HEALTH CARE/Joan Retsinas

Cutting Costs, Raising Health: The Barriers

Progress is change. The truism, however trite, is true. And so is its corollary: change will incite opposition. After all, the status quo benefits somebody, at the expense of somebody else. Upsetting the status quo inevitably upsets the balance.

So the history of medical progress is not sure-fire and steady. The germ theory did not, presto!, replace notions of miasma. Physicians did not immediately prescribe vaccinations and inoculations. Nor did they stop prescribing estrogen to pre-menopausal women after the Women’s Health study showed no wide-scale benefit. “Progress” often comprises battles, one idea versus another, one group versus another. And, not surprisingly, money propels these battles, in health care as in politics.

Here are a few small battles to watch. The much-vaunted “arc of history” points to change, but when?

The proposals promise to cut costs, without harming (if not bolstering) health. Call them fiscal chimeras. In the frenzied world of health policy, any action that promises to cut costs while improving health emerges as mythical. But researchers have estimated impressive savings from feasible measures, published in Health Affairs (June) (

Now we wait for the powers-that-be to disrupt the status quo.

1) Changing drugs for macular degeneration.

Currently Medicare spends one-sixth of its Part B drug budget on two drugs: ranibizumab and bevacizumab, both prescribed for macular degeneration. Medicare pays $2,023 per dose for the former, 40 times more than for the latter. The researchers (David Hutton, Paula Anne Newman-Casey, Mrinalini Tavag, David Zacks, and Joshua Stein) found the efficacy of both drugs similar; but the difference in costs, boggling. Their recommendation: switch from A to B. They calculate Medicare would save $18 billion, and patients almost $5 billion.

In a world ruled by reason, Medicare would instantly switch. In this instance, though, the manufacturers of drug B stand to lose money. In a political world swayed by profit-making corporations, the switch is unlikely to be instantaneous, or smooth.

2) Better infection control in hospitals.

Every study urges infection control in hospitals. Too often patients develop “iatrogenic” diseases that make them sick (in some instances, lead to death). The admonitions are old news. Researchers (R. Douglas Scott II, Ronda Sinkowitz-Cochran, Matthew E. Wise, James Baggs, Scott Goates, Steven L. Solomon, L. Clifford McDonald and John A. Jernigan) quantified the benefits of the Centers for Disease Control and Prevention (CDC)’s efforts to control blood stream infections from central lines (the tubes inserted near a major vein, generally to deliver medications or fluid. These lines can remain in place for months). From 1990 to 2008, they estimate hospitals saved from $640 million to 6.8 billion dollars – a rate of return on CDC efforts that ranged from $3.88 to $23.85. The measures to reduce infections are not draconian: sterile garb, hand-washing, keeping the site sterile, taking care when checking the line, or changing dressing. The authors suggest that investing in more infection-control measures “has the potential” for more savings. “If only” hospitals would extend these practices.

Yet inertia, yoked to custom, can block measures as beneficial – and cost-effective — as infection control.

3) Eliminate sodas from the Supplemental Nutrition Assistance Program (food stamps).

Even young children and teenagers are obese. And we all are developing diabetes, propelled by our growing girth. Everybody, including people whose body-mass— index tips them into the “obese” category, knows the dangers. Yet, unlike environmental toxins and genetics, this risk is preventable.

Based on a sample of 19,000 SNAP participants, the researchers (Sanjay Basu, Hilary Kessler Seligman, Christopher Gardner, and Jay Bhattacharya) used data to model obesity, type 2 diabetes, and food consumption patterns. If Uncle Sam eliminated the subsidy for “sugar-sweetened beverages,” what would happen, based on their model? Their conclusion: obesity, as well as the incidence of type 2 diabetes, would decrease. Specifically, they predicted 281,000 adults and 141,000 children would lose weight, through a 15.4% reduction in calories.

In a commonsense world, policy-makers would eliminate the subsidy – a slash that should please everybody eager to slash government spending. At the same time, some participants would lose weight. The “losers” would be the soda companies, whose clout has dampened previous commonsense efforts to nudge us into healthier eating habits. (e.g.,vending machines remain in many schools).

Kudos to the researchers who provided statistical support for these proposals to save taxpayers money. And kudos to the people stalwart enough to fight the status quo.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, August 1, 2014

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