How many aspirin can you buy for $11,000?

Evidence-based medicine requires that we treat patients with medications and procedures that have been proven to be safe and efficacious. Drug A might be indicated to treat an illness, for example, if it reduces the mortality of that condition over some period of time studied.

The efficacy of a drug is often determined by trials which statistically compare patients' outcomes using that drug, to outcomes in similar patients either treated with a different drug or with a placebo, a tablet or injection which has no drug in it at all.

Some drugs show such statistical superiority that their use is considered to be the "standard of care" in treating certain conditions. Recently, doctors have even been offered "bonuses" by Medicare, if they document the use of some of these agents in certain disease states, in a system called the Physician Quality Reporting Initiative (PQRI).

For example, Measure #6 in the PQRI determines what percentage of patients I treat with coronary artery disease are taking a drug that inhibits platelets from clumping together. Most commonly, this would be a prescription medication called clopidogrel (Plavix), or nonprescription aspirin. For years I have told my patients with coronary artery disease to take an aspirin daily, as a cheap and easy way to prevent future heart attacks or strokes. For the individual patient, it is a good decision, and the economic cost to that individual is minimal.

However, when we begin to look at the finances of healthcare delivery, as we debate the administration's evolving plans for healthcare reform, we have to consider the implications and costs of such a recommendation to the healthcare system. In 2002, a study by Gaspoz and his colleagues estimated the cost, based upon improvements in mortality with aspirin treatment, at $11,000 per quality-adjusted year of life gained by therapy. Using clopidogrel instead of aspirin, by the way, was estimated to cost $130,000 per quality-adjusted year gained.

Similar estimates have been generated for cardiology procedures. Parmley, et al, estimated in 1999 that performing an angioplasty in the setting of a heart attack costs $12,000 per quality-adjusted life year. Wong, et al, estimated in 1990 that angioplasty costs $6,400 to $8,800 per life year saved in patients with severe angina, but $28,000 to $132,000 per life year saved in patients with mild angina. Placing a stent in an artery, as opposed to angioplasty alone, was estimated by Cohen, et al, in 1993 to add another $32,000 per life year saved for patients with single vessel coronary artery disease.

It is difficult, if not impossible, to place a value on a year of a person's life, particularly if that person is your patient, or a family member, or yourself. On the other hand, if we, as a society, are going to pay for the health care costs of our fellow citizens, what costs are we willing to bear?

And what about promoting less expensive life-style changes, as well? What is the cost of throwing away our cigarettes? It might even save us enough to pay for our prescriptions. What is the cost of a healthier diet, to decrease our growing problems of obesity and to help control our elevated cholesterol levels and our diabetes? What is the cost of taking a walk each day to improve our physical conditioning, our blood pressure control, our good HDL cholesterol levels, and our muscle and joint health?

That daily aspirin may help us prevent our second heart attack. But the effect would be even more striking, if we took it on the way out of the house for our daily walk.

Too much food, too little exercise.....

It has been called the "obesity epidemic," the growing wave of obesity in the American population over the past 3 decades.

When we consume more calories in a day that we burn, we gain weight, even if those calories come from the fad food group of the month fueling the lastest diet frenzy.

A new study presented by Australian researchers attempted to determine whether the major driving force for weight gain in America was due to increasingly sedentary lifestyles or increasing food consumption.

They used data from the National Health and Nutrition Examination Survey (NHANES) maintained by the National Center for Health Statistics to determine the mean weight gains seen in American children and adults between 1971 and 1976 and between 1999 and 2002.

They compated this to food supply data from the U.S. Department of Agriculture to determine how much food was delivered to the American population between 1970 and 2002. This allowed them to estimate how much weight gain would have been expected between these periods solely from the change in calories consumed.

The mean weight gain of 4 kg seen in children was exactly what would have been predicted by increased caloric consumption alone. In adults, the observed mean weight gain of 8.6 kg was a little less that the 10.8 kg which would have been predicted from increased caloric intake. This suggested that adults may have been increasing their physical activity to some extent to burn off these extra calories.

While we could all benefit from increased physical activity, not only for weight control, but for increased cardiovascular health, this study strongly suggests that declining the offer to "supersize" our portions may be a more efficient way to stem the growth of obesity in the American population.

Wouldn't this time and money be better spent taking care of patients?

A recent study published in Health Affairs estimates that the cost of time spent by physicians and their office staffs interacting with insurance companies was $21-31 billion annually, or about $68,000 per physician per year. This includes nearly 4 hours of nursing staff time per physician per day, and 7.2 hours of clerical staff time per physician per day, as well as 43 minutes per day of direct physician time.

Wouldn't this time and money be better spent taking care of patients?

A thought to consider as we debate the future of healthcare delivery in this country.

Expanded healthcare coverage...at what cost?

The Obama administration's goals for expanding healthcare coverage to those who are currently uninsured is admirable, and who could criticize such a plan? Wouldn't we all like to have the security of knowing that our healthcare needs will be met, no matter what the future brings?

Much has been written about the direct costs of such a plan. The estimates are probably no more accurate than the estimates for GM's needs to avoid impending bankruptcy.

What about the indirect costs to our society in the form of future tax increases for funding the plan, and in the form of inflation created by growing deficits that will be passed on to our children and grandchildren?

How about the costs to our healthcare delivery system, that will be forced to accept lower payment rates for providing healthcare services. One cannot afford to deliver care that costs more than the reimbursement given for very long. Neither hospitals nor physicians can make up the loss generated on each transaction by increasing the volume of transactions.

Meanwhile, our patients demand better, more accurate diagnostics and cures, despite the costs involved in providing them. Our current healthcare delivery often removes the consumer (the patient) from the financing of the purchase, which is handled by anonymous insurers or government agencies. There is always unlimited demand for a "free" service, and patients feel they are entitled to unlimited care, despite their ability or inability to pay for it.

As we transition to increased public financing of this effort, how do adjust our patients' expectations that they can continue to use services without any limits? And if limits are imposed, will they simply access the system through healthcare's back door, the emergency room, where the threat of a plaintiff's attorney's shadow is always lurking if a bad outcome occurs?

We need more than the bandaid of a new entitlement program to solve the problems of healthcare financing and delivery. We need a frank discussion of what our society's goals and objectives should be. Only then can we design a system to take us there. As Lewis Carroll wrote: "If you don't know where you are going, any road will get you there." We have come to a fork in the road. We should follow Yogi Berra's advice, and take it.