EDITORIAL
Advances in cardiology and escalating costs to the
patient: a view from the government
CLAUDE LENFANT, M.D.,
AND
CARL A. ROTH, PH.D., J.D.
"THE HEALTH of nations is more important than the
wealth of nations.
1
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
Even if we accept this dictum of historian-philosopher Will Durant, we must face a troubling question:
How much of the nation's wealth can we afford to
devote to the nation's health? It is a question that
assumes increased importance when we consider the
percentage of the gross national product (GNP) allocated to medical care over the period from 1955 to the
present. In 1955 the United States devoted only 4.4%
of its GNP to health care, and as late as 1965 health
care costs comprised a relatively modest 6.0% of the
GNP.2 However, by 1975 the figure was 8.6%2 and in
1983 the nation spent 10.8%3 of its GNP on health
care. Moreover, there is reason to believe that the
proportion of GNP absorbed by medical care costs will
continue to increase. Between 1981 and 1982, medical
costs increased at approximately twice the general rate
of inflation.4
The increasing costs of medical care are, in one
economist's view, attributable to the successes of
medical research coupled with the expansion of medical insurance coverage .5 A recently released survey6
indicates that the advances in medical treatments and
equipment are widely viewed as the main reason for
escalating medical costs. The survey included national
samples from the six following groups: a cross section
of the public (adults); physicians heading local, state,
and specialty medical societies; administrators from
the nation's largest hospitals; senior health insurance
executives; corporate benefit officers; and trade union
leaders responsible for health care benefits. Participants were presented with three alternatives and asked
to identify the one that they believed to be the main
reason for increased spending on health care services.
The alternatives were phrased as follows: (1) the increasing cost of the same services, (2) the use of new
From the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD.
Address for correspondence: Claude Lenfant, M.D., Director, National Heart, Lung, and Blood Institute, Bldg. 31, Room 5A-52, 9000
Rockville Pike, Bethesda, MD 20205.
424
and more expensive treatments and equipment, and
(3) people using more health care services than they
used to.
According to data published by the Health Care Financing Administration (HCFA),2 the correct response
is clearly the first of the three alternatives. Increased
costs for the same medical goods and services accounted for 78% of the increase in personal health care
expenditures between 1981 and 1982. With another
8% of the increase accounted for by population
growth, only 14% of the increase could be attributed
to such other factors as the aging of the population
and changes in the nature and quantity of services
rendered.
Figure 1 suggests that the survey respondents were
not generally familiar with the HCFA analysis. The
use of new and more expensive treatments and equipment was the most frequently cited reason among physician leaders, hospital administrators, and insurance
executives, and the second most frequently cited reason by the public cross section, corporate benefit officers, and union leaders.
It is important to note that in selecting the alternative
relating to medical treatments and equipment, the respondents not only evinced an unfounded belief that
advances in medical technology are the primary source
of escalating medical costs, but also implicitly accepted the concept that new medical treatments and equipment are necessarily more expensive. This implication
warrants examination since there are instances in
which advances in research and technology actually
lead to reduced costs. In performing our examination,
we will first draw on the wisdom of Lewis Thomas,
who in The Lives of a Cell discussed the cost-effectiveness of three levels of "technology of medicine."7 We
will then consider a number of advances in the treatment of heart diseases in the context of economist
Burton Weisbrod's graphic representation of the historical relationship between health expenditures and
the state of medical technology (figure 2).
As used by Dr. Thomas, "non-technology" is not
really a technology. Non-technology consists of what
CIRCULATION
ADVANCES IN CARDIOLOGY
Number el
Respondents 1501
100
100
50
26
250
Percent
80 _
-Using More Health
,
.....
.,.,
._Services
_ .,.,., .....
WCare
.. _
a,
c
CD
Q
m
60
Increase Cost of
wc
40
Z W |i i
i
i
;"1~~~~~~~reaments and
E
20
Public Physicians Hospital Insurance Corporate Union
Cross
Adminis- Execuives Benefit Leaders
Section
Officers
trators
-New.
Non-Technology
More Expensive
FIGURE 1. Main reasons for the increased spending on health care as
estimated by six identifiable groups. Data from the Equitable Health
Care Survery, 1983.
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
is sometimes called supportive therapy because it tides
the patient over diseases that, by and large, are not
understood.
"High technology" makes it possible to treat diseases successfully (e.g., antibiotics) or to prevent them
(e.g., immunizations). It is based on a genuine understanding of the disease mechanism and when it becomes available it is likely to be relatively inexpensive
and easy to deliver.
