Health Costs

You may have heard about the new research showing that bypass surgery is better than stents for diabetics: In a Mount Sinai School of Medicine study of 1,900 diabetics with multi-vessel coronary disease, heart bypass surgery increased the five-year survival rate by 30 percent compared to the use of artery-widening stents.

I spoke with Mark Hlatky, MD, professor of health research and policy and of cardiovascular medicine at Stanford, who said that this study should settle the 17-year debate on bypass-vs-stent effectiveness with “compelling evidence.”

In a New England Journal of Medicine editorial, Hlatky goes on to say that many of the stent procedures today are performed on the fly, during a diagnostic angiogram, with the same physician making the diagnosis, recommending the treatment, and performing the procedure. He feels that these new findings will result in a change for the better in clinical practice and will enable patients to be better informed about their choices.

This study should settle the 17-year debate on bypass-vs-stent effectiveness with ‘compelling evidence.’

“Patients and their doctors need to allow time for discussions on which procedure should be done, based on outcomes that are important to them,” said Hlatky. “They need time to digest the information, discuss it with family members and members of the heart team, and come to an informed decision.”

It’s worth noting that cost may be a factor in treatment discussions. Bypass surgery costs more than implanting stents, but because it results in fewer deaths and heart attacks, it is worth the front-end expense, said researchers on the cost-analysis part of the study. After factoring in the stent-related costs of new heart attacks and follow-on operations to re-open arteries, bypass surgery still costs about $3,600 more than the stent procedure over five years.

Previously: New test for heart disease associated with higher rates of procedures, increased spending and To stent or not to stent: not always an easy answer

When I interviewed Manali Patel, MD, a Stanford oncologist, for an article on improving poor-prognosis cancer care, she cited a shocking statistic: Less than a third of oncologists have end-of-life discussions with terminal cancer patients. She went on to tell me:

Many patients are rushed off to chemotherapy without understanding the big picture. And when predictable treatment side effects happen at night and on weekends, patients who are unable to reach their oncologist end up in misery in emergency rooms and hospitals. Later in their illness, many die painfully in intensive-care facilities that bankrupt their families emotionally – and sometimes financially.

With gritty determination, Patel is working to change all this. A little over a year ago, she joined a small, idealistic band of physicians, engineers and management scientists at a new Stanford center tasked with battling the waste and perverse financial incentives in America’s increasingly unaffordable medical system.

I followed Patel for six months, as she refined her plan for better cancer care and went on the road to sell it to a medical system resistant to change — in the middle of coping with a mother with cancer.

To read her inspirational story, check out the latest issue of Stanford Medicine magazine, which also includes a special report on the money crunch in medicine.

Previously: The money crunch: Stanford Medicine magazine’s new special report and New Stanford center to address inefficient health care delivery
Photograph by Jamie Kripke

If you don’t have your health, you don’t have anything. Unfortunately, in the United States protecting this most precious asset is breaking the proverbial bank. As I edited the new issue of Stanford Medicine magazine, which includes a report on the medical world’s money crunch, I came across harrowing statistic after harrowing statistic.

Among them:

• U.S. health-care spending neared $2.6 trillion in 2010, which is 17.9 percent of the nation’s gross domestic product. This translates to $8,402 per person.
• More than 75 percent of U.S. health-care spending is due to chronic conditions, which are expected to become even more prevalent as the baby boomer generation ages. In 2000, 125 million people suffered from chronic conditions; by 2020, that number is projected to reach 157 million.
• Competition for biomedical research funding has become cutthroat. At the National Institutes of Health, the world’s biggest funder, requests for dollars rose from 3.6 times the supply in 1998 to 6.5 times the supply in 2011.

What’s behind the crisis? How can we dig ourselves out of this predicament? The new issue offers some answers and poses more questions. Inside the report:

“The competition”: A feature on the intense competition for funding for biomedical research — competition that has reached an all-time high.

“Against the odds”: A story about a young oncologist’s experience as member of a small band of physicians, engineers and management scientists training to battle the waste and perverse financial incentives in America’s medical system. She is part of Stanford’s Clinical Excellence Research Center, led by Arnold Milstein, MD, a major national force in medical service innovation.

