January 2009

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Book Review: The Great American Heart Hoax

January 13, 2009 in Books | 2 comments

A new book by Dr. Michael Ozner takes on the cardiovascular surgery industry head-on.  The aptly titled Great American Heart Hoax claims that although insurers pay $60 billion per year  invasive cardiovascular surgery, 70%-90% of these procedures are unnecessary.   The book has three major themes: What is heart disease?  Why is heart surgery a hoax?  and What is the solution?

What is heart disease?  

The book has a nice summary of some of the risk factors from heart disease as well as the types of cardiovascular surgeries.  Dr. Ozner also describes the different the side effects from bypass surgery and pharmaceuticals used to treat atherosclerosis.  This portion of the book is educational and clearly explained.

Why is heart surgery a hoax?

Dr. Ozner cites numerous studies demonstrating that bypass surgery does not generally help heart patients.  Two studies–the Coronary Artery Surgery Study (CASS) and the European CASS–both found that “a majority of patients who underwent bypass surgery did not live significantly longer or have fewer heart attacks than those who did not undergo surgery.”  However, bypass surgery can be beneficial for patients with “critical left main coronary artery disease and a weak heart muscle, and patients with severe disabling chest pain despite maximal medical therapy.”  Most patients who undergo bypass surgery, however, do not fall into these groups.

Dr. Ozner also criticizes the use of other surgical procedures.  The Atorvastatin Versus Revascularization Treatments (AVERT) Trial found that “the lives of patients treated with angioplasty were not significantly prolonged compared to similar patients who received medical therapy alone, nor did they suffer fewer heart attacks.”  Stents were also shown to be problematic in the Occluded Artery Trial.  

Even CAT scans are dangerous because they expose patients to excessive radiation.  CAT scans can be useful when heart disease symptoms appear, but Dr. Ozner finds that CAT scans are counterproductive for healthy patients.  When the doctor conducts a CAT scan, it may substitute for time spend taking the patient’s medical history–which is much more useful. 

The problems with these types of surgeries are certainly the heart of the book.  Financial incentives, however, continue to give doctors the motivation to continue performing these surgeries.  Showing that these high cost surgeries may not be in the patient’s best interest is the most important contribution of the book.

What is the solution?

This portion of the book is fairly disappointing.  Dr. Ozner’s solution is to eat healthier and exercise more.  This is nothing new.  In the “eating healthier” portion, Dr. Ozner pushes the “Mediterranean Diet” he advocated in an earlier book.  Getting people to eat healthier and exercise is easier said then done.  Deep dish pizza tastes better than broccoli; eating healthier means forgoing some of these tasty treats.  Further, some people enjoy exercise while others dread it.  Working out 30 minutes per day involves a significant time and energy commitment.  Thus, while Dr. Ozner’s solution is sensible, it is not easily implemented.  

Conclusion

Overall the book is important in that it clearly explains the dangers of excessive heart surgery.  However, the solutions of eating healthy and exercising are already well-known and the Dr. Ozner’s support of the Mediterranean Diet dominates the last half of the book.

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5 Health Care Myths

January 12, 2009 in Healthcare IT, Obesity, Physician Compensation | No comments

Bob Laszewski has a great posts on 5 false  “solutions” to reduce health care costs.  These are:

  • EMR: Making electronic medical records universal will greatly improve health care quality, but the impact on cost will be minor.  Better quality care can reduce iatrogenic injuries and reduce cost, but the cost reduction–if any–will likely be small in magnitude.
  • Prevention.  From the CBO: any gains from reducing obesity would be concentrated in the short and intermediate period “because some of the savings will be offset by increased longevity and the cost of disease that are most prevalent during old age.”
  • Outcomes Research:  Laszewski claims that “inefficient use of technology is the key driver in health care spending accounting for an estimated 38% to 65% of spending growth.  The problem…with the suggestions that more outcomes research will save us money is that more than twenty years of outstanding outcomes research, Dartmouth for example, has not kept our health care costs under control.”  Outcomes research is important; it is imperative for physicians to prescribe cost effective treatment.  However, I agree with Laszewski that if financial incentives are not aligned to promote physician use of evidence-based medicine, then health outcomes research will have little impact.
  • P4P: Laszewski doesn’t like pay-for-performance because in order for it to save money, it must lead to a reduction in physician payment on average.  Another reason why P4P won’t work is that paying individuals to check a diabetic’s A1C level may increase the frequency the physician monitors this metric, but it also may compel the physician to substitute their time away from other necessary medical services.
  • Universal Coverage.  Universal coverage should reduce the percentage of individual who go to the emergency room for primary care needs;.  Nevertheless, providing universal health insurance coverage will certainly increase healthcare spending due to the moral hazard problem as well as supplier-induced demand.

