Image: Illustration by Alex Nabaum
In Brief
- Soaring bill: U.S. health care costs are expected to top $2.7 trillion in 2011 and are growing at an unsustainable rate. One way to save money is to pay only for the most effective treatments.
- Roadblock: Proving which treatments work best can be expensive and time-consuming. Randomized controlled trials, the most scientifically rigorous, often require hundreds of millions of dollars.
- Sensible solution: Analyzing information found in the medical records of large health networks could reveal which treatments are most effective at a fraction of the cost of standard clinical trials.
- Political reality: Many Americans fear that talk about cost-cutting in health care will lead to rationing. But who wants to spend money on something that does not work?
More In This Article
It was the largest and most important investigation of treatments for high blood pressure ever conducted, with a monumental price tag to match. U.S. doctors enrolled 42,418 patients from 623 offices and clinics, treated participants with one of four commonly prescribed drugs, and followed them for at least five years to see how well the medications controlled their blood pressure and reduced the risk of heart attack, stroke and other cardiovascular problems. It met the highest standards of medical research: neither physicians nor their patients knew who was placed in which treatment group, and patients had an equal chance of being assigned to any of the groups. Such randomized controlled trials have long been unmatched as a way to determine the safety and efficacy of drugs and other treatments. This one, dubbed ALLHAT (Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial), cost an estimated $120 million and took eight years to complete.
The results, announced in December 2002, were stunning: the oldest and cheapest of the drugs, known as thiazide-type diuretics, were more effective at reducing hypertension than the newer, more expensive ones. Furthermore, the diuretics, which work by ridding the body of excess fluid, were better at reducing the risk of developing heart failure, of being hospitalized and of having a stroke. ALLHAT was well worth its premium cost, argued the National Heart, Lung, and Blood Institute (nhlbi), which ran the trial. If patients were prescribed diuretics for hypertension rather than the more expensive medications, the nation would save $3.1 billion every decade in prescription drug costs alone—and hundreds of millions of dollars more by avoiding stroke treatment, coronary artery bypass surgery and other consequences of high blood pressure.
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11 Comments
Add CommentAlthough this article addresses a critical issue in relation to the cost of health care, the control of health care as exerted by organized medicine, hospitals, pharmaceutical companies, the Joint Commission and others was not addressed. The several organizations of "Organized medicine" continue to control all aspects of the regulation and financing of health care. The obvious conflicts of interests are ignored by government, insurance companies, and other major 'players' in health care. It is my opinion that until control of health care is removed from those with the most to gain by continued lack of unbiased supervision, the cost of and unnecessary use of expensive medications and technologies will continue. Those that suffer the most will continue to be the patients who pay high insurance premiums, copays, and deductibles; receive tests with high false positives; pay for drugs which are contributing to the increasing number of multiple drug resistant bacteria, and continue to be denied care by other providers who are qualified to meet the patient's needs in a variety of settings.
Reply | Report Abuse | Link to thisMs. Rowell, you well may be right. While Ms. Begley's article offers a glimmer of hope that medical care costs might be controlled, I too am convinced that the medical industry is powerfully motivated by profit and will persist in controlling their lucrative income in many subtle ways at the expense of the public. I have posted on the subject at this link:
Reply | Report Abuse | Link to thishttp://jwheeler59.wordpress.com/2011/05/12/ice-bergs-and-ice-cubes/
Well-meant as your article and leader were, they rest on a mistaken premise. Our health care system is actually almost perfectly successful in doing what it was designed for: to transfer wealth from sick people to the special interests who control the political process. Is it not time to say out loud what we all know? Health care is broken for the same reason the economy is bankrupt, and much else too: because the political process is bankrupt in every sense of the word. Scientific American could help us better by suggesting ways in which our kleptocracy can be replaced by scientifically designed, effective structures of social organization. Constitutional Convention anyone?
