Health costs vary by state

[Rich_in_Tampa]

A new study abstracted here shows that costs vary up to 50% by state with little impact on quality.

Some key points:

• residents of Massachusetts, Maine, New York, Alaska, Connecticut, Delaware, Rhode Island, Vermont, West Virginia and Pennsylvania had the highest spending, with an average of $6,345 per capita.
• Utah, Arizona, Idaho, New Mexico and Nevada—had an average of only $4,244 per person.
• the higher-spending states generally had the highest concentration of physicians, the highest incomes and the smallest percentages of uninsured
• geographic differences in health care spending grew in 1991-1998 and decreased in 1998-2004. They attributed this change to managed care plans’ influence
• higher spending does not appear to be related to better health care quality [there was not enough information presented for me to know the validity of this claim - the socioeconomic variables can throw such claims off as to cause and effect]

Often, wide variation in health care practices and outcomes is caused by failure to follow evidence-based guidelines by patients, doctors, or both.

[FinanceGeek]

Interesting. I wonder how much of the spending differences are attributable to cost differences based on each state's economic cost structure, e.g. cost of living, cost of doing business, cost of malpractice insurance, etc?

For example, I think we could easily show AT LEAST a 50% difference in cost in housing among groups of states - again I suspect we'd find no apparent differences in overall quality...

[LeatherneckPA]

Originally Posted by Rich_in_Tampa

Often, wide variation in health care practices and outcomes is caused by failure to follow evidence-based guidelines by patients, doctors, or both.

Rich Could you explain "failure to follow evidence based guidelines..." in English please?

[Rich_in_Tampa]

Originally Posted by lthrnckpa

Rich Could you explain "failure to follow evidence based guidelines..." in English please?

If the best research says it is not useful to get annual screening chest x-rays, we shouldn't get them. That's evidence-based medicine.

If Dr. Casey orders more x-rays than the evidence justifies this is not evidence-based medicine. Many things simply do not have credible evidence one way or the other, but most medical decisions do have some supporting research.

When there's no good evidence, you have to really on biologic plausibility (the decision should at least be consistent with what we know about the basic science of the disease or treatment).

The best evidence may point to doing more of a service, or to doing less. It only looks at outcomes from carefully designed and executed research into how patients do with and without various interventions.

Reasons for variation from evidence-based medicine (EBM) include financial benefit, ignorance, pressure from patients, perceived medicolegal risk if a test is not done, pressure and subterfuge from pharmaceutical reps and ads ("Ask your doctor about Gorillacillin."), and many others.

While theoretically EBM might increase or decrease overall costs, most services studied tend to show a considerable (20-30%) decrease, with same or better outcomes.

Hope that helps.

[LeatherneckPA]

OK, but how are WE simple folk to know what the medical evidence indicates vs what our doctor says? Isn't that why we go to doctors, because they know this stuff and we don't?

For instance, I was hospitalized last November for chest pains. After a complete battery of tests it was determined to be stress related angina. My doctor prescribed Citalopram, which seems to be working. He said we might try to do away with it after I finish my high-stress career in prisons. I understand the logic of that.

He also put me on Simvastatin. My total cholesterol was only 164. Dave said it was due to family history and "new guidelines" that say I should be under 130. I always thought anything under 200 was pretty decent and over 240 was bad. I'd have thought my 164 was great, especially for a 300+ guy. The Simvastatin seems contra-indicated to me, but Dave says the evidence indicates it could literally add decades to my life expectancy.

[kcowan]

I am suspicious that the new guidelines for cholesterol are the results of lobbying by drug companies. Has anyone seen evidence-based research to show it to be a good approach?

[FinanceGeek]

Originally Posted by kcowan

I am suspicious that the new guidelines for cholesterol are the results of lobbying by drug companies. Has anyone seen evidence-based research to show it to be a good approach?

This could also have come from the insurance industry, as an excuse to up-rate most people.

[teejayevans]

Comes from a panel of experts:
New Cholesterol Guidelines - Lower Recommended Levels of LDL Cholesterol Indicate Earlier Intervention for Hundreds of Thousands of Americans

Whether these experts have an agenda is another question.
TJ

[ziggy29]

Originally Posted by kcowan

I am suspicious that the new guidelines for cholesterol are the results of lobbying by drug companies. Has anyone seen evidence-based research to show it to be a good approach?

As am I. Whether we're talking about "optimal" weight or cholesterol, it seems like the "standards" are constantly redefined to make more and more of the population "unhealthy" by the numbers.

Whether Big Pharma or Big Insurance is behind it, I can't say...but it wouldn't shock me.

I was on another board when someone reported they had a blood screening and the LDL cholesterol reading was 100 -- which was marked as "high." Most charts I've seen list up to 99 as "desirable" and 100-129 as "nearly normal/desirable." Then, 130-159 is "borderline high" and 160+ is high. I think showing 100 as "high" is unnecessary fearmongering unless we're talking about an individual with a history of heart disease, heart attacks, high blood pressure or perhaps diabetes. But none of these applied in her case.

[kcowan]

Originally Posted by teejayevans

Comes from a panel of experts:
New Cholesterol Guidelines - Lower Recommended Levels of LDL Cholesterol Indicate Earlier Intervention for Hundreds of Thousands of Americans

Whether these experts have an agenda is another question.
TJ

Thanks for the link. It eases my concern because I am in the low risk group (except for high triglycerides). This statement:

This is the second update to the guidelines since their inception in 1993, and is based on five major clinical trials of statin therapy (a cholesterol-lowering pharmaceutical treatment) conducted since the release of the first update in 2001

makes me think the trials were conducted by statin vendors.

