Very often, I see news stories touting some new wonder treatment only to discover that its cost is so extremely high as to make it irresponsible to ever use the treatment unless some millionaire is paying for it out of his or her own pocket. The fact is that most Americans want Rolls Royce treatment with someone else paying the bill. We are rapidly driving our nation bankrupt with no hope of ever being able to pay the bills. I am not an expert in statistical manipulation and in calculating the time-value of money and discounting rate. Therefore, most of the dollar values below, which are my own calculations, are in the general ballpark of the true figures, but a fiscal statistician would arrive at somewhat more precise numbers.
By my calculations, the average psychiatrist with 1,000 patients can easily save society $500,000 per year in medication costs without hurting the treatment of his or her patients at all. If 10,000 psychiatrists did this, the national savings would be $5,000,000,000 a year. I am sure that the same holds true in every other specialty of medicine. If the entire field of medicine were conscious of cost-effectiveness, the savings would be in the range of $50 billion per year. Unfortunately, being responsible in this manner doesn't benefit the individual physician at all and instead often subjects him or her to intense pressure from drug companies, poorly informed patients, peers, and governmental regulators to conform with whatever the current norms dictate.
Many less expensive treatments are totally ignored by the field of medicine. Without the chance to make a profit, drug companies aren't going to research and promote low cost treatments. Surgeons don't make money not doing surgery. Psychiatrists don't make money making their patients healthy too fast. And lawyers, we won't even think about them. Also, one has to ask whether society isn't already spending too much on medical care and getting too little in return. One out of every six dollars in the U.S. is already spent on medical care. This means that there is little money left for other important things in life, like having children, taking vacations, being able to pay your bills, etc.
The High Cost of Some Medical Care
Evista Giant Waste of Money for Osteoporosis: Evista (raloxifene) is $84/mo at Walgreens.com (9/27/04) or $1008 per year. In the industry sponsored raloxifene study of 7705 women with osteoporosis covered in the 2004 Physician's Desk Reference, after 3 years only 4.3% of elderly women had vertebral fractures with placebo vs. 1.9% with placebo. All received 500 mg of calcium and 400-600 IU of vitamin D. In 3 DB PC studies for prevention of osteo, That's $125,000 and taking pills 40,000 times and filling 1,333 prescriptions to prevent one vertebral fracture. If it was your money and your time, would you do it? Even this miniscule benefit is bogus, since taking one vitamin D 1000 IU capsule instead of a 400 IU capsule, 1000 mg of calcium instead of 500 mg, and taking one vitamin K tablet daily would have considerably increased the benefits to the control group. Also, some of the fractures were noticed by the patients, but found on x-ray.
Interferon and Glatiramer Not at All Cost-Effective for Multiple Sclerosis According to Harvard Researchers: Treatments for newly diagnosed nonprimary progressive MS with interferon beta-1a, interferon beta-1b, and glatiramer acetate, assuming a 10-year treatment duration found that interferon beta-1a yielded the largest gain with an incremental cost-effectiveness ratio of $2,200,000/quality-adjusted life year added for women and $1,800,000/QALY for men, compared with no treatment. For a 5-year treatment duration, a "no treatment" strategy yielded more quality-adjusted life years than any of the treatment strategies. Cost-effectiveness ratios were similar for all three immunomodulatory treatments evaluated. Cost-effectiveness of interferon beta-1a, interferon beta-1b, and glatiramer acetate in newly diagnosed non-primary progressive multiple sclerosis. Prosser LA, Kuntz KM, et al. Department of Ambulatory Care and Prevention, Harvard. Value Health. 2004 Sep-Oct;7(5):554-68.
