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12 Ways Health Reform May Improve Care and Save Costs

Cheryl Clark, for HealthLeaders Media, August 11, 2009

Uncle Sam is poised to spend $1.1 billion in stimulus funds to compare the effectiveness of 100 treatment categories in coming years, so providers, taxpayers, and insurance premium payers will stop wasting money on worthless care.

But many experts say there's already enough evidence to start changing clinical practice to cut waste, improve outcomes, and save as much as 30% of what is being spent today.

There are 12 possible ways that health reform could look to improve care while saving costs:

1. If health reform creates a public plan, the federal government will have to make decisions on whether to spend money on procedures like vertebralplasty. Researchers point out this is not to ration care, but to approve spending to target only that which has been shown to make people better, and live longer, more enjoyable lives.

Last week in the New England Journal of Medicine, two studies compared vertebralplasty, a surgical procedure on the vertebrae done in 8.9 per 1,000 persons in the U.S, with a simulated or "sham" procedure.

Both groups of patients reported the same improvements in pain and disability, even six months later. An accompanying editorial carried a colorful chart of the country showing such wide variations in use of the procedure, 66 regions in the nation used the procedure 30% higher than the national average while 105 regions used it 25% less frequently.

As described in another New England Journal of Medicine article published Monday, Dan Callahan decried an April 29 Senate Finance Committee report that demands that those conducting comparative effectiveness research with that $1.1 billion "should be prohibited from issuing medical practice recommendations or from making reimbursement or coverage decisions or recommendations."

Callahan called it "the first shot across the bow of serious cost reform."

Research is essential to use science to inform the process through which patients and doctors make honest and realistic decisions based on the best interests of the patient. When that happens, there will be a lot of avoided costs, not to mention avoided risk, from unnecessary tests, procedures, and medications.

Researchers with the Dartmouth Atlas crunched Medicare utilization data throughout each region and county in the country and determined that up to 30% of Medicare dollars are wasted each year, in part because of wide variations in care practices.

Douglas Wood, MD, of the Mayo Clinic in Rochester, MN, and Joe Scherger, MD, chairman of the Right Care Initiative of the Rand Corp., and a clinician at Eisenhower Medical Center in Rancho Mirage, CA, helped prepare a list of procedures, drugs, and screenings that offer little or no benefit, yet are commonly used in healthcare, often at tremendous and unnecessary expense.

2. Coronary stents may be overused by 30%, and far too many bypass graft procedures are done on patients who could be better, more safely managed with medications. Since concern about stent thrombosis incidents that occurred after drug eluting stents were implanted, the number of stent placements has started dropping, which Wood says "is a pretty good clue we were overusing them."

At the Mayo clinic, Wood says, the same cardiologist does not do the exam, the angiogram, and the angioplasty. "Here there are at least two opinions before you get an angioplasty," he says.

3. Coronary calcification screening in asymptomatic people over age 70 may be a waste of money. "Most people of that age have coronary calcification, but it won't predict whether they are going to have a heart attack," Wood says. With these expensive tests comes an increased risk of cancer from radiation. A recent study found between 42 and 62 extra cases of cancer per 100,000 people would occur over the course of their lives if they underwent such tests every five years, after age 45 for men and 55 for women.

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