Health care is an expensive endeavor, and this is as true in the United States as it is anywhere else in the world. By 2015, it is projected that health care spending in the U.S. will be around $4 trillion. Even in its present state, health care makes up a larger percentage of our country's economy than any other country based on gross domestic product. On one hand, a booming health industry is a good sign, as it reflects an increase in jobs being created in health care. However, there is also a growing concern that increased health care spending is causing significant strain on individuals and businesses that are having to shoulder the costs. With this in mind, cutting or stabilizing health care costs is a worthy goal.

What does it mean to cut costs?

Cost control in the health industry is typically framed in a political sense. When a person says that we should cut health care costs, the implication usually being made is that the government should reduce its health care budget. That is obviously one way to cut health care spending, but that isn't the topic that I mean to address here. In the book Understanding Health Policy, Drs. Bodenheimer and Grumbach compare painful and painless ways of controlling costs. Cutting the government's health care budget (without changing health care delivery) is a painful method of cost control because it would likely have a negative impact on either the quality of care or access to care. The approaches to cost control I would like to highlight are the so-called painless ones: methods where a decrease in cost is not accompanied by a decrease in quality of care or access to care.

What are painless ways to cut costs?

Drs. Bodenheimer and Grumbach highlight a number of ways to cut costs, many of which would fall into the political arena (controlling provider incomes, cutting pharmaceutical prices). However, they do point out three apolitical methods:
1. Eliminate medical interventions that have no benefit
2. Substitute cheaper treatments in favor of more expensive ones where both are equally effective
3. Increase those preventive services that cost less than the illnesses they prevent

Health care providers offer treatments with no benefit?

Yes! Every field of medicine is abound with examples. Just recently, the drug Avastin received FDA approval for advanced breast cancer despite showing no evidence of prolonging life or increasing quality of life. Avastin did reduce the size of the tumors. Knowing all the terrible side effects and risks that a person undertakes when starting chemotherapy with Avastin, is shrinking a tumor merely for the sake of shrinking it considered a benefit? In this case, the FDA thought so, even though its advisory panel did not (That's not to say that doctors aren't allowed to prescribe a medication that isn't FDA approved -- they are allowed to and frequently do). However, Avastin costs $50,000 a year, and widespread use of a drug that so far hasn't been shown to improve anything other than a radiographic finding seems difficult to justify.

A very common example of a medical intervention that hasn't demonstrated clear benefit is fetal heart monitoring in pregnant women during labor. From the standpoint of the pregnant woman (or her family), monitoring the fetus' heart has an obvious advantage. If the fetus gets into trouble, the doctors can take immediate action. But can fetal heart rate monitoring accurately detect when a fetus is in trouble? The recommendations from the 2005 guidelines published by the American College of Obstetricians and Gynecologists (ACOG) are sobering.
- The false-positive rate of electronic fetal monitoring (EFM) for predicting adverse outcomes is high.
- The use of EFM is associated with an increase in the rate of operative interventions (vacuum, forceps, and cesarean delivery).
- The use of EFM does not result in a reduction of cerebral palsy rates.
- Reinterpretation of the fetal heart rate (FHR) tracing, especially knowing the neonatal outcome, is not reliable.
Despite many measures showing no clear advantage and in the face of the disadvantage of the risks that come with performing a C-section, U.S. physicians continue to monitor fetal heart rates during labor. One of the reasons frequently brought up for the existence of this practice is legal protection for physicians. I am not aware of the outcomes of individual lawsuits related to this issue, but to me (again as an outsider), it seems that if you showed the ACOG recommendations to a judge/jury, you would have at least some evidence on your side. Eliminating the practice of fetal heart monitoring would reduce the number of unnecessary C-sections being conducted and could save millions of dollars without affecting quality of care or access to care.

Is cheaper better when two treatments are equally effective?

Let's say you're a physician who evaluates a patient who is feeling nauseated. You're given two options. On one hand is promethazine ($22 for 30 tablets) and on the other is ondansetron ($570 for 30 tablets). For noncritical conditions in non-pregnant and non-chemotherapy patients, the two medications are equally effective in treating nausea. Another study in ER patients suggests that promethazine may cause more side effects than ondansetron, but that the medications otherwise are similarly effective. Anecdotally, I will say that I have seen and worked with many physicians who will prescribe ondansetron (known more commonly by its trade name of Zofran) because "Phenergan (promethazine) doesn't work for everyone." Interestingly, when pharmacists contact physicians who inappropriately prescribe ondansetron to let them know the proper guidelines, it's been shown that the cost of care goes down without worsening patients' nausea.

Is it cheaper to prevent problems instead of dealing with the costs of those problems?

In most cases, the answer is no. That's not necessarily a reason to avoid prevention programs, because cost isn't the only factor people use to make decisions about their own health. But with the exception of childhood vaccinations (and things like having access to clean water), there are very few preventive health programs that end up being cheaper than treating life-threatening complications. For example, it costs more money to treat high blood pressure than to let people develop massive heart attacks (at which point hospitals are obligated to offer treatment because of the Emergency Medical Treatment and Active Labor Act). It also costs more money to conduct routine mammograms and breast biopsies than to wait for patients to get metastatic breast cancer with severe emergent complications (again requiring hospital emergency care). If the goal is to cut costs, increasing prevention programs does not accomplish it.

Can we implement painless cost control strategies?

This isn't really clear. It's hard for me to imagine a major academic hospital doing away with fetal heart monitoring unless national guidelines specifically recommend against its use. I can see physicians changing prescribing practices when faced with two equally effective but differently priced medications, but this would require some kind of intervention: automated reminders when inappropriately prescribing expensive medications, opting out of free medical sample programs (that alter prescribing practices in favor of more expensive medications even when free samples run out), and forming a national panel of physicians who review data and issue specific cost-control guidelines.