"Halfway technology" represents the kinds of
things that must be done to compensate for the incapacitating effects of disease or to postpone death and is
likely to be both complex and costly. According to Dr.
Thomas, it is the appropriate characterization for most
of the presently available treatments for heart disease.
As indicated by the Weisbrod curve (figure 2), the
introduction of new halfway technologies may either
increase or decrease medical treatment costs. In the
following discussion we will explore the cost implications of several halfway technologies for heart disease.
Treatment for coronary artery disease. The most wellknown and widely practiced halfway technology for
coronary artery disease is the coronary artery bypass
graft (CABG) procedure. The number of procedures
performed in the United States is estimated to have
increased from 20,000 in 1971 to 50,000 in 1974,
70,000 in 1977,8 and 191,000 in 1983.* The rapid rate
of increase in bypasses is not surprising given the
marked relief from angina obtainable with CABG at
relatively low operative risk. As a result of its widespread adoption, CABG alone is estimated to have
accounted for approximately 1 % of the nation's annual
health care costs in 1980.9
Concurrent with the continued dissemination of
CABG, research continued on improved medical treatments for heart disease and on percutaneous translu-
FIGURE 2. Health expenditures and the state of technology. (Reproduced with permission of the American Enterprise Institute.4)
minal coronary angioplasty (PTCA), an altemative operative procedure for some potential CABG patients.
As indicated in figure 3, both medical treatment and
PICA are associated with lower treatment costs than
CABG. Therefore, a showing that either medical treatment or PTCA is equal to CABG in effectiveness
for any substantial percentage of patients eligible
for CABG would necessarily result in substantial cost
savings.
The question of comparative effectiveness of medical and surgical treatment in selected patients was addressed in the recently reported Coronary Artery Surgery Study (CASS) supported by the National Heart,
Lung, and Blood Institute. The study consisted of both
a registry of patients undergoing diagnostic coronary
arteriography and a randomized trial of surgical vs
medical treatment among registry patients for whom
the best therapeutic choice was a matter of physician
judgment and patient preference rather than generally
accepted practice. At the end of 5 years, the trial results`0 showed no statistically significant differences in
average mortality between medically and surgically
assigned patients either overall or when separated according to whether they had single-, double-, or triplevessel disease. An additional 15 months of follow-up
altered the initial CASS results for only those patients
with triple-vessel disease and ejection fractions below
0.50."1 An apparent mortality advantage associated
with surgery in such patients was suggested in the
initial results but became statistically significant only
after further follow-up. The initial results'0 also
CABG
Vol. 71, No. 3, March 1985
PTCA
X
Medical Treatment
1A1l
Non-Technology
*National Center for Health Statistics: Unpublished data in the Hospital Discharge Survery, 1983.
Time
High Technology
Halfway Technology
Halfway Technology
Tirmn
1 lme
b.
High Technology
FIGURE 3. State of technology for coronary artery disease: impact on
health expenditures.
425
LENFANT and ROTH
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
showed that at the end of 5 years, less than one-quarter
of the medically assigned patients had "crossed" to
surgical therapy, with most of the crossover resulting
from worsening angina despite vigorous medical therapy. The excellent survival observed in both the medically and surgically assigned CASS patients and the
similarity of survival rates in groups of patients assigned to the two therapies suggests that patients similar to those who particiated in CASS, i.e., patients
with mild-to-moderate angina and angina-free survivors of myocardial infarction with surgically approachable coronary artery disease, who do not have
both triple-vessel disease and ejection fractions below
0.50 can safely defer bypass surgery until worsening
symptoms require surgical palliation.
The cost-saving implications of CASS are threefold.
First, surgical costs were not incurred for three-fourths
of the medically assigned patients during the 5 years of
the study. Second, after entry into the trial, the medically assigned patients experienced fewer incidents of
hospitalization and averaged 5 fewer days of hospitalization than those in the surgically assigned group.12
Therefore, for the medically assigned patients there
were savings in direct costs because the surgery was
not performed and because they required fewer days of
hospitalization. Finally, there were savings in indirect
costs among the medically assigned patients in that
they lost fewer days of employment due to hospitalization.
