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Journal of Community Health
Published in: Journal of Community Health 6/2010

01-12-2010 | Original Paper

Further Opportunities for Cost Reduction of Medical Care

Authors: M. Malach, W. J. Baumol

Published in: Journal of Community Health | Issue 6/2010

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Abstract

The already high and still rising cost of health care has become a matter of serious concern and a subject of political dispute. The problem has no magic cures but, as is shown here, there are a number of promising modifications in current practice that promise to reduce the required outlays without impairing appropriate health care. Continual reports of new medicines, new tests, and new procedures have created an urgent need for careful comparison and evaluation of the advantages and beneficial results that these innovations offer. The same is true for the growing knowledge of genetic variations, which affects the course of therapy for some patients. Costs also can be saved, in some instances, by utilization of medical therapy, rather than interventional procedures. Preventive medicine provides still more opportunities for cost savings. This paper provides an overview of promising potential approaches to reduce the cost of health care.
Footnotes
1
In the interest of thoroughness, some of the examples cited in our previous paper [2] are repeated here.
 
2
For instance, in testing new cardiovascular devices, the United States Food and Drug Administration premarket approval process has been found to be lacking in strength and also subject to possible bias, as noted in a report published in the Journal of the American Medical Association by Dhrunetal et al. (December 23/30, 2009, Vol. 302, pp. 2679–2685).
 
3
There is a large literature on statistical and econometric methods in which the pitfalls of the use of careless statistical evidence are spelled out. For an illuminating and amusing compendium of widespread economic misunderstandings resulting from careless statistical reasoning, see Freakonomics [9].
 
4
CT angiography carries with it a risk of cancer because of radiation exposure. There has been some diminution of radiation dosage in the process, but there is wide variability among institutions in this change. The number of all CT scans performed annually in the United States is estimated to be 75 million, as reported by Wachser in Newsmax (December 24, 2009).
 
5
The vasodilating flushing effect of niacin is largely minimized by the addition of aspirin, or by slow uptitration of niacin.
 
6
For example, Medicare allocates a hospital stay of four days or less for a diagnosis of uncomplicated heart attack. This policy grants no leeway for the care of unrelated, but associated medical conditions, like gout, peptic ulcers, urinary tract infections, or other non-coronary vascular occlusions.
 
7
It is noteworthy that as many as 40% of patients with heart attacks may not have an early elevation of cardiac enzymes in the presence of an acute coronary syndrome (ACS). Although they may have low risk factors for coronary disease, inflammation or infection may provoke an acute coronary vessel occlusion by rupture and embolism of an unstable, previously non-occluding atherosclerotic placque or coronary artery spasm [36]. This, then, later may be identified as a heart attack. An autopsy study revealed that placque ruptures and placque erosion are the source of emboli causing sudden death and heart attack before microscopic anatomic cellular damages became visible [37].
 
8
Now it has been reported that makers of brand name drugs have paid generic drug makers to delay the marketing of cheaper, alternative generic drugs. However, new health care legislation may curtail such agreements, which could save health consumers several billion dollars a year on prescription drugs (Singer, New York Times, 13 January 2010, pp. B1, B4).
 
9
In addition, red wines have been found to decrease tooth decay, as reported by Hubbard in Newsmax (January 8, 2010).
 
10
Elevation of HDL levels tend to lower LDL levels reciprocally.
 
11
Although arteriosclerosis was known for a long time to cause death in patients with coronary disease, no successful therapeutic treatment was available until the advent of statins. The accumulation of lipids and inflammatory cells in the walls of arteries is not newly discovered. Marchand in 1904, Ignatawsky and Neudauss in 1905, and Anitchvov in his classic paper in 1913 all connected the relation of cholesterol to obstructive atherosclerotic vascular disease. An editorial in 1958, by William Dock, published in the Annals of Internal Medicine likened Anitchvov’s discovery to that of the tubercle bacillus by Koch and Harvey [47, 48].
 
12
Biomarkers here are interleukin-1 receptor (ST2) and N-terminal pro-B type naturetic peptide (N-pro-BNP).
 
13
The use of diuretics as an essential medication for treatment of hypertension requires close and careful monitoring for electrolyte imbalance and dehydration.
 
