Colin Kopes-Kerr, MD
6444 Timber Springs Drive
Santa Rosa CA 95409
E-mail: cpkerr@nni.com
Kopes-eticHealth.com:
A New Dawn for Health Care Information
Cost Containment Ideas
We all know that health care in the U.S. has become simply too expensive to do much good. At all levels of participation in the enterprise we should be alert to potential ways of being more efficient and saving dollars. Here I offer some ideas of my own, and I invite you to submit your in our discussion page.
1. Asthma management: Among adult asthmatics use of nebulizer machines is common, but, according to the medical literature, they are no more effective than hand-held MDIs (inhalation devices). Since they are costly to provide, to service, and to supply with medication, their use could be limited by requiring pulmonary function testing to show both that they provide at least a 20% improvement in lung function over baseline and that they perform at least 10% better than an MDI.
2. Hypertension management: The medical literature clearly supports generic diuretic (thiazide) therapy as the drug of first choice for the treatment of hypertension. This is also the cheapest of all the drugs available for the treatment of hypertension (one of those perfect cost-containment situations in which the cheapest solution is also the best). Thus a restriction could be put on the majority of other (more expensive) anti-hypertensive medications, limiting their use to patients who either are currently on a diuretic or who have tried and had to discontinue a diuretic due to an allergy or adverse effect. An exception could be made for patients who are under the care of cardiologists.
3. Heart
disease prevention and treatment: One of the greatest expenses among
covered drugs are those known as "statins" (cholesterol lowering medication).
According to the medical literature (both in the US and internationally) these
very expensive drugs are being overused and often used inappropriately. The
clear principle justifying their use according to the literature is the
designation of the patient as "high-risk" for a cardiovascular event. Most
physicians, however, either don't classify the cardiac risk status of their
patients or do so subjectively (which the literature has shown consistently and
significantly overestimates risk, and thus leads to overuse of these drugs).
Patients can be easily classified into high, medium, or low-risk groups based on
readily available clinical data–i.e., blood pressure, age, gender, smoking
status, cholesterol, diabetes status, exercise status, and family history. There
are a large variety of validated ways of extracting the risk status from this
information–computerized scores (Framingham equation), clinical forms (e.g. the
New Zealand Heart foundation chart is the best), or a simple counting of risk
factors. However it is done, the potential cost-effective intervention is two
fold:
(1) restrict statin prescriptions
(Lipitor, Crestor, Zocor, Mevacor, etc.) from those at low-risk; and
(2) provide a physician prompt to
prescribe it/consider it for those at high-risk (possibly medium risk). There is
probably more money to be saved by avoiding the low-risk prescriptions (probably
the majority of current prescribing) and enough to offset the increased cost of
providing additional prescriptions to those at high risk. The literature also
clearly indicates that there are significant long-term cost savings and reduced
mortality from treating high-risk patients with statin medications.
4. Management of Hyperlipidemia: [This should
really be understood as any lipidemia in high-risk patients.] The
most cost-effective approach is to follow the principles of the British Heart
Study. (See FP Revolution 1 No 1 2007)
1. Calculate global cardiac risk
(using the 10 basic risk factors, the Framingham equation, the New Zealand Heart
Foundation guideline, or whatever your favorite cardiac risk calculator is).
2. Decide where you will set your
own cut-offs for low-risk vs. intermediate risk, vs. high-risk.
3. Treat all high-risk patients
with the highest tolerated dose of a statin forever (or until
subsequent global cardiac risk assessments show that the patient is no longer in
the high-risk group).
4. Do not order serial lipid
panels.
5. Do not attempt to titrate
the dose other than to increase it to the limit of tolerability.
6. Perform global cardiac risk
assessment at least once a year.
Rationale: There is no good evidence to support the NCEP's policy of testing and re-testing lipids with repeat dose titration until you reach certain arbitrary targets. The British Heart Study shows that just picking a dose and leaving it without further testing achieves as much benefit in high-risk patients as the NCEP approach with far less cost and trouble.
5. Prevention of Cervical Cancer: The most
important (and only important) historical information that you need to obtain is
an reliable answer to the question, "Have you have had an abnormal Pap smear
result?" [Of course, if the answer is affirmative, you need to track down the
specific histological information.] The sole objective of Pap smear screening
is the detection of high-grade precursor lesions (HSIL). Pap smear
screening need not begin until 3 years after the onset of sexual
activity. It should be repeated annually for 2 additional years and then be
performed only every 2-3 years depending upon the risk status of the women. For
women at low risk (i.e., they have never had a prior abnormal Pap smear) every 3
years is a very suitable interval for screening. If you really want to do
something about cervical cancer prevention in the U.S. all you need to do is to
seek out women who have either never been screened or who have not been screened
with the above-recommended frequency. These are very easily identifiable; they
just don't have much money or good insurance.
For most women (i.e., for all those who do NOT have
HSIL on their Pap smear) there is no need for ThinPrep, HPV testing, colposcopy,
cyrotherapy, LEEP, or laser. An enormous amount of money in the U.S. is wasted
on this disease by ordering frequent 'frill' tests like the above for low-risk
women (healthy, well-insured women, who have never had a significantly abnormal
Pap smear.