[Nords]

Originally Posted by kcowan

Thanks for the link. It eases my concern because I am in the low risk group (except for high triglycerides). This statement:
makes me think the trials were conducted by statin vendors.

My impression of the media hailstorm of cholesterol "education" is that higher cholesterol isn't really a big deal unless there are also other risk factors.

If it's over 300, well, that may be an issue. But even at 200 I've been subjected to finger-wagging and pharmaceutical threats that tend to ignore a 20-year history of such numbers.

Has anyone here had their doctor turn cartwheels & backflips over their cholesterol profiles? Or has everyone been subjected to varying degrees of professional concern all the way to downright grumpiness?

[IBWino]

My total cholesterol has been above 200 (210 to 240) for the past 15 years, but each time I had it checked, my doctor told me that I was "below average risk for heart disease" and he made no recommendations for medication (my HDL and triglycerides have always been good). He recently retired, so I'm curious to see what my new doctor will have to say about it. From discussions with friends and coworkers, I definitely get the impression that the response to elevated cholesterol levels varies widely between doctors.

[Want2retire]

Originally Posted by Nords

Has anyone here had their doctor turn cartwheels & backflips over their cholesterol profiles? Or has everyone been subjected to varying degrees of professional concern all the way to downright grumpiness?

My doctor liked my cholesterol until it got to be above 250. When lifestyle changes didn't seem to help even a little, he suggested Vytorin (which I am now taking). Now, he does cartwheels and backflips over my cholesterol numbers: 127 last time! HDL and LDL are corrected now, too.

He said, "I have no problems with this bloodwork" which is about as enthusiastic as I have ever seen him.

[Rich_in_Tampa]

50-something male with high cholesterol who have never had a cardiac event (It's much higher for secondary prevention - patients who already have coronary disease or diabetes):

• Sudden death + heart attack rate = around 1.7 to 2% per year untreated
• Sudden death + heart attack rate = around 1% per year treated
• 30 to 40% relative reduction in heart attacks and sudden death from statins. This is the number pharma companies use in their ads.
• 0.7% absolute reduction per year (roughly). This is the number good doctors use to help their patients decide.
• 1% risk of important side effects from statins (rarely serious or fatal if drug is stopped, though dramatic rare exceptions have occurred); such side effects are much less serious than a heart attack.
• Probably a moderate relative reduction in strokes and possibly in Alzheimers (still unclear, data are interesting but not definitive)

The .7% per year net benefit does not sound impressive to most people hearing it for the first time. It is cumulative so that a 50 year old at risk for 25 years has an aggregate risk of 17.5% treatment premium advantage over a reasonable lifespan compared to those who decline treatment.

I actually do an individual risk analysis for every patient in this situation (a more sophisticated version on my Palm). They decide, I coach, everyone's happy (most of the time ).

It's not a political question. You just have to decide if the cost is worth it to you or not. Your doctor makes no money off of prescribing statins or any other drugs.

Hope that helps. Oh... and see my signature line.

[ziggy29]

Originally Posted by IBWino

My total cholesterol has been above 200 (210 to 240) for the past 15 years, but each time I had it checked, my doctor told me that I was "below average risk for heart disease" and he made no recommendations for medication (my HDL and triglycerides have always been good). He recently retired, so I'm curious to see what my new doctor will have to say about it. From discussions with friends and coworkers, I definitely get the impression that the response to elevated cholesterol levels varies widely between doctors.

When my cholesterol was last checked it was 227 total, and LDL was 'borderline high' at 138, but between very high HDL (69), a "favorable" LDL/HDL ratio of exactly 2, and absolutely no family history of heart problems going back at least three generations, my doctor wasn't terribly concerned about it other than to watch that it doesn't go much higher.

[unclemick]

Originally Posted by Rich_in_Tampa

Often, wide variation in health care practices and outcomes is caused by failure to follow evidence-based guidelines by patients, doctors, or both.

After 14 years of taking those stinging eyedrops for glaucoma - my eye doc(about my age) got newer equipment for eye ball pressue measurement - decided that that I was ok after all - AND since I had ER'd - went part time as a med school prof and persued his passion of international fishing.

The moral here escapes me - other than that's my evidence based story.

heh heh heh - oh yeah - he played end on the Illoinis team that beat us (UW Huskies ) in the Rose Bowl when I was a Junior.

[Rich_in_Tampa]

Originally Posted by unclemick

After 14 years of taking those stinging eyedrops for glaucoma - my eye doc(about my age) got newer equipment for eye ball pressue measurement - decided that that I was ok after all - AND since I had ER'd - went part time as a med school prof and persued his passion of international fishing.

The moral here escapes me - other than that's my evidence based story.

Mick, one moral from your story is that "best" evidence is usually not "perfect" evidence. Glaucoma detection technology advanced greatly in the last few years, to where they can actually count nerve fibers and other things to determine which patients who seem to have glaucoma actually do have it. This is a good thing - improved evidence leading to a reduction in treatment.

You were a "false positive" using the old technology, but the risk of withholding treatment based on your findings would have led to blindness for a predictable proportion.

Glad you're off the drops and that your high-tech test was negative.

[LeatherneckPA]

Originally Posted by Rich_in_Tampa

Oh... and see my signature line.

Rich, as always, informative and insightful. I had no idea the effect was cumulative. Neat. And I love the signature line, read it previously too. Pity it's necessary though, isn't it?