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Pharmaceuticals as an excuse, not treatment

January 11, 2009 in Pharmaceuticals | 3 comments

Should doctors prescribe pharmaceuticals to patients who have heart disease.  Statins and ACE inhibitors are frequently prescribed to patients with cardiovascular problems.  These medications have been shown to decrease the risk of heart attack in clinical trials, but could they actually increase the risk of a heart attack in the real world?

The answer is yes if taking the drugs changes behavior.  Without any pharmaceutical treatment, patients with a family history of a heart attack may decide to exercise more and eat healthier. Once the patient starts taking the pharmaceuticals, however, this may give them less of incentive to take care of themselves.  The drug can give them an excuse to engage in an unhealthy lifestyle.

 ”Yeah, I’m still smoking and eating philly cheesesteaks for breakfast, but I’m taking a statin so I’ll be fine.”  It is true that clinically statins reduce the risk of heart attack.  If heart medications also produce a sense of false security and adversely affect patient lifestyle behaviors, then prescribing these medications may actually be counterproductive.

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Are we winning the war on cancer?

January 9, 2009 in HC Statistics | 3 comments

Since the early 1980s, age-adjusted cancer mortality rates have been falling over time. Is this due to better screening, better treatment, or healthier behavioral factors? Is this progress cost-effective? Are we really winning the war on cancer?

A paper by Culter (2008) tries to answer this question. First it is important to note that there are two types of cancer. Localized tumors are located only in the originating tissue and metastatic tumors have spread to other parts of the body. “Localized cancer isn’t fatal; metastatic cancer is both lethal and incurable—even with recent treatment advances.”

Falling Cancer Mortality Rates

Raw cancer mortality statistics mask the significant benefits of cancer treatment and screening.  Since the reduction in the number of deaths from cardiovascular disease has fallen since 1970, the concurrent decline of cancer deaths is even more impressive since individual who will not die of heart disease are more at risk now of dying of cancer.  Of the decline in cancer-related mortality, 78% of this decline is due to decrease mortality in 4 types of cancer: lung cancer, colorectal cancer, breast cancer, and prostate cancer.   The risk factors for each of these disease can be found in Table 1.

Explanations for the reduction in cancer mortality can be found in Table 2.  Of the reduction in cancer mortality 78% comes from improved mortality from lung, colorectal, breast, and prostate cancers.  Of this reduction, 71% is due to healthier behaviors and better screening; only 29% is due to improved treatments.

Cost Effectiveness

One question that remains was whether or not this reduction in mortality was worth the cost.  Many people will say that life is priceless and we can not measure the value of a year of life…but economists believe they can.  “The analysis of screening is complicated, because the cost-effectiveness of screening depends on how frequently it is performed: if screening is either too frequent or too infrequent, it will have high costs relative to benefits.”  Further, decreasing mortality, but ignoring side effects may not be rational.  “Treatment of prostate cancer, for example, may lead to greater survival, but it frequently leads to reduced quality of life—impotence and incontinence are common side effects. For cancers where treatment is not very effective or where cancer would often not be a cause of death, treatment may even reduce quality-adjusted life expectancy.”

Table 3 shows Cutler’s evaluation of the cost effectiveness of various cancer screening tests.  Breast cancer and colorectal cancer screening are highly cost effective.  On the other hand, lung cancer screening is not seen to be cost effective since the knowledge of the existence of lung cancer rarely alters the treatment.  Prostate cancer screening does improve longevity, but the cost effectiveness depends on how one values the potential side effects of impotence and incontinence.

