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Sparing No Expense

Paul Solman reports on the high cost of medicine.

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  • SPOKESMAN:

    On bypass coming up on flow.

  • PAUL SOLMAN:

    Medical costs are rising again, faster than any year since President Clinton took office. 14 cents of every dollar in the entire U.S. economy is now spent on some type of health care. And in the future? Well, that's where my own recent health travails may be ominous. A demographic pacesetter born in 1944, just ahead of the baby boom, your economics correspondent– here out of uniform– has been well served by medicine as this recent stress test confirmed, but I've been racking up costs at an alarming clip.

  • SPOKESPERSON:

    About 15 more seconds it's going to get a little faster and a little higher.

  • PAUL SOLMAN:

    I may have looked fine back in June of last year during this appearance on the NewsHour, but while bicycling to the studio, I'd felt a wave of exhaustion, upper body tightness, chest tingling. No trace of family heart trouble, low cholesterol, but the next day, my doctor ordered an immediate stress test, which wasn't taped. I failed on a Thursday, failed a fancier one Friday morning, was in Cambridge's Mount Auburn hospital by early afternoon for an angiogram, where dye is squirted through a catheter running from groin to coronary arteries to see if any are clogged. Here we're reviewing my x-rays.

  • DR. LEONARD ZIR, Cardiologist:

    This is a diagnostic coronary angiogram, first to just find out what's wrong, where the blockages are, and what needs to be done to fix the blockages.

  • PAUL SOLMAN:

    Cardiologist Lenny Zir says my primary care doctor, Alan Brush, had saved my life by acting so quickly.

  • DR. LEONARD ZIR:

    And the problem in the artery that you had is this artery called the left anterior descending. So that's a particularly dangerous location. Some cardiologists have referred to the blockage in the section that you had as the "widow maker," which means…

  • PAUL SOLMAN:

    Yeah, you…

  • DR. LEONARD ZIR:

    If you take care of it, you stay, you're fine. But it can be the one blockage that can really cause quite a lot of trouble or sudden death.

  • PAUL SOLMAN:

    The x-rays showed near-total blockage of the widow maker right over there. No muscle death yet, thus no heart attack — but almost. So when he had me on the slab back in June, Dr. Zir had reopened this artery with a stent, a little metal mesh that squishes the fatty gunk clogging the artery to its walls, like so much wet snow. Total cost: Some $20,000 depending on which insurance plan is paying. And the weekend had just begun. As I knew from vice President Cheney's case, about 1 percent of all stents are blocked within days by blood clots. So when I suddenly felt wiped out again on Sunday, I called Dr. Brush, who ordered another catheterization, cost be damned. The cardiac team reassembled on Sunday. This is later footage of them. The lab was reopened, I was rushed back to the hospital by ambulance.

  • DR. ALAN BRUSH, Internist:

    My concern was that you were having active cardiac symptoms at the time. And so whatever it cost to get you there was going to be far less than the worry I would have had if you were driving down or were in a car and could have had a serious event.

  • PAUL SOLMAN:

    Of course, it's music to my patient's ears when caretakers, like my HMO, Harvard Vanguard, does whatever they can fast, at whatever the price. But, and here's the theme of this story: The more that can be done, the more costs grow, as my second catheterization would suggest. Dr. Stanley Forwand's a member of the cath team.

  • DR. STANLEY FORWAND, Cardiologist:

    All told, it's got to be about $20,000, $25,000 I think.

  • PAUL SOLMAN:

    $20,000 or $25,000.

  • DR. STANLEY FORWAND:

    I would think, yeah. By the time you take into account the overtime that we pay the people coming in, opening the lab, opening the facilities, I would guess it's around that much.

  • PAUL SOLMAN:

    For what turned out to be a false alarm. The point is, in health care, higher technology has meant higher costs, just the opposite of what we've seen with other economic basics. Five hundred years ago, 12-penny nails cost 12 English pennies per hundred, something like $250 today. 150 years ago, food was about 60 percent of the average middle-class budget. Today, it's less than 15 percent, including eating out. Inflation adjusted, the first ballpoint pens cost $125 each in 1945. The first color TVs: $6,700 for a 15-inch screen. In short, productivity has driven down the price of almost everything, but not health care.