“Melinda Gates on family matters”: A Q&A with philanthropist Melinda Gates on her campaign to expand access to contraception.

“Testing testing”: A piece on the dangerous and costly problem of overscreening for medical conditions, focusing on the seemingly intractable debate over prostate cancer screening.

“Giving well”: Interviews with four major Stanford financial supporters about why they give.

In addition to the special report, this issue includes a feature, “Marathon man,” on the career of Stanford medical school’s dean, Philip Pizzo, MD, a pioneer in pediatric HIV research as well as an academic leader, who is stepping down from the position after 12 years.

Previously: The data deluge: A report from Stanford Medicine magazine; The future of psychiatry: A report from Stanford Medicine magazine and Cancer’s next stage: A report from Stanford Medicine magazine
Illustration by Brian Rea

It’s well-established that the United States needs to reduce its level of health spending, but the $1 million question (or, more accurately, the $2.6 trillion question) is how. As Stanford’s Arnold Milstein, MD, MBA, and UC-Berkeley’s Stephen Shortell, PhD, MBA, argue in a Journal of the American Medical Association perspective piece published today, “the most immediate progress” is likely to come from better caring for the sickest of patients. They write:

Opportunities include preventing expensive health crises among medically fragile patients, helping patients in late stages of serious illness avoid dying in a hospital, increasing patient flow through hospitals to lower average fixed cost per hospitalization, and reducing hospital readmissions.

Milstein directs Stanford’s Clinical Excellence Research Center, which develops innovative models of health care delivery that lower per-capital health spending and improve quality. In the editorial, he and Shortell, dean of Berkeley’s School of Public Health, go on to offer specifics for each approach, including helping very sick patients be more involved in the decision-making process of how and where they spend their last days. (Columnist Bill Keller explored this very issue in yesterday’s New York Times.) The authors go on to say:

Medicare spends 25% of its budget on the 5% of beneficiaries who die during a given year. Increasing evidence suggests that palliative care programs are improving the quality of life and lowering the costs of care for patients in late stages of serious illnesses. These programs rely on interdisciplinary teams for patient assessment, helping patients better anticipate their experience of both aggressive and conservative care and respecting patient and family goals of care across a range of nonhospital settings such as home, hospice, and nursing facility.

The two authors also emphasize the importance of slowing the rate of growth of health spending, warning that not doing so could lead to “shifting of funding away from resources for elementary and high school education, infrastructure (such as highways), and basic science research, as well as weakening the global competitiveness and financial health of US workers and their employers.”

Previously: Stanford physician discusses rapid growth of palliative medicine and legislation to meet demands, HHS offers $1B for health care innovations – What would MacGyver do?, When it comes to health-care spending, U.S. is “on a different planet”, New Stanford center to address inefficient health care delivery and Is $618,616 too much to (try to) save a life?
Photo by 401(K) 2012

Next week, “Money and Medicine,” a documentary examining the nation’s health-care spending, will premiere on PBS. The film aims to illuminate the waste and over-treatment that burden America’s health-care system as well as explore potential methods for curbing medical costs and improving quality of care for patients.

A full description of the documentary is available on the PBS website:

The film was shot at two world-renowned hospitals – UCLA Medical Center in Los Angeles and Intermountain Medical Center in Utah. The dramatic doctor/patient stories the film captures at these two hospitals illustrate the powerful forces driving excessive medical care as well as proven strategies that can reduce unnecessary medical spending, such as improving the coordination of patient care, facilitating shared patient decision-making, and practicing evidence-based medicine.

At both hospitals, Money & Medicine exposes the painful end-of-life treatment choices made by patients and their families, ranging from very aggressive interventions in the ICU to palliative care at home. The film also investigates the controversy surrounding diagnostic testing and screening as well as the shocking treatment variations among patients receiving a variety of elective procedures.

Watch the above trailer and then tune in on Tuesday to see how the story unfolds.

Previously: Stanford experts argue need for health care, not sick care, Does the Affordable Care Act address our health-cost problem? and Stanford economist Victor Fuchs: Affordable Care Act “just a start”

This summer, Stanford medical students contributed to projects in communities around the globe as part of the Medical Scholars Research Program. In this special back-to-school Q&A series, five students share their experiences developing preventive medicine strategies, gaining hands-on clinical experience and conducting field research.

