September 24, 2013
News Review From Harvard Medical School -- Costs in Year after Heart Attack Rise
Costs for each Medicare patient treated for a heart attack rose 17% in the last decade, a new study finds. Only about 26% of that increase came in the first 30 days, including the hospital stay. The rest of the increase occurred in the next 11 months. Researchers looked at cost data for more than 300,000 patients. Each of them had a hospital stay for a heart attack in 1998, 1999 or 2008. The total number of hospital stays for heart attacks fell, probably because of better preventive treatments. But costs for each patient rose about $6,100. About $4,500 of the increase occurred later than the month after the heart attack. Costs paid for nursing homes, hospice, home health care, medical equipment and outpatient care nearly doubled. Researchers noted that Medicare limits what it will pay for heart attack treatment and the 30 days afterward. But beyond that point, the costs are paid on a fee-for-service basis. They said changing this system may help to control Medicare costs. The journal JAMA Internal Medicine published the study. HealthDay News wrote about it September 23.
By Howard LeWine, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
Americans now spend 18 out of every 100 dollars on health care. And health care spending continues to rise at a rate higher than inflation and faster than economic growth. This means there will be even less money in the future for all the other services we want government to support.
But how do we slow the growth of health care spending? Many new developments in medicine put upward pressure on prices. These include new diagnostic tools, advances in drugs and other treatments, and therapies that have extended the lives of people with long-term diseases. But these new expenses don't always translate into better outcomes and improved quality of life.
Most experts agree that value should be the driving force in health care spending, as in everything else we buy. But defining value in health care is very challenging. One commonly used measure is the amount of money spent per year of life saved. It's hardly an ideal measure of value. Just living longer is not something many of us are looking for in health care. But at least researchers have some numbers they can use.
This study focused on where money might be saved during the first year after a heart attack. The health care dollars spent in the hospital right after a heart attack were only 7% more than 10 years ago. That's a relatively small increase compared with most other health care spending. During that same decade, the risk of death in the 30 days after heart attack fell by 18%. That's a very good value.
The same thing is not true for the 11 months after a heart attack. The costs during that time rose 28% compared with what was spent for those 11 months a decade earlier. But the benefits were marginal, with little change in death rates.
These higher costs included:
- More doctor visits
- More tests
- Greater use of home care services
- More people going to nursing homes for short-term rehabilitation services
- More home medical equipment
How much added value did any of these provide? All of us have a stake in answering this question, and not just for heart attack care.
What Changes Can I Make Now?
On a personal level, there is much you can do to improve your health after a heart attack. Doctors call it secondary prevention. (Primary prevention includes those things you can do to prevent ever having heart disease in the first place.)
Secondary prevention begins on the day you are admitted with your first heart attack. Most of the drugs prescribed on Day 1 will be with you for a long time, often for the rest of your life. They include:
- Aspirin, usually 81 milligrams per day (a baby aspirin), to help prevent blood clots in arteries around your heart.
- A statin drug, even if your cholesterol is normal. Statins help reduce inflammation, an important cause of heart attacks.
- A beta-blocker to slow your heart rate and lighten the heart's workload.
- An angiotensin-converting enzyme inhibitor (ACE inhibitor) to promote healing of the heart. These drugs also can lower your risk of future heart attack.
Of course, lifestyle changes are just as important.
- Absolutely no smoking.
- Eat a Mediterranean-style diet.
- Start an exercise program, as specified by your doctor. He or she may recommend a formal cardiac rehab program.
The drugs are available as generics. A healthy diet does not need to cost a lot. And exercise is free. There are no greater values in post-heart attack care!
What Can I Expect Looking to the Future?
This type of study must be done for many more health conditions. It will become obvious how much of our health care spending produces no value or very low value.