Is Technology Responsible for Rising Healthcare Costs?

There’s an interesting article in the Washington Post that articulates the case that the reason for rising costs in health care is that each incremental improvement, propelled by increasingly more sophisticated technology, is more costly than the last:

In the 1960s, the chance of dying in the days immediately after a heart attack was 30 to 40 percent. In 1975, it was 27 percent. In 1984, it was 19 percent. In 1994, it was about 10 percent. Today, it’s about 6 percent.

Over the same period, the charges for treating a heart attack marched steadily upward, from about $5,700 in 1977 to $54,400 in 2007 (without adjusting for inflation).

I found the article alternately intriguing, frustrating, and tantalizing, a sort of intellectual fan dance that conceals what you actually want revealed. Take the sentence above, for example. The author could just as easily have point out that the charges for treating a heart attack, adjusted for inflation, increased from $20,000 in 1977 to $54,000 in 2007.

Or this:

The treatment of coronary heart disease — of which heart attack, or acute myocardial infarction, is the most significant component — this year will cost about $93 billion. It’s a huge contributor to the $2.3 trillion annual bill for medical care in the United States. Cardiovascular disease is responsible for 35 percent of deaths in America and has been the leading cause of death every year since 1900, except 1918, the year of the Spanish flu epidemic.

$93 billion is a huge figure. $2.3 trillion is a huge figure. But $93 billion is about 4% of $2.3 trillion. Is that a “huge contributor”? I don’t think so. That’s the sort of thing that makes me wonder if journalists have no feel for numbers.

In addition I don’t believe the figures on leading causes of death are correct. My recollection, supported here, is that the leading cause of death in 1900 was pneumonia. Where does David Brown, the author of the WP article, get his figures? He doesn’t say. He may well be making them up.

I know where he gets the figure of 35% of deaths being due to cardiovascular disease: the American Heart Association. I think that’s a little overstated, although it might be correct. Remember that most deaths are ultimately caused by heart failure.

Here’s the one that really bugged me:

An angioplasty costs more than 10 times the price of a dose of TPA. In 1993, American cardiologists performed 375,000 angioplasties. In 2000, they did 676,000, according to data prepared by Anne Elixhauser, a biostatistician at the federal Agency for Healthcare Research and Quality.

The number inched up further after 2002, when a study showed that it was worth doing angioplasties even if a hospital didn’t have heart surgeons on hand to rescue patients from the occasional catastrophic complication.

That opened smaller, community hospitals to the procedure. In 2007, U.S. cardiologists did 721,000 of them.

Clinical trials in the 1990s also showed that if a wire-mesh tube — a stent — was put into the blocked artery, there was less chance that the vessel would close up. Stents didn’t change heart attack survival significantly, but they became standard practice nevertheless, adding to the bill.

In recent years, researchers have sought to learn whether stents impregnated with an anti-inflammatory compound perform better than bare metal ones. The answer appears to be: Yes, a little.

Bare metal stents cost $600 to $800 apiece, while “drug-eluting” ones go for $1,500 to $2,200. About 70 percent of angioplasties use the more expensive ones. The benefit, though, is very small. People who get a $1,500 stent have a 5 percent lower risk of needing a whole new procedure than people who get a $600 one.

This is a fan dance. The cost of an angioplasty averages around $35,000. For budgetary purposes let’s say that the difference in cost between a bare metal stent and a drug-eluting stent is $1,600 and four of them are used in a single angioplasty. That’s $6,400, about 15% of the total. The surgeon’s fee can account for nearly half of the total (Medicare pays a lot less). Rather than proving that technology is raising the cost of healthcare the author may well be demonstrating how little of the cost is technology.

The example of angioplasty is an interesting one for another reason as well: it’s somewhat controversial. I can show you any number of studies showing no reduction in mortality due to ischaemic heart disease as a consequence of the 721,000 angioplasties performed in the United States annually or no difference in outcomes between angioplasty and medication (the medications cost about $10,000 less than the surgery). At the very least there’s a difference of opinion on this subject.

That complication isn’t mentioned in the article. We may, corporately, be paying a heckuva lot of money (721,000 X $10,000= $7.2 billion) for no improvement in outcomes at all let alone the “best treatment available”, as claimed in the article.

Note: the cost of angioplasty in Germany is about a quarter of what it is here. Are stents so much less expensive there?

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