Cheaper may be better for heart


It may be impressive that nine specialists surround your recovery bed after you have survived a heart attack. But don't take that to necessarily mean you will do better.

What matters more, and costs a whole lot less, is that your doctor prescribes a beta blocker when you leave and reminds you to take an aspirin every day. When it comes to care after a heart attack, adding a couple of thousand extra dollars to the bill doesn't result in longer life.

In a study published in Health Affairs last month, researchers examined records of nearly 3 million people 65 and older and found the areas of the United States that saw the least amount of increase in the cost of treating heart attacks had the best outcomes. Those that spent the most on treatment actually had poorer outcomes.

"Conventional wisdom is that health care costs a lot, but that it's OK because you're getting all this good stuff out of it," says Jonathan S. Skinner, economics professor at Dartmouth College and an author of the study.

People want to think the things that increase health care spending are the things that save lives. And earlier studies have supported that notion. A 1998 study in the Quarterly Journal of Economics found the cost of treating a heart attack increased by about $10,000 between 1984 and 1998. For the extra money, patients got an extra year of life -- "a terrific value for the dollar," Skinner wrote in his paper.

But the new analysis shows the added value isn't continuing into the new century.

Although costs have gone up more in some regions of the country than in others, survival is better in regions with lower costs. One reason, Skinner says, may be that physicians in lower-cost regions are more likely to send heart attack patients home with a prescription for a beta blocker and instructions to take aspirin daily. Studies have shown that those low-cost interventions increase life span after a heart attack. "That's one of the biggest reasons why people have done better," Skinner says.

In contrast, regions where a lot of specialists are called in to consult rack up higher bills. Not only does it require payments to more physicians, but doctors also may be more likely to duplicate tests. Regions varied in the number of physicians assigned to a heart attack patient from a low of 4.8 in Portland, Ore., to a high of 9.2 in Philadelphia. More doctors at the bedside didn't add up to improved results. "Part of what they may be getting is large numbers of physicians who don't talk to each other," Skinner says.

"People are no sicker going in and no healthier coming out in those high-spending areas," says David Cutler, professor of applied economics at Harvard University. "Some areas just have their act together."

As health care spending increases, "we don't really know that the things we're spending money on are the things that are making us live longer," says Alan Garber, internist and director of the Center for Health Policy at Stanford.

Clearly technology such as stents and cardiac care units have contributed to heart attack survival in the past couple of decades. "But if you look at regions where people are treated more aggressively, have more procedures and doctors use more resources, is survival better?" Garber asks. "The answer is no."

Confronted with the choice, your money or your life, most people will hand over their wallets.

Studies such as this, economists say, will be increasingly important to make sure people across the country get equal value for their dollars.

Susan Brink writes for the Los Angeles Times.

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