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Tag: Naomi Freundlich

If Doctors Lead, Will Health Care Costs Follow?

Can doctors and other health care providers be the driving force in achieving cost-effective health care? In their commentary in the New England Journal of Medicine, Stanford professors Victor Fuchs and Arnold Milstein, call this the “$640 billion question.” That figure represents the savings to the national health care bill if all U.S. physicians and health care organizations could follow the example of individual providers who already deliver high-quality care at a costroughly 20% lower than the average.

The authors ask “Why don’t cost-effective models diffuse rapidly in health care, as they do in other industries?” The answer, according to Fuchs and Milstein, is that a long list of stakeholders has interests that are effectively blocking the “diffusion of cost-effective care.” These include drug and medical device-makers who tout their new, more expensive products as always better than older (and cheaper) alternatives; insurance companies with high administrative costs; employers who offer just one or two benefit plans to workers; legislators who accept donations from health industry insiders, academic health centers that tolerate cost inefficiency as the price of training residents; and others whose vested interests keep them from fully embracing cost-effective care.

The media is also to blame, write the authors, by publishing articles that tout miracle cures and treatments to boost newsstand sales and failing to convey risk/benefit information accurately.

Trying to cut health care costs has often been compared to squeezing a balloon; pinch the air out of one end and it will fill up the other. Or as the Canadian economist Robert G. Evans recently told a Group Health audience, “look carefully at so-called ‘waste’ in the U.S. health care system. ‘Nothing is ever wasted… Every dollar ‘always goes somewhere, which is what makes it so difficult to bend the (cost) curve.’ In other words, one person’s waste is another person’s income.”

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Medicare Costs Rise, Health Outcomes Suffer When Seniors Are Over-Medicated

The problem of elderly people taking too many medications is not new, but continues to pose a serious risk to health as well as contribute significantly to rising Medicare costs. The fact is that nearly 20% of adults aged 65 years and older who are not hospitalized take 10 or more medications daily. This number is not the result of shoddy care, but rather achieved when doctors simply follow practice guidelines for several common, co-existing conditions like diabetes, high blood pressure and depression, for example. If you look at all seniors (those both in and out of the hospital) the American Society of Consultant Pharmacists reports that the average 65-69 year old takes nearly 14 prescriptions per year; by ages 80-84 that number averages an astounding 18 prescription drugs per year.

What’s troubling is that instead of improving the health of seniors, evidence is growing that the more medications an elderly person takes, the more likely he is to experience falls, cognitive decline, loss of mobility, depression and even cardiac problems. These adverse drug effects may be mistaken for Alzheimer’s disease or other dementias too. The bottom line: Experts estimate that up to one-third of the elderly in our communities may be over-medicated and some 20% of their hospital admissions are due to adverse drug events. The costs related to over-medication in the elderly are thought to exceed $80 billion each year.

Although the problem of so-called “polypharmacy” among seniors results in significant economic and public health costs, little has been done to remedy the problem. In fact, in a recent commentary in the Journal of the American Medical Association, Jerry Avorn, associate professor of medicine at Harvard Medical School and author of the book “Powerful Medicines,” says that “many aspects of the US health care system act to discourage optimal prescribing” for the elderly.

For example, elderly Americans are highly underrepresented in the clinical trials for many of the drugs that doctors commonly prescribe for them. Seniors may metabolize these medications differently and they are often more sensitive to side effects and counter-indications with other drugs than younger people. They also take many more drugs (often all at the same time) than any subjects who take part in controlled clinical trials. Disturbingly, doctors sometimes end up prescribing a new medication to treat the adverse effects of a pill the elderly patient has been taking for years.

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