High Dose Atorvastatin (Lipitor) Made Absolutely No Difference on Rate of Death; May Increase Death: In a massive 4.9-year DB PC study of 10,001 patients with clinically evident coronary heart disease and LDL cholesterol levels of less than 130 mg, there was no difference in the rate of death between those on 10 mg or 80 mg of atorvastatin per day. The primary end point was the occurrence of a first major cardiovascular event, defined as death from CHD, nonfatal non-procedure-related myocardial infarction, resuscitation after cardiac arrest, or fatal or nonfatal stroke. LDL cholesterol levels were 77 mg/dl with 80 mg of atorvastatin and 101 mg/dl with 10 mg of atorvastatin. Persistent elevations in liver aminotransferase levels was 0.2% with 10 mg and 1.2% with 80 mg of atorvastatin (P<0.001). Nonfatal non-procedure-related myocardial infarction, resuscitation after cardiac arrest, or nonfatal stroke occurred in 8.7% receiving 80 mg vs. 10.9% with 10 mg of atorvastatin, representing an absolute reduction in the rate of major cardiovascular events of 2.2% (P<0.001). Intensive Lipid Lowering with Atorvastatin in Patients with Stable Coronary Disease. Larosa JC, Grundy SM, et al. N Engl J Med. 2005 April 7. Ed: The number of patients needing to take the high dose for 5 years to prevent one non-fatal event was 45. That means that $450,000 extra Lipitor had to be taken to prevent one non-fatal event! The news coverage of this study made it sound like the treatment was great and saved lives. The corrupt people behind this study slyly lumped together the fatal and non-fatal events, headlined the word "died" ("died or suffered a stroke, heart attack or other major problem") to the news media as part of the events that were decreased by 22% without ever saying that fatal events weren't decreased at all! In fact, deaths, especially cancer deaths, were actually non-significantly higher with the high dose treatment! Also, a 22% decrease sounds like a lot. In fact, only 2% of the people taking the high dose for 5 years were helped. Only such a huge study was able to tease out such a small difference. The Associated Press said, "The risk of strokes and heart attacks was cut more impressively than expected." Since the impact was so small, I wonder what had been expected. The PRNewswire-FirstCall also makes no mention of the fact the deaths were not decreased and used the same wording to leave the read with the misimpression that lives were saved. Dr. Joseph Feczko, Pfizer's chief medical officer crowed, “TNT is the very first study to demonstrate even greater cardiovascular benefits of lowering LDL beyond recommended guidelines with Lipitor 80 mg." He claims "outstanding benefits" and that this study was "critical new information." in Medical News Today which also made no mention that there was no difference in the actual rate of death. Only Healthday News told the truth and even there it was buried in the fluff. No one calculated the money spent. WebMD made no mention that deaths were not reduced by Lipitor and gave readers the same misimpression.
Aggrenox Cuts Strokes, Not Death, and is very $$$: Dipyridamole with aspirin prevents the formation of thromboxane A2 and dipyridamole inhibits the uptake of adenosine through phosphodiestaerase inhibition. Warfarin is used if there is atrial fibrillation, a heart value, or stroke while on antiplatelet treatment. Med Let 2/7/00. A two year DB study of 6602 patients at $88.50/mo per patient cost $258,000 for each non-fatal stroke prevented. There was no difference in fatal strokes. Thus, aspirin at 81mg/d is better due to its being much less costly.
Angioplasty Drugs in Heart Attacks: A Waste of Money: Platelet glycoprotein IIb/IIIa receptor antagonists are used in angioplasty for acute coronary syndromes, i.e. unstable angina or non-Q-wave heart attacks. There are three of these new angioplastry drugs: eptifibatide at $1625, tirofiban $1260, abciximab (ReoPro) $2160. The drugs increase the number of patients alive at one month by only 1-2%. They add roughly perhaps $200,000 per year of life saved (This assumes that the average extra person alive at one month lives an additional six months, but it is doubtful that such an added benefit exists). They are used routinely despite their very high cost. Indeed, 10% of the people receiving these medications are over age 80 and those given the meds don't live any longer at all, but have to be kept in the hospital longer than those not getting the medicine! (J Am Coll Cardiol. 2003 Aug 6;42(3):428-32). Another study found that "the administration of the glycoprotein IIb/IIIa antagonist xemilofiban before percutaneous coronary revascularization and for up to six months thereafter does not significantly reduce the incidence of important clinical end points." The incidence of death or myocardial infarction was also similar in placebo and medication groups. N Engl J Med. 2000 May 4;342(18):1316-24; By contrast, the use of stents has proven quite cost-effective at $11,237 per quality life year gained. Circulation 2003;108:000-000
COX-2 Inhibitors Expensive with No Real Advantage: Celebrex is a patented medicine for osteo and rheumatoid arthritis. It is a selective COX-2 inhibitor and is promoted over much cheaper medicines because it is supposed to cause fewer stomach ulcers. Cyclooxygenase enzyme (COX) is required for synthesis prostaglandins and thromboxanes. COX-1 thought to protect gastric mucosa and in platelets. COX-2 is found in brain, kidney, and sites of inflammation. Both are in synovial fluid. Celebrex supposedly doesn't affect the COX-1 in the stomach significantly so shouldn't cause ulcers. Celebrex 100-200mg BID cost $86 for lowest dosage vs. ibuprofen $3, naproxen $8, diclofenac (Voltaren) $55. It is metabolized by CYP2C9 and inhibits 2D6 and may increase some antidepressants and antipsychotics. Dosages up to 400 BID are OK ($344/mo.). After 12 weeks, ulcers appeared in 7% on Celebrex vs. 10% declofenac, 35% naproxen 500 BID, 23% ibuprofen 800 tid, 4% placebo. However, after 1 year, cumulative UGI perforations, clinically significant ulcers and bleeds occurred to 1.3% on rofecoxib vs. 1.8% other NSAIDs (JAMA 282:1929, 1999). Not a clear advantage (Ann Intern Med 2000;132:134). Rofecoxib ($72) 25-50mg QD. COX-2 inhibitor may be prothrombotic leading to higher incidence cardiovascular events (Med Let 7/10/00). No mention of evidence that help with AD. (Ed: In other words, these highly expensive COX-2 inhibitors are simply not worth billions of dollars per year being spent on them. There is evidence that one of the manufacturers deliberately suppressed unfavorable information. Since I posted this, it has been proven that these medicines also make you die sooner.)