14
The cost of defensive medicine is commonly thought to account for no less than 25% of all medical care costs in the United States. However, it is impossible to quantify these costs.
 
15
Related to defensive medicine are patient demands for specific tests or treatments that may not be necessary, which also contribute significantly to the costs of unneeded medical care and can be dangerous.
 
16
Epigenomes, which sit on the outside top of each gene, promote or quiet the expression of that particular gene. Environmental forces, such as starvation or overeating, can cause epigenomes to enhance or suppress a particular gene in a mother or father’s genetic material—ova, sperm, and the embryo in utero, thereby passing on a new trait to the next generation. This could explain some genetic mysteries, such as why only one member of a set of identical twins may develop asthma or bipolar disorder. Furthermore, as has been shown in animals, the addition of a methyl group can change the expression of a gene by increasing or decreasing its activation [84].
 
Literature
1.
Baumol, W. (1993). Social wants and dismal science: The curious case of the climbing costs of health care and teaching. Proceedings of the American Philosophical Society, 137(4), 612–637.
2.
Malach, M., & Baumol, W. (2009). Opportunities for the cost reduction of medical care. Journal of Community Health, 34(4), 255–261.CrossRefPubMed
3.
Malach, M., & Rosenberg, B. (1958). Acute myocardial infarction in a city hospital: Clinical review of 264 cases. American Journal of Cardiology, 1(6), 682–693.CrossRefPubMed
4.
Killip, T., & Kimball, J. (1967). Treatment of myocardial infarction in a coronary care unit: A two-year experience with 250 patients. American Journal of Cardiology, 20(4), 457–464.CrossRefPubMed
5.
Ting, P., et al. (2007). Trends in mortality from acute myocardial infarction in the coronary care unit. Annals of the Academy of Medicine, Singapore, 36(12), 974–979.PubMed
6.
Ford, E., et al. (2007). Exploring the decrease in US deaths from coronary disease, 1980–2000. New England Journal of Medicine, 356(23), 2388–2398.CrossRefPubMed
7.
Malach, M., & Imperato, P. (2006). Acute myocardial infarction and acute coronary syndrome: Then and now (1950–2005). Preventive Cardiology, 9(4), 228–234.CrossRefPubMed
8.
Stewart, J., et al. (2007). Participation in surgical oncology clinical trials: Gender-, race/ethnicity-, and age-based disparities. Annals of Surgical Oncology, 14(12), 3328–3334.CrossRefPubMed
9.
Levitt, S., & Dubner, S. (2005). Freakonomics. New York: HarperCollins.
10.
Stampfer, M., et al. (1985). A prospective study of postmenopausal estrogen therapy and coronary heart disease. New England Journal of Medicine, 313(17), 1044–1049.CrossRefPubMed
11.
Taubes, G. (2007, September 16). Do we really know what makes us healthy? New York Times Magazine: 52 and 78.
12.
Rossouw, J., et al. (2002). Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the women’s health initiative randomized controlled trial. Journal of the American Medical Association, 288(3), 321–333.CrossRefPubMed
13.
Brownlee, S. (2007). Overtreated: Why too much medicine is making us sicker and poorer. New York: Bloomsbury Publishing.
14.
Kolata, G. (2008, February 7). Diabetes study partially halted after deaths. New York Times: Sec. A1 and A23.
15.
Ernst, M., & Moser, M. (2009). Use of diuretics in patients with hypertension. New England Journal of Medicine, 361(22), 2153–2164.CrossRefPubMed
16.
Pollack, A. (2007, December 26). The for-profit side of cancer treatment. New York Times: 1.
17.
Fazel, R., et al. (2009). Exposure to low-dose ionizing radiation from medical imaging procedures. New England Journal of Medicine, 361(9), 849–857.CrossRefPubMed
18.
Schneeweiss, S., Seeger, J., Landon, J., & Walker, A. (2008). Aprotinin during coronary-artery bypass grafting and risk of death. New England Journal of Medicine, 358(8), 771–783.CrossRefPubMed