Compared to screening or behavior changes, cancer therapies are much less cost effective (Table 4).  The author notes that “Spending on cancer is generally U-shaped with time from diagnosis. Costs are high immediately after diagnosis, decline as the cancer goes into remission (if it does), and then increase substantially at the end of life.”

More Cost Effectiveness

The cost of treatment is growing over time.  One example of this the price of cancer drugs (see Table 5).  In the U.S., drugs only have to meet a safety and a minimum efficacy requirement.  In the UK, NICE ensures that drugs are cost effective as well.  In fact, NICE does not cover Avastin or Erbitux because they are not deemed to be cost effective.  Another issue related to drug cost-effectiveness is that “Many of the new, expensive drugs are tested first in metastatic settings because that is where clinical trials are easiest to conduct. Only later are tests done in non-metastatic cases. It is possible—even likely—that the effectiveness of new medications will be greater in non-metastatic settings.”

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The Health Wonk Review is up

January 9, 2009 in Carnivals | No comments

The latest edition of the Health Wonk Review is up at The Health Care Blog.

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Resource: State Coverage Initiatives Website

January 8, 2009 in HC Statistics, Medicaid/Medicare, Public Policy | 2 comments

Wisconsin’s Medicaid plan covers children from 0-5 years old whose parents have income below 150% of the poverty line.  Sixty percent of Massachusetts residence receive coverage through their employer compared to 53% nationwide.  Forty-six percent of Californian firms with less than 50 employees offer health insurance compared to the national average of 43%.

How did I know these facts?  Am I a genius?

No, I used the State Coverage Initiatives website provided by the Robert Wood Johnson Foundation.  The website has a nice summary of each state’s SCHIP, Medicaid eligibility rules and well as graphs showing where individuals do (or don’t) receive insurance coverage.

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Effect of Regulation on Health Care Quality: U-Shaped?

January 7, 2009 in Current Events | 4 comments

The Cato Institute’s Michael Cannon moderates an interesting policy forum on “Does America’s Health Care Sector Produce More Health?”  A podcast of the forum is available here.

Is a single payer system better than an unregulated health care system? If they U.S. scores worse on health care metrics, does that mean that unregulated health care systems are inherently inferior? Not necessarily. The U.S. is not a truly unregulated health care system. In fact, it could be the case that health care quality as a function of regulation could be related as follows:

The U.S. is somewhat regulated, but less regulated than health care systems in most European countries. Thus, it could be the case that moving the U.S. towards a single payer system or moving towards a completely deregulated system could both improve health care quality in America.

Hospitals as Hotels

January 6, 2009 in Current Events | 2 comments

The Mayo Clinic is renowned as one of the best health care facilities in the world.  Yet it also spends millions of dollars to make its buildings look like this.  Why do hospitals spend so much money on making their buildings look beautiful instead of directing those funds towards clinical care?

An NBER working paper by Goldman and Romley (2008) finds that patient demand is based much more on hospital amenities than on their clinical quality.  

“From the patient perspective, hospital quality…embodies amenities as well as clinical quality. We also find that a one-standard-deviation increase in amenities raises a hospital’s demand by 38.4% on average, whereas demand is substantially less responsive to clinical quality as measured by pneumonia mortality. These findings imply that hospitals may have an incentive to compete in amenities, with potentially important implications for welfare.”

Defense Spending as an Economic Stimulus

January 6, 2009 in Economics - General | No comments

” A substantial short-term rise in spending on defense and intelligence would both stimulate our economy and strengthen our nation’s security.” – Martin Feldstein in WSJ.

Robert Higgs disagrees.

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Cigarette taxes are bad for your health?

January 5, 2009 in Obesity, Taxes | No comments

Many economists and public plicy researchers have found that cigarette taxes reduce smoking.  This means that cigarette taxes must be good for your health…right?

A study by Baum (2009) claims that cigarette taxes may improve health, but not by as much as previously thought.  The paper finds that increasing the cigarette tax decreases smoking, but decreased smoking–an appetite suprressant–increases obesity.  Thus Baum finds that the health benefits of cigarette taxes may be overstated.

Disclaimer: Baum does state that “this research in no way concludes that [cigarette taxes] should be decreased to prompt weight loss.”

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