    There seems to be no limit on how much of it we want, how much more of it technology can deliver. At a certain point, we're happy enough with our nails and color TVs, but the demand for less pain, less disease, new joints, longer life seems infinite. And the usual price constraints don't work because most consumers don't pay for health care directly. Patients with insurance routinely ask for pricy new procedures, in part because someone else is paying. And hospitals and doctors also have an incentive to do everything for patients who are insured, because they get paid. Consider the case of 66-year-old Lou Ceddia. He had three blockages, but the cath team couldn't get past the first. The artery had hardened too much. You may be able to make out the narrowing over there.

  • DR. STANLEY FORWAND:

    He's disposed of three or four $1,800 catheters in an attempt to get across this narrowing. He's not been successful yet, and each one of those is a one- time use catheter, so they're all in the wastebasket now.

  • PAUL SOLMAN:

    Wow.

  • DR. STANLEY FORWAND:

    And he'll keep going.

  • PAUL SOLMAN:

    So the doctor doing the procedure tried another expensive new device.

  • DR. STANLEY FORWAND:

    Oh, he's going to… all right, he's going to try a roto-blader. A roto-blader is A… people always ask you, "hey doc, don't you have a little roto-rooter that I can put in there, clean this thing out?"

  • PAUL SOLMAN:

    Yes.

  • DR. STANLEY FORWAND:

    Well, we do, and that's what he's going to use. It's a little gadget with A… some spinning knives on the… in the catheter, very tiny, and they will try and cut out what's in there and give him a little room to get through.

  • PAUL SOLMAN:

    The roto-rooter didn't work, though; and after all those tossed stents, another $15,000 or so for people and machines, Ceddia wound up with open-heart surgery anyway– a triple bypass at another $36,000 or so. A man who years ago might have died untreated is now doing fine, thanks to ever higher technology at ever higher cost. And that's been the story for decades now.

  • DAHLIA REMLER:

    Spending per person has tended to rise a lot for really two reasons.

  • PAUL SOLMAN:

    Health care economist Dahlia Remler:

  • DAHLIA REMLER:

    We do bypass surgery on the kind of people we wouldn't have done bypass surgery on in the past, and then there's new stuff like stents. So those two things, doing more of the same stuff and doing new things, have caused total expenditures to rise.

  • PAUL SOLMAN:

    Case in point: A decade ago before stents hit it big, some 300,000 people got coronary bypass operations in the U.S. each year. Nowadays 350,000 Americans get bypasses and 500,000 get stents. Total procedures: Up almost 300 percent. And that's just the beginning.

  • DR. DAN LEVY:

    It turns out that roughly one out of every two men and one out of every three women will end up dying from heart disease.

  • PAUL SOLMAN:

    Dr. Dan Levy is director of the Framingham Heart Study, a massive federal research project that since the late 1940s has tracked thousands of Framingham, Massachusetts, residents, their children, and now their children's children to identify what causes heart disease. There are hundreds of suspected risk factors. The term was invented here– and six rock-solid culprits.

  • DR. DAN LEVY:

    Older people, men, those with high blood pressure levels, those with high cholesterol levels, diabetics, and smokers are at high risk for the development of heart disease.

  • PAUL SOLMAN:

    Levy showed us a risk calculator on the study's Web site, plugging in numbers from my medical history.

  • DR. DAN LEVY:

    A man who's the same age as you, who has a total cholesterol of 192 and an HDL of 55– which is actually a fairly good HDL cholesterol– a systolic blood pressure of 134, we can calculate or estimate the risk of developing a heart attack in the next ten years. And that risk comes out to about 7 percent.

  • PAUL SOLMAN:

    One chance in 16. But now get this: If I had a perfect profile, I'd still have a 3 percent risk of a heart attack within the next ten years.

  • PAUL SOLMAN:

    If everything was great or looked great, I'd still have one chance in 33 of getting a heart attack in the next ten years.

  • DR. DAN LEVY:

    That's right.

  • PAUL SOLMAN:

    In other words, nearly everyone is at some risk for heart disease, which grows with age. If I nearly had a heart attack, what's to become of the 75 million baby boomers right behind me? To quote a former sun king: Après moi, le deluge. We could be looking at millions of heart procedures a year, not to mention expensive new treatments for, say, cancer and stroke. And with the onetime cost savings, shorter hospital stays managed care already made, we're doomed to ever-rising costs, right?

  • DR. MEHMET OZ, Cardiac Surgeon:

    There's no question about it that health care costs are going to increase. And the real challenge for us as a society is to make sure we get our money's worth for what we're spending.