Reply | Report Abuse | Link to thisI am disappointed with Scientific American for publishing this article. This article is deceptive because it ignores the largest single element of waste in our medical system; the money extracted by for profit insurance companies. Many studies have documented the burden they place on our health care dollars. Since this money in profits to the insurance industry provides nothing in the way of patient care it should be the first area to look at for savings, instead the author completely ignores this fertile area for cost cutting and focus on victims of the for profit money squeeze . We learn from the author that the problem is very complex, but it boils down to being primarily caused by stupid doctors wasting money on ineffective treatments. The only thing complicated about our health care crisis is that it is caused by a corrupt system that provides lavish lifestyles to a few individuals who weld enormous political power. What bothers me the most about this article is that there seems to be more of conservative propaganda then science about it. If Scientific American continues to fill its pages with politically driven pseudo science it will lose its integrity and its readership.
Reply | Report Abuse | Link to thisUnfortunately a 10 paragraph commentary can hardly address the complexities of US health care. However, the SCIAM editors should have done a better job than trumpeting of the same tired and largely invalid critiques of US healthcare.
Reply | Report Abuse | Link to thisWHO measures of US vs. other nation’s borders on fraud. The comparison of say, Japan to the US is fraught with problems:, genetics, cultural differences, etc. If we take account of these issues in DALE score and compare apples to apples you will find the US is at the top of its comparable group of nations. Other discrepancies of measurement are rife in the Dale score data and too lengthy to go into here. Do not take others word for it, I encourage you to study it yourself.
Contrary to the claim in the article, we have not had fee for service medicine for a very long time. We have a system where money is handed to those not consuming the service. Providers are then left to weasel the money away from the third party who has no interest in the outcome of the service provided. This leaves the patient as a mere commodity to both the payer and provider instead of being the purpose of the transaction. Just look at the emphasis of the debate. It is all about how the payer relates to the provider. As long the health data gets massaged to look good everyone is happy except the patient.
The only thing worst than fee for service is fee for no service. The most corrupt incentive is to give the money up front to a passel of administrators and expect them to conduct business in favor of the patient. In such systems Public Health types demand "Barriers to Care" to limit patient access. Less access to therapy means more money. Again, the health data can always be massaged to look good enough to justify the actions.
Want solutions try this:
Physicians must interact with their patients regarding the cost of therapy and patients must pay something for treatment up front. Several RAND studies make it clear that patients seek and select care differently if they have a hand in the game. The current system cuts off this essential component of market based price control; it is not surprising our costs have soared.
P1ace a moratorium on medical advertising. In my little town of 100K the hospitals together spend $25 Million on advertising to what end. Multiply that around the country and you are talking some real money.
Remove the entrenched administrative class whose only job is pander to payers.
Turn all this back to patient care and you will have accomplished much to fix our current problem.
I wonder if the commentators read the article. The article merely was suggesting better ways to use existing data. This would be wise even in a system not controlled by pharma, gov't, facists, capitalists or whomever it is they are blaming/praising for a failed/successful system.
Reply | Report Abuse | Link to thisThe article did a good job showing the need to establish practice guidelines based on scientific inquiry of patient records. As good physicians know we need to standardize the science of medicine and individualize the art of medicine. My issue is with the time-worn comparision of the Untied States with other OECD countries, particularly the United Kingdom. No other OECD country enjoys are rich ethnic mixture or history. For example, the United Kingdom is as of last census over 92% white. When comparing our health care costs and outcomes let us use as comparisions countries that share our diversity, if we can find one.