19.
Shaw, A., et al. (2008). The effect of aprotinin on outcome after coronary-artery bypass grafting. New England Journal of Medicine, 358(8), 784–793.CrossRefPubMed
20.
Yu, C., et al. (2009). Biventricular pacing in patients with bradycardia and normal ejection fraction. New England Journal of Medicine, 361(22), 2123–2134.CrossRefPubMed
21.
Taylor, A., et al. (2009). Extended-release niacin or ezetimibe and carotid intima-media thickness. New England Journal of Medicine, 361(22), 2113–2122.CrossRefPubMed
22.
Lee, J., et al. (2009). Effects of high-dose modified-release nicotinic acid on atherosclerosis and vascular function: A randomized, placebo-controlled, magnetic resonance imaging study. Journal of the American College of Cardiology, 54(19), 1795–1796.CrossRef
23.
24.
25.
Markowitz, S., & Bertagnolli, M. (2009). Molecular basis of colorectal cancer. New England Journal of Medicine, 361(25), 2449–2460.CrossRefPubMed
26.
Damani, S., & Topol, E. (2007). Future use of genomics in coronary artery disease. Journal of American College of Cardiology, 50, 1933–1940.CrossRef
27.
Voora, D., et al. (2009). The SLCO1B1*5 genetic variant is associated with statin-induced side effects. Journal of the American College of Cardiology, 54, 1609–1616.CrossRefPubMed
28.
Priori, S. (2009). What to expect from genetic footprinting in clinical arrhythmology. ACCEL (American College of Cardiology) 41–11, Disc 1, Track 2.
29.
Judge, D. (2009). Use of genetics in the clinical evaluation of cardiomyopathy. Journal of the American Medical Association, 302(22), 2471–2476.CrossRefPubMed
30.
31.
32.
Hochman, J., et al. (2006). Coronary intervention for persistent occlusion after myocardial infarction (occluded artery trial). New England Journal of Medicine, 355(23), 2395–2407.CrossRefPubMed
33.
Boden, W., et al. (2009). Impact of optimal medical therapy with or without percutaneous coronary intervention on long-term cardiovascular end points in patients with stable coronary artery disease (from the COURAGE Trial). American Journal of Cardiology, 104(1), 1–4.CrossRefPubMed
34.
Curtis, J., et al. (2009). All-cause readmission and repeat revascularization after percutaneous coronary intervention in a cohort of medicare patients. Journal of the American College of Cardiology, 54(10), 903–907.CrossRefPubMed
35.
Javaid, A., et al. (2007). Outcomes of coronary artery bypass grafting versus percutaneous coronary intervention with drug-eluting stents for patients with multivessel coronary artery disease. Circulation, 116, I-200–I-206.CrossRef
36.
Rudd, J., Davies, J., & Weissberg, P. (2007). Atherosclerotic biology and epidemiology of disease. In E. Topol (Ed) Textbook of Cardiovascular Disease (3rd ed), (pp 2–12) Philadelphia: Lippincott Williams and Wilkins.
37.
Schwartz, R., et al. (2009). Microemboli and microvascular obstruction in acute coronary thrombosis and sudden coronary death. Journal of the American College of Cardiology, 54, 2167–2173.CrossRefPubMed
38.
Deshmukh, S. (2009). Ranolazine improves endothelial function in patients with stable coronary artery disease. Coronary Artery Disease, 20(5), 343–347.CrossRefPubMed
39.
Alderman, L. (2009, December 19). A new disquiet about generic drugs. New York Times: B6.
40.
Bertelli, A. & Das, D. (2009, September 18). Grapes, wines, resveratrol and heart health. Journal of cardiovascular pharmacology (Epub ahead of print).
41.
42.
Blumenthal, R., & Michos, E. (2009). The HALTS trial—halting atherosclerosis or halted too early? New England Journal of Medicine, 361(22), 2178–2180.CrossRefPubMed
43.
Rodés-Cabau, J., et al. (2009). Acute effects of statin therapy on coronary atherosclerosis following an acute coronary syndrome. American Journal of Cardiology, 104(6), 750–757.CrossRefPubMed
44.
