Why do we see these headlines in our medical journals

Nasor - Mario L Maiese

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Number 138 September 2009 Let’s Agree To Agree Let’s forget about Obama’s selling of reform–it’s In 1999 health care costs were 8% of the median high-class hucksterism. Let’s forget about the family's income, today they are 18% and, if conservative opponents who match or exceed his nothing is done, will be 35% in less than a exaggerations with low-class fear-mongering. decade. Both distort the facts. If coverage is expanded and improved, how can This Heartbeat will discuss why it’s important costs be controlled? I believe physicians have for physicians to become involved in the more direct control over costs than many of the healthcare reform debate. With our pens or in other sectors of the industry (hospitals, rare instances computer keys, we’re responsible insurance, pharmacy), and I think we should be in large part for the quality, quantity and cost of able to agree on a few examples. healthcare. We also have a vested interest in healthcare reform because it is our livelihood. Tort Reform Whether from the far right or radical left, I think there are issues on which we can agree to agree This is a no-brainer. All doctors need to be and participate. We can do this by “smart” telling their legislators and the public that there responsible management of our patients and by has to be tort reform as part of any healthcare voicing our opinions. reform. The ...

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Number138 September2009 Let’s Agree To Agree Let’s forget about Obama’s selling of reform–it’sIn 1999 health care costs were 8% of the median highclass hucksterism. Let’s forget about thefamily's income, today they are 18% and, if conservative opponents who match or exceed hisnothing is done, will be 35% in less than a exaggerations with lowclass fearmongering.decade. Both distort the facts. Ifcoverage is expanded and improved, how can ThisHeartbeatdiscuss why it’s importantcosts be controlled? I believe physicians have will for physicians to become involved in themore direct control over costs than many of the healthcare reform debate. With our pens or inother sectors of the industry (hospitals, rare instances computer keys, we’re responsibleinsurance, pharmacy), and I think we should be in large part for the quality, quantity and cost ofable to agree on a few examples. healthcare. We also have a vested interest inhealthcare reform because it is our livelihood.Tort Reform Whether from the far right or radical left, I thinkthere are issues on which we can agree to agreeThis is a nobrainer. All doctors need to be and participate. We can do this by “smart”telling their legislators and the public that there responsible management of our patients and byhas to be tort reform as part of any healthcare voicing our opinions.reform. The threat of lawsuits increases costs becauseit affects how we practice. It’s not as First we should be able to agree on the premiselarge of a component of healthcare costs as most that we need healthcare reform.The goals ofbelieve, buttort reform would help to decrease healthcare reform are to expand coverage to thehealthcare costs and should be part of uninsured, improve coverage for thehealthcare reform—and we should agree! underinsured while simultaneously controllingthe everexpanding costs that are bankruptingDeath Panels? our country. Andwhether we believe there are 15 or 47 million uninsured, I think we can agreeI believe we all should be upinarms about the that there are too many. Most physicians, left or“Death Panel” scare tactics and how lawmakers right politically, believe they have an obligationcaved into them. Why shouldn’t we be paid to to care for less fortunate people with limiteddiscuss endof life care with our patients? resources. One American now dies every 12Patients, families and physiciansshould be minutes from lack of health insurance.discussing this, so that the patients’ wishes are