The Osa and Golfito Initiative (INOGO) is an ongoing effort to develop a conservation and health-improvement plan in the Osa and Golfito cantons of Costa Rica. The initiative is facilitated by the Woods Institute for the Environment at Stanford.

Stanford medical student Lauren Yokomizo became interested in INOGO after learning how the effort used health statistics and demographics to educate government officials and community members about the effects of unsustainable environmental practices on human health, as well as the impact of community health on the environment.

One such project in the ongoing initiative involves an analysis of Costa Rica’s health-care system. More than a half century ago, the country mandated (.pdf) universal social security services, including health-care coverage. As a result, the country implemented a strategy to deliver primary care to all citizens and increased its emphasis on prevention. Despite this effort, a significant percentage of Costa Rica’s health-care spending goes towards hospital-based care.

This summer, Yokomizo traveled to the Central American country to investigate how hospital utilization in rural communities of the country compare to urban areas and differences in facility-use rates due to chronic diseases, specifically cardiovascular disease and diabetes.

I recently spoke with Yokomizo about her summer project.

What data did you analyze and what methods did you use in the process?

I’m reviewing hospital admissions at three levels of care – county, regional and national – to investigate any differences in access to higher level or referral care. Through the use of direct standardization methods, I will examine differences in hospital use between the wealthy central valley and [less affluent] rural counties of the INOGO study area. My analysis will include both general admissions and those conditions responsible for significant morbidity that require advanced care, such as cardiovascular disease and cancer.

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For patients with coronary artery disease who are interested in being proactive in their own health care, I’ve written a series of stories on published studies co-authored by Stanford cardiologist William Fearon, MD, that might provide some helpful insight.

Fearon’s ongoing research has delved into the potential benefits of using a somewhat new technology called “fractional flow reserve,” or FFR, to determine most accurately which heart patients need artery-opening stents – those small tubes inserted into weakened arteries to increase blood flow to the heart.

Coronary heart disease, also called hardening of the arteries, which is caused by the buildup of plaque in the arteries to your heart, is the biggest killer of men and women in the United States. So new research that helps in determining accurately when a stent is needed can help prevent heart attacks or even death.

Fearon’s most recent study, published today in the New England Journal of Medicine, found that the FFR technology (which involves inserting a coronary pressure guidewire into the artery to measure blood flow) can help pick out which patients with stable coronary artery disease need early placement of artery-opening stents rather than being treated with only medical therapy – aspirin or statins. Fearon explains the significance of the results in my story:

We believe there is a significant proportion of patients who benefit from stenting early on as opposed to receiving only medical therapy … For this group of patients who have significant ischemia [blood vessel narrowing that compromises flow to the heart muscle] based on assessment with FFR, the need for hospitalization and urgent revascularization is much higher and the pain relief is much less when only medical therapy is prescribed. People feel better and do better with FFR-guided placement of coronary stents up front in this setting.

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Demand for palliative care has grown (.pdf) tremendously over the past decade. VJ Periyakoil, MD, director of Stanford’s hospice and palliative medicine fellowship program, has experienced firsthand how the burgeoning specialty has exploded, and how the nation’s physician workforce has struggled to keep pace.

“We are at a point in time where the demand for quality palliative care far exceeds the supply of clinicians with required expertise,” Periyakoil told me. “It takes a long time to train doctors and currently we are churning out about 300 fellows annually. Each year, the fellows who graduate from our palliative care fellowship get multiple job offers and most are often recruited to leadership positions.”

A recent American Medical News story offered a detailed look at the rapidly growing need for palliative care services, as well as physicians trained in hospice care:

From 8,000 to 10,000 physician specialists are needed to meet demands in hospice and palliative care programs nationwide, according to the [American Academy of Hospice and Palliative Medicine], a professional organization for hospice and palliative medicine physicians. But only 4,500 doctors specialize in the field, and training programs are expected to produce only an additional 4,600 specialists in the next 20 years, the academy said.