Amarenco, P., & Labreuche, J. (2009). Lipid management in the prevention of stroke: Review and updated meta-analysis of statins for stroke prevention. Lancet, 8(5), 453–463.CrossRef
45.
Mahmarian, J. & Pratt, C. (2007). Myocardial perfusion imaging in identifying a low-risk group after acute myocardial infarction. Cardiology Review 24(7): 19–24.
46.
Ridker, P., et al. (2008). Rosuvastatin to prevent vascular events in men and women with an elevated C-reactive protein. New England Journal of Medicine, 359(21), 2195–2207.CrossRefPubMed
47.
Konstantinov, I., Mejevoi, N., & Anichkov, N. (2006). Nikolai N. Anichkov and his theory of atherosclerosis. Texas Heart Institute Journal, 33(4), 417–423.PubMed
48.
Dock, W. (1958). Research in arteriosclerosis—The first 50 years. Annals of Internal Medicine, 49(3), 669–705.
49.
Downs, J., et al. (1998). Primary prevention of acute coronary events with lovastatin in men and women with average cholesterol levels: Results of AFCAPS/TexCAPS (air force/Texas coronary atherosclerosis prevention study). Journal of the American Medical Association, 279(20), 1615–1622.CrossRefPubMed
50.
Tsimikas, S. (2009). High-dose statins prior to percutaneous coronary intervention. Journal of the American College of Cardiology, 54, 2164–2166.CrossRefPubMed
51.
Setoguchi, S., et al. (2007). Ten-year trends of cardiovascular drug use after myocardial infarction among community-dwelling persons ≥65 years of age. American Journal of Cardiology, 100, 1061–1067.CrossRefPubMed
52.
Teo, K., et al. (2009). Optimal medical therapy with or without percutaneous coronary intervention in older patients with stable coronary disease. Journal of the American College of Cardiology, 54, 1303–1308.CrossRefPubMed
53.
deFilippi, C., & Seliger, S. (2009). Biomarkers for prognostication after acute coronary syndromes: New times and statistics. Journal of the American College of Cardiology, 54, 365–367.CrossRefPubMed
54.
Pagani, F., Miller, L., Russell, S., et al. (2009). Extended mechanical circulatory support with a continuous-flow rotary left ventricular assist device. Journal of the American College of Cardiology, 54(4), 312–321.CrossRefPubMed
55.
Lev, E., et al. (2010). Treatment of aspirin-resistant patients with omega-3 fatty acids versus aspirin dose escalation. Journal of the American College of Cardiology, 55, 114–121.CrossRefPubMed
56.
Wang, T., Bhatt, D., & Topol, E. (2006). Aspirin and clopidogrel resistance: An emerging clinical entity. European Heart Journal, 27(6), 647–654.CrossRefPubMed
57.
Bhatt, D. (2009). Prasugrel in clinical practice. New England Journal of Medicine, 361(10), 940–942.CrossRefPubMed
58.
Flossmann, E., & Rothwell, P. (2007). Effect of aspirin on long-term risk of colorectal cancer: Consistent evidence from randomized and observational studies (British doctors aspirin trial and the UK-TIA aspirin trial). Lancet, 369(9573), 1603–1613.CrossRefPubMed
59.
O’Keefe, J. H., Gheewala, N., & O’Keefe, J. O. (2008). Dietary strategies for improving post-prandial glucose, lipids, inflammation, and cardiovascular health. Journal of the American College of Cardiology, 51, 249–255.CrossRefPubMed
60.
Kostis, J. (2007). A new approach to primary prevention of cardiovascular disease. American Journal of Medicine, 120(9), 746–747.CrossRefPubMed
61.
Malach, M., & Imperato, P. (2004). Depression and acute myocardial infarction. Preventive Cardiology, 7(2), 83–90.CrossRefPubMed
62.
Mitrou, P., et al. (2007). Mediterranean dietary pattern and prediction of all-cause mortality in a US population. Archives of Internal Medicine, 167(22), 2461–2468.CrossRefPubMed
63.
Féart, C., Samieri, L., & Barberger-Gateau, P. (2010). Mediterranean diet and cognitive function in older adults. Clinical Nutrition and Metabolic Care, 13(1), 14–18.CrossRef
64.