Reply | Report Abuse | Link to thisI agree with the frustration exhibited by the first few comments posted about this article. Why not call it what it is: Disease Care! We don't have a Health Care System in the USA. This article seems supportive of the inevitability of Disease and not the sustainability of Health. Why have alternative approaches not been included in the research? Are we to believe that once a diagnosis is made our only option is precription medications? Anyone whose paying attention realizes that people have reversed various "degenerative" diseases without the use of meds. Follow the money trail... who is enriched by the current mainstream approach? How about, Big Pharma, the Insurance Companies and, yes, even Med School educators. Professors are oftem at least partially supported in their "research" by Big Pharma...and do we then think it could be comprehensive unbiased research? Who are the professors educating? and with what biases? Nevertheless, The Scientific American must avoid gettng caught up in the broken system. Be as you say you are...SCIENTIFIC! Dr. JK
Reply | Report Abuse | Link to thisIn “The Best Medicine" seems that the importance of a diagnosis and therefore a personalized treatment is overlooked. Both classic trials and comparative effectiveness research (CER) provide statistics about what works best for most people but they ignore the uniqueness of each individual. Taking as example the case-study the author provides: hypertension, it is well recognized today that approximately 10% of all hypertensive cases are due to primary aldosteronism (Ann. Clin. Biochem. 2010, 47:195-199), if those cases are treated in the same way the majority 90% is, they not only will failed to be treated correctly, but also the long term cost of treatment will be much higher than if the cause of the hypertension is identified from the beginning. Today, primary aldosteronism can be diagnosed with inexpensive renin activity and aldosterone tests (www.dbc-labs.com). However, very few physicians prescribe this or other tests to pint-point the cause of hypertension, this result in that in the industrialized nations only between 10 and 30% of hypertensive patients are controlled (Curr. Cardiol. Rev. 2010, 6:119-123). The cost of this failure is colossal; nevertheless it represents an extraordinary opportunity for prevention of the consequences of hypertension, in particular stroke and boost the bang for the health care buck.
Reply | Report Abuse | Link to this@Cubanchemist My thoughts exactly. CER's are great ways to determine what treatment is better for the general population. But unfortunately, a 5% benefit for a 32 000 person study group may not turn out to be any benefit for the patient standing in front of a doctor. If doctor's weren't around for assessing the needs of individual patients, robots would easily be able to give every man, woman, and child a thiazide diuretic when their blood pressure spiked. I don't think any healthcare decisions should be solely based upon CER results, but I do agree they should be used in conjunction with clinical trials.
Reply | Report Abuse | Link to this
Reply | Report Abuse | Link to thisThe problem is entrenched money. We should use the known, tested, successful therapies, but they are not FDA approved. We can bypass the FDA. When diagnosed 14 years ago with aggressive prostate cancer, I chose high-dose vitamin C, but kept my doctors informed. I am in excellent remission. I had bypassed the FDA.
Patients can bypass the FDA and have an immediate help for diseases treatable with over the counter supplements.
The National Cancer Institute1 in 1969 reported that vitamin C kills cancers. In 1971, Cameron2,3,4 and others treated many types of terminal and hospitalized cancer. Of the first 1,100 patients, the 100 vitamin-treated ones lived 4.2 times as long as the controls.
Abram Hoffer, MD5,6,7 received mostly advanced cancer patients that had failed regular treatments. He gave oral-only vitamin C with other vitamins and minerals. Most of his patients took 12,000 mg/day of vitamin C, as limited by diarrhea. He followed an early test group of 134 patients with 30 types of advanced cancer for 15 years. Those who refused vitamins lived a mean of only 2.6 months. The 101 who accepted vitamins lived 45 months. Cameron and Hoffer found that vitamin C did not loose its effectiveness by cancer mutation, as does chemotherapy.
The big drug companies objected. Creagan8 and Moertel9 ran double blind tests using high-dose vitamin C, but incorrect procedures. Their tests can be neglected. Vitamin C is not approved for cancer therapy. Patients can safely and legally use vitamin C as cancer therapy since they are not bound by the FDA restrictions on doctors.
The vitamin C therapies of Cameron and especially Hoffer are safe, tested, effective, and can be used now without further tests, but proper medical supervision is recommended. The above example of bypassing FDA approval by using over the counter supplements applies to many diseases. If enough patients bypass the FDA, the cost of medicine in the US could drop significantly in a few years.
References
1. Benade at NCI. 1969;23:33-43.
2. Cameron Campbell. Chem-Biol. Interactions. 1974;9:285-315
3. Cameron & Pauling. Proc Natl Acad Sci, USA. 1976;73(10):3685-3689.
4. Cameron & Pauling. Proc Natl Acad Sci, USA; 1976(9):4538-4542.
5. Hoffer & Pauling. J of Orthomolecular Medicine. 1993;8:1547-167.
6. Hoffer. Vitamin C and Cancer. 2000
7. Houston. Vitamins Can Kill Cancer. 2006
8. Creagan. New England J of Medicine. 1979;301:687-690.
9. Moertel. New England J of Medicine. 1985;312:137-41.