  • PAUL SOLMAN:

    Surgeon Mehmet Oz, whom we shot performing a bypass several years ago:

  • DR. MEHMET OZ:

    The real cost is the lost productivity when people have a fatal or crippling injuries to their heart. Thus the challenge for us becomes "how do we move the money to the most profitable place?" And that is to prevent the heart attacks in the first place.

  • PAUL SOLMAN:

    Prevention. But wait — that should lower costs. So at Dr. Oz's urging, I booked a top-flight preventive cardiology consultation in New York City, a work-up that typically costs some $650, but presumably more than pays for itself down the road. To paraphrase the old adage, a penny of prevention should be worth a pound of cure.

  • SPOKESMAN:

    Just about 180 so….

  • PAUL SOLMAN:

    At 179 pounds, I was just 20 pounds heavier than in high school. But that's not how Dr. Lori Mosca saw it.

  • DR. LORI MOSCA, Preventive Cardiologist:

    Do you know what 20 pounds looks like? This is five pounds of fat right here. It's five pounds. So four of these, is what you've gained since you've left high school. And this, if you lift it, I mean, that's a lot of work for your heart.

  • PAUL SOLMAN:

    Not to mention the other problems obesity sets you up for: Diabetes, hypertension, high cholesterol, which in turn promote heart disease, as does even slightly elevated blood pressure.

  • DR. LORI MOSCA:

    Blood pressure is related really point by point with risk for coronary heart disease.

  • PAUL SOLMAN:

    Even my low cholesterol suddenly didn't seem low enough.

  • DR. LORI MOSCA:

    The problem that we have in the United States is that 50 percent of all heart attacks occur in what we call a normal cholesterol range. Normal. So our normal is probably wrong.

  • PAUL SOLMAN:

    But cholesterol-lowering drugs known at statins reduce the risk of heart attack, as do beta-blockers, which lower blood pressure, heart rate, adrenaline surges. So I'm on both, at a cost of $1,000 a year. If I took Dr. Mosca's further suggestions– an ACE inhibitor for blood pressure, an antidepressant, since depression is bad for your arteries– the total tab would be over $2,000 every year, for life.

  • DR. LORI MOSCA:

    I'm going to have you take some nice deep breaths. Okay, nice deep breath.

  • PAUL SOLMAN:

    Fortunately, I don't smoke, don't eat meat, and exercise diligently. But now here's the stunning bottom line: If all these preventive efforts work, my total health bills would almost surely be higher.

  • DAHLIA REMLER:

    If people live a long time and you go on to have some more expensive treatment or need long-term care, then on net, it's cost increasing. In many ways, smokers save us all medical care expenses. If you die relatively young of lung cancer, it's a relatively inexpensive thing to die from. People like that don't live longer. They don't break their hip, they don't get Alzheimer's, they don't go into the nursing home. They don't collect their Social Security, they don't collect their pensions as much. They're actually saving us all a lot of money.

  • DR. LORI MOSCA:

    The most cost effective thing is for you to die, right? It's cheap to be dead for our managed care.

  • PAUL SOLMAN:

    So is health care in America an economic nightmare? Are things only going to get worse? No, argues economist Dahlia Remler, just the opposite. Sure, there are inefficiencies in the system. But there's nothing wrong, she says, with spending so much of our money on health care.

  • DAHLIA REMLER:

    After all, these things are really effective. You save people's lives. And if you measure it as dollars per year of life saved, the price has gone way down, and it's a great deal. And it's not unreasonable to say, "hey, you know, the price of health improvement has gone down? Let's buy more health improvement."

  • PAUL SOLMAN:

    We end with a vision of the future: A patient we met at the Framingham Heart Study, 85-year-old Mo Featherman. After his second heart attack in 1986, at a cost of $22,000, he had a bypass.

  • MO FEATHERMAN:

    That's why I'm still playing tennis.

  • PAUL SOLMAN:

    Is that right?

  • MO FEATHERMAN:

    Yes.

  • PAUL SOLMAN:

    There are now some four million Americans 85 and older. By the year 2050, just if current trends hold, there will be some 24 million Mo Feathermans in America. And I myself, if medical technology continues to advance, will be 106. Sure, plenty of health care money already is and probably will continue to be wasted. Yes, we may need to get used to paying for costs that aren't insured. And a huge final question looms: Who, if anyone, will pay for those who can't afford the uninsured costs themselves? But leaving those questions for another story, will total future expenditures be worth the price? If technology gets me that far, I expect my answer will be: I'll spend whatever I can to keep on trucking.

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