An estimated 508,000 coronary angiographic procedures were performed in 1983. * Extrapolating from
the CASS data, an estimated 64,500 (12.7%) of the
patients undergoing these procedures would have been
eligible for randomization into surgical or medical
groups, and approximately 27,735 (43%) of them
would have undergone coronary bypass surgery. Since
patients with triple-vessel disease and ejection fractions below 50% comprised 10% of the randomized
patients, it is reasonable to conclude that all but 2774
of the 27,735 bypass procedures could have been deferred without jeopardizing any lives. Assuming the
cost of bypass surgery to be $20,000,t the estimated
cost savings associated with foregoing approximately
25,000 bypass procedures would be on the order of
$500 million. It should be noted, however, that in the
course of each year about 5% of the medically assigned
patients in the trial elected to undergo bypass surgery
because of worsening symptoms.
*National Center for Health Statistics: Unpublished data in the Hospital Discharge Survery, 1983.
tUsing the average estimate in Greuntzig and Meier1' (p IlI-61) and
adjusting for medical cost inflation between 1981 and 1982.
426
As indicated in figure 3, PTCA offers another lower-cost alternative to CABG in selected cases. Because
the PTCA procedure can be performed in cardiac catheterization laboratories, patients do not incur hospitalization costs. In a recent study conducted at 11 centers
among patients with single-vessel disease, the mean
success rate for PTCA was 80%. 1' Bypass surgery was
performed on each of the patients in whom PTCA was
unsuccessful. Estimates of the comparative direct
costs of PTCA and CABG are available from the
study. The direct costs per case for 206 patients undergoing PTCA averaged $5315, compared with $15,580
per case for 195 patients undergoing the CABG procedure. Allowing for the costs of surgery and hospitalization among the 20% who required bypass graft after
PTCA, the total cost per case for PTCA was $7149.
Assuming that the number of patients with single-vessel disease who receive PTCA instead of CABG each
year is between 17,000 and 25,000, the annual direct
cost savings would be between $122 and $179 million.
Sizeable savings can also be expected in indirect costs
because 79% of the patients who underwent PTCA
returned to work compared with 69% of those who
underwent CABG. Moreover, the average time
elapsed before returning to work was only 3 weeks for
the former compared with 11 weeks for the latter patients. 14
Cardiac pacemakers. The pacemaker appears to be an
example of a halfway technology with increasing cost
per case. The new dual-chamber, multiprogrammable
models cost on the order of $5000, compared with the
$2500 unit cost for the most commonly used singlechamber models. 5 In addition, dual-chamber units are
not as long-lived as single-chamber units so that greater operative costs are associated with dual-chamber
implants.
There are indications that the dual-chamber technology is beginning to be widely adopted. A 1978 survey
found that in only 4% of the 67.000 new implant procedures in the United States that year was any use
made of the atria, whereas a follow-up survey found
that 12% of the 118,000 new implants in 1981 had
atrial leads.'5 Because the 1978 data included implants
with single-chamber atrial pacing and less sophisticated dual-chamber models than those models available
in 1981, the 1978 and 1981 data are not directly comparable. At a minimum, however, the new technology
has resulted in an increase of 8% in the percentage of
implants with atrial capability. Thus the number of
possible dual-chamber implants increased from approximately 2700 in 1978 to nearly 14,200 in 1981.
The increase in the rate of possible dual-chamber imCIRCULATION
ADVANCES IN CARDIOLOGY
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
plants by 8% between 1978 and 1981 suggests that
about 9400 of the 14,200 atrial-lead implants in 1981
were due to the new dual-chamber technology. At a
$2500 per unit difference in cost between the most
commonly used single-chamber model and the new
multiprogrammable dual-chamber model, the resultant
incremental device cost for 1981 was approximately
$23.6 million.
Opinions differ widely on the percentage of the permanent pacemaker population for whom a dual-chamber device is indicated. Table 1 lists a number of published estimates of the appropriate percentage of
dual-chamber implants along with the corresponding
incremental costs that each would entail when compared with the 1978 rate for atrial-lead implants.
Heart replacement. By far the most costly halfway
technologies developed in recent years have been those
relating to replacement of the irreparably damaged
heart. Despite its great expense and the limited availability of donor hearts, transplantations have been effective for some patients. Public attention has recently
focused on the artificial heart because of the relatively
successful experience with Dr. Barney Clark. At the
NHLBI current programs have been emphasizing the
development of a circulatory assist device to sustain
prospective transplant recipients pending the procurement of a satisfactory replacement organ. It is clear
that the costs associated with transplants that are preceded by circulatory assist implants will substantially
exceed those of transplants alone.