Debridement & Lavage No Benefit for Knee OA: DB study of a type of surgery given to 650,000 people per year in U.S. found it is of no benefit despite a cost of $5000 per treatment! 180 patients. NEJM 7/11/02. Houston VA. That's over $3 billion a year wasted on unless surgery.
Implanted Defibrillator Helps at Extremely High Price: The 3/21/02 New England Journal of Medicine reports a 31% increase longevity at 20 months in a study of 1232 heart attack victims (14% dead with the defibrillator vs. 20% in control group) at a cost of $40-60,000 per person to install. This is roughly $750,000 per year of life saved through the end of the study, but this figure was not reported by the cardiologists who make lots of money implanting defibrillators. This treatment was heralded in the newspapers as a great medical advance and it was reported that the Vice-President had received this treatment. Of course, a longer study would have brought the cost per year of life saved down somewhat, but the cost will almost certainly remain well over $200,000 per year saved. No one wrote that implanting defibrillators in the typical heart attack victim is a huge waste of taxpayers' money that will help dry up Medicare funds long before the post-war baby-boomers retire! Maybe, for the stability of the nation, the public paying for the Vice-President's defibrillator might be reasonable, but a mere senator or Secretary of Defense should have to pay out of his or her own funds if he or she wants to spend $200,000 to live one more year. Besides, most of the people receiving this treatment could have added years to their lives much more easily by adopting better diets, exercise, losing weight, etc. and they chose instead to ignore the widely available medical advice. Ed: Biased cardiologists in Annals of Internal Medicine 2005;142: 593-600 try to claim that the life benefits will grow much larger with time and that the cost per year of life saved in only $50,000. However, they have no prospective data to back up their claims. Also, they recommend that the U.S. double the number of defrillators implanted each year to 65,000. They claim the cost is only $35,000 each, which keeps their costs down.
Meningococcal Vaccines Very Dear: Meningococcal meningitis kills only 300 people a year in the entire U.S. While college cases attract a lot of news coverage, they make up only 3% of all cases. The rates for freshmen in dorms is 4.6/100,000 or seven times higher than undergrads in general and 3.5 times higher than the general population. Immunization costs $75 with protective antibodies developing in 7-10 days. (Med Letter 8/7/00). This means that a general immunization campaign such as is done on some college campuses costs $20 million for each life saved for dorm freshmen! This is outrageously wasteful even for a supposedly wealthy country like ours.
Pneumococcal Vaccine Very Costly-$$$: For children under two, the new Prevnar heptavalent vaccine is available. A DB study of 37,868 resulted in 46 fewer cases of pneumococcal infection and two fewer deaths. The cost per dose is $58 and four to six doses are required. If we assume a $10 cost of administration to pay for the nurse's time, etc., this adds up to $6,440,000 plus 100,000 needle sticks to save one infant's life, a very high cost that seems unreasonable. The needle sticks might seem a trivial issue, but if the doctor told you that your own infant child had to receive 100,000 needle sticks in order to save his life, i.e., 1,500 every day or one every 30 seconds of awake time for the first two years of his life, would it make you stop and think for a minute or two?
