Waste not, want not . . .

This report in Health Affairs by Jonathan Skinner, Douglas Staiger, and Elliott Fisher is a pretty hard slog and won't help you wake up in the morning, so read it at your own risk, but it's definitely instructive.

They took a second look at some earlier analyses that had found that, while the average cost for treating Medicare beneficiaries after acute myocardial infarctions (that's AMIs, basically heart attacks in English) increased by $10,000 from 1984 to 1998, average survival increased by one year. So it looks as though the increased expenditure on new medical technologies is worth it. Most people would pay 10 grand for a year of life. However, it turns out that the relationship between spending in different regions of the country, and outcomes, is negative, i.e. the more spending on people with AMI in a given region of the country, the sooner they die. What gives?

I'll skip the complex analysis and cut to the chase: the improvements in life expectancy, which largely ended in 1996 anyway, are mostly due to inexpensive interventions: aspirin (yup, my old friend acetylsalycilic acid, known to the ancients) and drugs such as beta blockers and ACE inhibitors which are now available as generics. Immediate ways of restoring blood flow to the heart, using drugs or angioplasty, can also help where indicated.* But regions where the tendency is to spend the most had worse survival. One reason seems to be that in those parts of the country, people tend to see many different specialists, who aren't necessarily communicating with each other very well, so people get confused, contradictory, and uncoordinated care. The important takeaway lessons, in my view, which seem to be more or less those of the authors although they are less direct, are two:

1. We can get as good, or better results than we do now by doing less, and spending less money, but we need to do things right;
   
2. Just putting cost constraints on top of the present non-system won't work, because it won't necessarily lead to a more effective allocation of resources. We need a much better coordinated system, in which care is coordinated by doctors who know their patients and can keep track of their needs and the services they get; and standards for effective, appropriately conservative care based on evidence can be promulgated and followed.

The best context in which to accomplish those goals is universal, comprehensive, single payer national health care. That's what I say, anyway.

*Of course, heart attacks can be prevented by eliminating tobacco use, proper diet, exercise, emotional tranquillity, and all that good stuff, but that's for another day.