The project director for the National Heart Transplantation Study sponsored by the HCFA estimated a
1980 cost of $177,600 to perform a transplant and then
maintain the recipient for 1 year.18 A potential transplant recipient who first received an artificial assist
device would incur all of the costs included in the
transplant estimate along with the additional operative
costs for a second implantation procedure. Allowing
the $120,000 reported as the total operative cost for a
transplant, a reasonable estimate of the total cost for a
TABLE 1
Estimated rate of use of dual-chamber pacing: added costs (1981)
Added costs
in millions
Rate of use(%)
(1981)
71`)
8.9
12'15
23.6
26'7
67.2'5
85
15
Vol. 71, No. 3, March 1985
64.9
186.4
239.0
Dollars (In Thousandsl
600,000
r
500,000
400,000
300,000
200,000
100,000
.......,.,...
1964
1966
1968
..................
1970
1..
Artificial
Heart
......... .............
1976* 1978 1980 1962
.....
.............
1972 1974
Years
FIGURE 4. NHLBI expenditures for the circulatory assist/artificial
heart program relative to NHLBI total extramural expenditures.
temporary circulatory assist device implant followed
transplant would be $297,600.
Over the years the program to develop an artificial
heart has engendered considerable comment, the most
frequently expressed concern being that there will be
wide demand for access to a successful device. Despite
the attention directed toward the artificial heart program, the Institute's support for the program has remained relatively constant in absolute dollars (figure
4). When adjusted for inflation, there has been an
actual decline in the level of support. The total NHLBI
commitment for the program from its inception in fiscal year 1964 through fiscal year 1982 has been approximately $161.5 million. The returns on the
NHLBI investment include a number of major contributions to the treatment of heart disease as well as
results that have proved to be beneficial outside the
area of heart disease.
Research for the artificial heart program led to the
development of the heart-lung machine, the device that
permitted a total of 84,000 open heart operations and
191,000 bypass procedures to be performed in 1983.*
The program also led to the development of the intraaortic balloon that provides circulatory assistance to
patients recovering from corrective heart surgery. Results of biomaterials research sponsored by the program have found applications in areas ranging from
replacement heart valves to airplane windshields. It is
likely that such advances would not now be available if
the program had been abandoned over concern about
the cost and extensive demand for its end product.
When compared with the overall NHLBI appropriations in fiscal years 1964 through 1982, it is clear that
the, artificial heart program never absorbed a major
portion of NHLBI resources and since fiscal year 1967
tended to receive an ever-decreasing share of those
by
a
resources.
*National Center for Health Statistics: Unpublished data in the Hospital Discharge Survey, 1983.
427
LENFANT and ROTH
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
While the applied research of the artificial heart
program continued, the basic research supported by
the NHLBI added further to our understanding of the
underlying processes of atheroslerosis and the risk factors associated with the development of heart disease.
It is not unreasonable to expect that the product of our
basic research efforts will be the most effective control
on the demand for the ultimate end product of the
artificial heart program.
Summary. We have discussed some of the new halfway technologies in cardiology and showed how they
differ markedly in their relative effects on overall patient treatment costs. We have tried to present a balanced picture by providing examples in which advances in cardiology offer clear reductions in medical
care costs, while acknowledging the potential for increased costs due to other advances. The results of
CASS and the development of PTCA indicate that
there are lower-cost replacements for bypass surgery in
selected patients. On the other hand, the new dualchamber pacemakers offer greater patient benefits but
also carry an increase in unit cost. Use of the artificial
heart as an interim measure in transplant candidates
will expand the applicability of the existing transplant
technology. We know that the overall patient treatment
cost for transplants will increase dramatically if the use
of two implantations in each patient becomes routine,
and when coupled with the expanded availability of
transplants, the resultant increase in total medical care
costs could be substantial. The social benefits of expanded transplant capability remain speculative.
What we do know is that overall our national investment in heart research continues to provide dramatic
returns. We need only look at the coincidence of research advances related to and the declining national
mortality for cardiovascular disease to gain an appreciation of the benefit of our research commitment. In
fact, while reductions in age-adjusted mortality are
associated with increased medical care expenditures in
general, substantially greater reductions are associated
with increased expenditures for the treatment of cardiovascular disease. 19
We as a nation have clearly benefited from the continued increase in the percentage of the GNP devoted
to the health care cost. Without discounting the importance of restraining further growth in medical care
costs, we must keep in mind the nature of the medical
care costs included in the GNP. They are only direct
costs. The GNP does not attempt to capture the indirect
428
costs of disease. According to Mushkin,20 the indirect
costs of disease, including output loss due to sickness
and the costs of premature death, comprised 90% of
the total economic cost of disease in 1900 and 67% of
that in 1975. Assuming that the existing trends in direct costs of disease continued, Mushkin estimated that
it would not be until the year 2000 that the direct costs
of disease would be approximately equal to the indirect
costs. With a continued emphasis on basic research,
we should soon be developing high technology approaches to cardiovascular disease that may not merely
restrain the growth of direct costs of illness but actually
serve to reduce the total economic costs of cardiovascular disease.
