite a heated controversy about whether to use ivermectin for Covid-19.  The FDA , a US federal agency responsible for providing unbiased information to protect people from harmful drugs, foods, even tobacco products, has said that there is not good evidence of ivermectin's safety and effectiveness in treating Covid 19, and that just about sums up what we truly know about ivermectin in the context of Covid. The CDC, Centers for Disease Control, a branch of the department of Health and Human Services, tasked with preventing and treating disease and injury, also recently warned  people not to use ivermectin to treat Covid outside of actual clinical trials. Certain highly qualified physicians, including ones who practice critical care medicine and manage many patients with severe Covid infections in the intensive care unit vocally support the use of ivermectin to treat Covid and have published dosing schedules and reviews of the literature supporting it for tr

Old Fangak, South Sudan--Bedside Ultrasound and other stuff

I just got back from a couple of weeks in Old Fangak, a community of people living by the Zaraf River in South Sudan. It's normally a small community, with an open market and people who live by raising cows, trading on the river, fishing and gardening. Now there are tens of thousands of people there, still displaced from their homes by the civil war which has gone on intermittently for decades. There are even more people now than there were last year. There is a hospital in Old Fangak, which is run by Jill Seaman, one of the founders of Sudan Medical relief and a fierce advocate for treatment of various horrible and neglected tropical diseases, along with some very skilled and committed local clinical officers and nurses and a contingent of doctors, nurses and support staff from Medecins Sans Frontieres (Doctors Without Borders, also known as MSF) who have been helping out for a little over a year. The hospital attempts to do a lot with a little, and treats all who present ther