Osteoporosis: Highly Biased Study Promotes Alendronate (Fosamax) for All Post-Menopausal Women: In a 6-year, industry-funded, poor-designed study of 1609 healthy, early postmenopausal women, fractures occurred in 11.5, 10.3, and 8.9% of women taking placebo, 2.5 mg alendronate, or 5 mg alendronate daily. The authors claimed that alendronate is "an effective and promising strategy for the prevention of postmenopausal osteoporosis." Prevention of postmenopausal bone loss: six-year results from the early postmenopausal intervention cohort study. McClung MR, Wasnich RD, Hosking DJ, Christiansen C, Ravn P, Wu M, Mantz AM, Yates J, Ross PD, Santora AC 2nd. Portland, Oregon. J Clin Endocrinol Metab. 2004 Oct;89(10):4879-85. Ed: This is another extremely biased study designed to make sure the sponsor’s medication looks better. 40 women had to take Fosamax for 6 years to prevent one fracture as a cost of $230,000 of medication per fracture prevented. If the controls had been given vitamin D 1000 IU, vitamin K 500 mcg. and calcium 1000 mg/day, it is virtually certain the controls would have done as well or better with many other added health benefits (less cancer, less heart disease, etc.) and an annual cost of $60 vs. $1000.
Recombinant Interleukin-11 for Chemo-Induced Thrombocytopenia $$$$: Neumega, a cytokine produced by bone marrow stromal cells, stimulate the proliferation of stem cells and megakarocytes. It can be given to avoid platelet transfusions. It causes lots of side-effects. Medical Letter 7/31/98. It costs $20,000 per transfusion avoided. It's not worth it!
Tamoxifine: An Extremely Wasteful $$$ Prevention Breast CA: DB 13,175 women either over 60, or with a history of lobular CA in situ, or algorithm risk greater than 1.66% of developing cancer were treated with Tamoxifine 20mg/d for five years at $6000 med cost per woman. The treatment prevented 120 cases of breast CA (244 vs. 124) although it caused 19 more early endometrial CA (18 vs. 37), 14 more strokes, 12 more pulmonary embolisms, and 70 more cataracts. Fisher, J Natl Cancer Inst 90:1371, 9/13/98. $800,000 medication cost per cancer prevented! What an irresponsible waste of the public's money.
Teriparatide: An $$$ Treatment for Osteoporosis: Daily subcutaneous injections of teriparatide, recombinant human parathyroid hormone, for women who have already had fractures (the group most likely to benefit) cost $80,000 per vertebral and non-vertebral fracture prevented over the 19 months of the study. 13% of women benefited with prevention of a fracture. That's 4600 needlesticks to prevent a fracture. Some unreported number of fractures also prevented after the 19 months. Bisphosphonates are only $63/mo vs. $516/mo. for the parathyroid hormone. Teriparatide may be better, but added cost per fracture prevented would be still higher if it were compared to one of bisphosphonates or to still less expensive treatments. Simple salt-avoidance combined with calcium and high dose vitamin D may be better than either treatment for just a few dollars a month. Med Letter 2/3/03.
Ulcer Rx Regranex $$$ & Small value: Becaplermin (Regranex) is a new recombinant human platelet-derived growth factor gel applied topically to help heal ulcers in the skin such as are suffered by elderly nursing home residents. In a 20 week DB trial, 48% of Regranex patients vs. 25% of placebo treated ulcers healed with 30% recurrence. That's $378 for 3 wk of treatment. That's over $7,000 per ulcer healed. Many simple and inexpensive treatments are available at a much lower cost that might be as good or better, but of course the drug manufacturer is not going to compare his new drug to anything other than a placebo. Med Letter 7/17/98. In surgical patients, wounds healed in 35 days instead of 54 days with placebo. Am J Obstet Gynecol. 2002 Apr;186(4):701-4; Regranex is promoted in Europe for diabetes skin ulcer. A recent article concluded, "In practice, the very expensive topical becaplermin gel can help some patients, in whom it slightly accelerates ulcer healing." Prescrire Int. 2001 Dec;10(56):167-9. Oddly enough, several research studies have found that honey works better than every standard treatment against which it has been compared for severe burn patients, gangrene patients, and patients with leg ulcers. Cod liver oil also worked quite well in a small animal study of surgical wounds.
Nursing Homes Average $57,700/Yr: U.S. average without the costs of therapy, rehabilitation or medications. GE Financial 8/03Testing
Kidney Infection: Blood Cultures Not Needed: In this prospective study, the investigators collected data on 583 women with uncomplicated Acute Pyelonephritis (not diabetics or abnormal G-U tract). Only 2.4% of cases were discordant, defined as those cases in which different pathogens were isolated from urine and from blood. The discordances made no difference in treatment. Clin Infect Dis. 2003;37:1127-1130
Testing Routinely Before Cataract Surgery of No Value: Routine medical testing before cataract surgery does not measurably increase the safety of the surgery. An electrocardiography, complete blood count, and measurement of serum levels of electrolytes, urea nitrogen, creatinine, and glucose are routine. Random assignment for 18,000 patients found no benefit. NEJM 1/20/00