The demand for palliative medicine is driven in large part by advancements in biomedicine and the United States’ graying population. Additionally, a growing body of scientific evidence on the speciality is beginning to show it can improve quality of life for patients diagnosed with serious chronic illnesses and can reduce health costs. As a result, an increasing number of  hospitals are adding or expanding their palliative care programs and more patients seeking services.

In an effort to increase interdisciplinary training in hospice and palliative care, Congress is considering legislation that would allocate nearly $50 million for a range of programs, including training for doctors and fellowships to encourage mid-career physicians to transition to the specialty. The Palliative Care and Hospice Education and Training Act was introduced in July and would also provide awards to support educators in the field.

When I asked Periyakoil how the bill, in enacted into law, would help meet future hospice and palliative care demands, she responded:

If we look at the field of geriatrics, the federal Health Resources and Services Administration funds the Geriatric Academic Career Award (GACA) to increase the number of junior faculty at accredited schools of allopathic and osteopathic medicine. It also promotes the development of their careers as academic geriatricians who emphasize training in clinical geriatrics, including the training of interdisciplinary teams of health professionals. The proposed legislation is a similar effort to promote interdisciplinary palliative care.

The bill could also have important implications for Stanford’s fellowship program. Our fellowship is the oldest interprofessional palliative care fellowships in the country. Funded by the Office of Academic Affiliations, the program trains fellows from the field of medicine, psychology, social work and chaplaincy in palliative care. The fellows learn to train together and work together. Currently, this model is restricted to the fellows serving Veterans Affairs hospitals due to funding reasons. In the future, if the legislature passes, I hope that we will have funding to expand these interprofessional fellowships in academic medical centers.

Previously: Helping caregivers practice palliative care and Examining the generational gap between physicians and patients in hospice and palliative care
Photo by Don LaVange

Although smoking rates in the United States have been slowly declining, tobacco use is on the rise in several developing countries.

In a recent Atlantic post, Lindsay Abrams takes a closer look at the pervasive influence of cigarette manufacturers in the developing world and offers data from the latest Global Adult Tobacco Survey (subscription required).

Survey results show that nearly half of men in 14 developing countries are tobacco users and that women are starting to smoke at younger ages. Overall, researchers predict smoking will cause one billion deaths in the 21st century. Despite the grim outlook, Abrams says there’s reason to be optimistic:

Quit rates are noticeably higher in countries with programs in place for discouraging tobacco use and helping with quitting, such as the U.S., the U.K., Brazil, and Uruguay.

As the world looks to countries as models for tobacco use, Uruguay deserves note. It was included in GATS precisely because of its stringent anti-tobacco policies, including mandated graphic labels that take up 80 percent of cigarette packaging, sales tax increases, and bans on tobacco advertising and on indoor smoking in public places. Earlier this month, the International Tobacco Control Policy Evaluation Project (ITC) released a report indicating that the prevalence of tobacco use in Uruguay has decreased by 25 percent over three years.

Among other promising data, 70 percent of Uruguay’s smokers expressed regret for every having taken up smoking, and in the five-year period covered by the survey, over two-thirds of smokers at least attempted to quit. Positive health changes are already being seen, and may in part be attributed to these policies. The ITC found a 22 percent reduction in the rate of hospital admissions for heart attacks and a 90 percent decrease in air contamination in enclosed public spaces in the year after they were enacted.

Previously: A call to stop tobacco marketing, Study suggests genetics may predict success of smoking cessation methods and What’s being done about the way tobacco companies market and manufacture products
Photo by Alex Dram

In a new video, well-known health economist Victor Fuchs, PhD, shares his thoughts on health care in this country and whether he believes the Affordable Care Act does enough to curb runaway costs. (Spoiler: He doesn’t.) He’s interviewed here by John Shoven, PhD, director of the Stanford Institute for Economic Policy Research.

Previously: Stanford economist Victor Fuchs: Affordable Care Act “just a start”, Stanford experts respond to Supreme Court’s decision on health law, Views on costs and reform from the “dean of American health care economists”, Victor Fuchs talks health-care costs and reform in Q&A and Health economists give Obama their two cents on reform