Devol, R., et al. (2007). An unhealthy America: The economic burden of chronic disease—charting a new course to save lives and increase productivity and economic growth (research report). Santa Monica, C.A.: Milken Institute.
65.
Stueve, A., & O’Donnell, L. (2007). Continued smoking and smoking cessation among urban young adult women: Findings from the reach for health longitudinal study. American Journal of Public Health, 97(8), 1408–1411.CrossRefPubMed
66.
67.
Gerber, Y., et al. (2009). Smoking status and long-term survival after first acute myocardial infarction. Journal of the American College of Cardiology, 54, 2382–2387.CrossRefPubMed
68.
Shu, X., et al. (2009). Soy food intake and breast cancer survival. Journal of the American Medical Association, 302(22), 2437–2443.CrossRefPubMed
69.
Yan, L., & Spitznagel, E. (2009). Soy consumption and prostate cancer risk in men: A revisit of a meta-analysis. American Journal of Clinical Nutrition, 89, 1–9.CrossRef
70.
Ma, H., Li, J., Gao, F., & Ren, J. (2009). Aldehyde dehydrogenase 2 ameliorates acute cardiac toxicity of ethanol: Role of protein phosphatase and forkhead transcription factor. Journal of the American College of Cardiology, 54(23), 2187–2196.CrossRefPubMed
71.
72.
73.
Janszky, I., et al. (2009). Chocolate consumption and mortality following a first acute myocardial infarction: The Stockholm heart epidemiology program. Journal of International Medicine, 266(3), 248–257.
74.
Galleano, M., Oteiza, P., & Fraga, C. (2009). Cocoa, chocolate, and cardiovascular disease. Journal of Cardiovascular Pharmacology, 54(6), 483–490.CrossRefPubMed
75.
Rodwin, M., Chang, H., & Clausen, J. (2006). Malpractice premiums and physicians’ income: Perceptions of a crisis conflict with empirical evidence. Health Affairs, 25(3), 750–758.CrossRefPubMed
76.
Braunwald, E. (2009). Cardiology as a Profession in 2020 and Beyond. ACCEL (American College of Cardiology) 41–11, Disc 2, Track 1.
77.
Cohen, J., Neumann, P., & Weinstein, M. (2008). Does preventive care save money? Health economics and the presidential candidates. New England Journal of Medicine, 358(7), 661–663.CrossRefPubMed
78.
Phillips, R., & Andrieni, J. (2007). Translational patient care: A new model for inpatient care in the 21st century. Archives of Internal Medicine, 167(19), 2025–2026.CrossRefPubMed
79.
Horowitz, H. (2008). The interpreter of facts. Journal of the American Medical Association, 299(5), 497–498.CrossRefPubMed
80.
Berg, A., et al. (2009). National institutes of health state-of-the-science conference statement: Family history and improving health. Annals of Internal Medicine, 151(12), 872–877.PubMed
81.
Wilson, B., et al. (2009). Systematic review: Family history in risk assessment for common diseases. Annals of Internal Medicine, 151(12), 878–885.PubMed
82.
Berwick, D. (2009). Measuring physicians’ quality and performance. Journal of the American Medical Association, 302(22), 2485–2486.CrossRefPubMed
83.
Brook, R. (2009). Assessing the appropriateness of care—its time has come. Journal of the American Medical Association, 302(9), 997–998.CrossRefPubMed
84.
Cloud, J. (2010). Why your DNA isn’t your destiny. TIME, 175, 49–53.
85.
Fuchs, V. (2009). Eliminating “waste” in health care. Journal of the American Medical Association, 302(22), 2481–2482.CrossRefPubMed
86.
Emanuel, E., & Fuchs, V. (2008). The perfect storm of overutilization. Journal of the American Medical Association, 299(23), 2789–2791.CrossRefPubMed
87.
Reinhardt, U. (2007, August 5). What doctors make and why (letter to the editor). New York Times: 9.
Metadata
Title
Further Opportunities for Cost Reduction of Medical Care
Authors
M. Malach
W. J. Baumol
Publication date
01-12-2010
Publisher
Springer US
Published in
Journal of Community Health / Issue 6/2010
Print ISSN: 0094-5145
Electronic ISSN: 1573-3610
DOI
https://doi.org/10.1007/s10900-010-9253-6

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