References
I. Durant W: What is civilization? As cited in Bartlett J: Familiar
quotations. Boston, 1980, Little Brown, p 789
2. Gibson RM, Waldo DR. Levit KR: National health expenditures,
1982. Health Care Financing Review 5(l): 1, 1983
3. The bill: $1,459 a year. Washington Post, October 17, 1984, p D6
4. Nation's medical bill rises to $322 billion, 10.5 percent of GNP.
Washington Post, July 16, 1983, p A3
5. Weisbrod BA: Economics and medical research. Washington, DC,
1983, American Enterprise Institute, pp 32, 37
6. Equitable Life Assurance Society of the United States: The Equitable Health Care Survey: options for controlling costs. Conducted
by Louis Harris and Associates, 1983
7. Thomas L: The lives of a cell. New York, 1974, Bantam
8. Office of Technology Assessment: The implications of cost-effectiveness analysis of medical technology. Case study No. 9. The
artificial heart. Cost, risks, and benefits. Washington, DC, 1982,
U.S. Government Printing Office, p 9
9. Weinstein MC. Stason WB: Cost-effectiveness of coronary artery
bypass surgery. Circulation 66(suppl III): 111-56. 1982
10. CASS Principal Investigators and their associates: Coronary Artery
Surgery Study (CASS): a randomized trial of coronary artery bypass surgery. Survival data. Circulation 68: 939, 1983
11. Study group modifies recommendations about surgery for cad patients. Med World News 25(19): 20, 1984
12. CASS Principal Investigators and their associates: Coronary Artery
Surgery Study (CASS): a randomized trial of coronary artery bypass surgery. Quality of life in patients randomly assigned to treatment groups. Circulation 68: 951, 1983
13. Jang GC, Block PC, Cowley MJ, Gruentzig AR, Dorros G,
Holmes DR, Kente KM, Leatherman LL, Myler RK, Sjolander
SME, Stertzer SH, Vetrovec GW, Willis WH, Williams DO: Relative cost of coronary angioplasty and bypass surgery in a one-vessel
disease model. Am J Cardiol 53: 52C, 1984
14. Greuntzig AR, Meier B: Percutaneous transluminal coronary angioplasty: the first five years and the future. Int J Cardiol 2: 319,
1983
15. Parsonnet V, Bernstein AD: Cardiac pacing in the 1980s: treatment
and techniques in transition. J Am Coll Cardiol 1: 339, 1983
16. Cohen SI. Frank HA: Preservation of active atrial transport: an
important consideration in cardiac pacing. Chest 81: 51, 1982
17. Sutton R, Perrins J, Citron P: Physiologic cardiac pacing. PACE 3:
207, 1980
18. Evans RW: Economic and social costs of heart transplantation.
Heart Transplant 1: 243, 1982
19. Hadley J: More medical care, better health? Washington, DC,
1982, Urban Institute Press, p 67
20. Mushkin S: Biomedical research: costs and benefits. Cambridge,
MA, 1979, Ballinger, p 2
CIRCULATION
Advances in cardiology and escalating costs to the patient: a view from the government.
C Lenfant and C A Roth
Downloaded from http://circ.ahajournals.org/ by guest on June 15, 2017
Circulation. 1985;71:424-428
doi: 10.1161/01.CIR.71.3.424
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright © 1985 American Heart Association, Inc. All rights reserved.
Print ISSN: 0009-7322. Online ISSN: 1524-4539
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
http://circ.ahajournals.org/content/71/3/424.citation
Permissions: Requests for permissions to reproduce figures, tables, or portions of articles originally
published in Circulation can be obtained via RightsLink, a service of the Copyright Clearance Center, not the
Editorial Office. Once the online version of the published article for which permission is being requested is
located, click Request Permissions in the middle column of the Web page under Services. Further
information about this process is available in the Permissions and Rights Question and Answer document.
Reprints: Information about reprints can be found online at:
http://www.lww.com/reprints
Subscriptions: Information about subscribing to Circulation is online at:
http://circ.ahajournals.org//subscriptions/