known before they cannot express them.We♥Patients should not be on any angiotensin frequently do not do it because of timereceptor blocker (ARB) unless they are constraints and lack of payment. Heroic anddocumented to be allergic, have a cough or extraordinary care more often than not extendsangioedema secondary to an ACE inhibitor suffering rather than life. Yet, 25 to 30% of(ACEI). No study has found ARBs superior to Medicare spending (which represents onefifth ofACEI for blood pressure or heart failure. The personal health spending) occurs in the patient’sonly difference is significantly increased cost. last year—most in the last week. No one wants to deprive ill seniors of desirable care, but they♥ There isalmost no indication for using Coreg should be able to make an informed endof lifeSR or Bystolic for the treatment of heart failure decision when they’re able, and I believe mostor high blood pressure when we have many other want less suffering.I know I do.Appropriatecosteffective generic choices. endof life counseling will improve quality of lifeand decrease cost. It should be done and it♥The best current evidence shows that most should be paid for.patients with hypertension require combination therapy.The best is a calcium channel blocker Generic Medications/Smart Dosing(CCB) and ACEI or ARB for the treatment of themajority of patients with hypertension, We should all agree to use generic medicationsparticularly those at high risk of a secondary instead of brandname when possible. If theevent. Generic Lotrel (CCB/ACEI)— brandname drug is on formulary or tier 2, orbenazepril/amlodopine 5/20mg is the best buy there are coupons to decrease the copays, itfor the money. Taking two 5/20s and may not affect the patient’s immediate outofchlorthalidone (Hygroton) 25mg is probably the pocket cost, but it effectstotal cost andbest and one of the most cost effective triple eventually elevates all of our insurance rates. Atherapy treatments. comparable situation: we often choose to pay outright for the cost of a fender bender rather♥There is no benefit to using Lipitor 10mg to than use our insurance and have our rates go up20mg or Crestor 5mg to 10mg since generics for 10 years. We now have generics available tocan achieve the same degree of lipidlowering at treat blood pressure, cholesterol, diabetes, heartsignificantly decreased cost. (Remember two failure, etc. according to guidelines, and wepravastatin 40mg costs only $20 for a three should be using them.month supply). ♥Tell your patients about RiteAid, Walmart♥Doubling the prescription dose and using and Target’s $9.99 three month supply bargains.alternate day therapy for statins is very cost For those without prescription coverage, they areeffective when you need a brandname statin to obviously beneficial. For those with insurance, itget your patients to appropriate lipid goals (i.e. is often cheaper than their deductible. So theCrestor 40mg or Lipitor 80mg every other day patient benefits, and overall costs are lowered.(I forthose whom get to goal with Crestor 20mg or have a $40 deductible for my genericLipitor 40mg). Again this decreases the cost to medications and I go to RiteAid.)the patient and overall health care costs. 2

I still strongly advocate getting our patients to appropriate BP and lipid goals. Smart prescription writing can significantly decrease costs without compromising quality of care. Use your power and control! Engage brain before putting“pen in gear” We should always ask the question, “Will the result of a particular study or lab test alter my treatment plan?” If your eighty year old patient has already told you when you discussed endof life care that she/he would refuse any type of surgical intervention, your treatment will not change no matter what the results of an echocardiographic evaluation. The only thing it will do is increase healthcare costs. If a study will tell you what you already know or will give an incomplete answer, it’s wasteful to do it. Last week we had a ninety year old man come into the office for a consultation and request for a stress test. He has a known history of CAD and was taking all the appropriate treatments. He presented with a classic history of angina. We added betablockers and longacting nitrates and sent him for coronary visualization. If I had done a stress test, it would have been positive (adding risk and cost) and then I would have proceeded to coronary visualization. If it was negative, I would have to assume that the stress test was a possible false negative because of the highrisk setting and strong clinical history and still would have to send him for coronary visualization.We should use our clinical skills and diagnostics tests in a cost effective manner while providing quality care. We should be proactive “giving the right care at the right time every time,” because it’s the right thing to do.

Cardiologists should Measure If cardiologists measured fractional flow reserve (FFR) in conjunction with coronary visualization, better outcomes would be achieved at lower cost. FFR, in addition to angiographic guidance, as compared with PCI guided by angiography alone, results in a significant reduction in major adverse events at 1 year, a finding that supports the evolving strategy of revascularization of ischemic lesions and medical treatment of nonischemic lesions. This th study was in the January 15NEJM of this year and was summarized in our JanuaryHeartbeat.These results were sustained out to eighteen months per a recent presentation earlier this month at theEuropean Society of Cardiology 2009 Congressvalidating the meetings—further results. Measuring FFR is a more accurate way of assessing the functional relevance of an angiographic stenosis that improves safety, reduces costs and enhances the beneficial effects of PCI. Cardiologists should use it more often, especially in those 50% to 80% lesions. Conclusion I hope we can agree that more people need access to health care and that we have the power to control many costs while still providing good care. We need to speak out and make our concerns known, and we need to do what we can to lower costs for our patients, and ultimately for the whole system. Mario L Maiese DO, FACC, FACOI Clinical Associate Professor of Medicine, UMDNJSOM Email:maiese1@comcast.net Sign up forHeartbeatsonline:www.sjhg.org Heartbeatis a South Jersey Heart Group publication