After the death of a friend, Mr. Brown (not his real name) decided to make a trip to his local cardiologist for a stress test. Mr. Brown, a 68-year-old man, belonged to one of those managed Medicare plans. He had some mild hypertension but was otherwise fine. He saw the local cardiologist, requested “one of those nuclear stress tests,” and left being told he would have to wait for the doctor’s office to get approval from his insurer in order to perform the test.
Two weeks later he was back for the exercise treadmill study (the stress test), and a few days later he returned to discuss the results with Dr. White, his cardiologist. Even though he performed well on the treadmill and had no symptoms he was told the nuclear imaging study showed that there was a serious blockage in an artery supplying the bottom of his heart. Dr. White suggested that Mr. Brown have a cardiac angiogram with his associate, Dr. Green. Mr. Brown was relieved and thankful that he had that test.
A week later Mr. Brown had the angiogram. The study showed a 75% blockage of a diagonal artery so a drug-eluting stent was placed into that artery. He was prescribed a new medicine known as Effient, and he was told not to stop taking that drug for at least a year. Mr. Brown thanked his doctors and left feeling self-satisfied that he had been wise enough to go get that stress test.
What a great healthcare system! Or perhaps not.
Let’s deconstruct the treatment and services our healthcare system actually delivered to Mr. Brown and see just how well the system served him.
1. Dr. White committed a crime — insurance fraud — by getting that stress test approved and performing and billing for it. There was no reasonable indication that Mr. Brown should have had a nuclear stress test and the only way for it to get approved by the insurer, was for his doctor to have lied and told the insurer that the patient had chest pain or shortness of breath with exertion, multiple cardiac risk factors, and perhaps, an abnormal ECG.
2. In a patient with great exercise tolerance and without symptoms during a treadmill study, a defect in an imaging study, like the one Mr. Brown had, should not warrant an angiogram. It is very unlikely the patient would benefit from a cardiac angiogram, with its associated risks — that include radiation, contrast agents that are toxic to the kidneys, and a small, but very present risk of stroke or death from a major bleed, stroke, or heart attack.
3. The angiogram results, noting a lesion in an artery, were not consistent with the results of the patient’s stress test. The doctors found a lesion that supplies a relatively small area of the lateral part of the anterior wall, not the bottom of the heart, which is what the nuclear scan suggested. So the lesion they opened did not even cause symptoms, EKG changes with exercise, or even a defect on the nuclear scan. The nuclear scan findings were more likely an artifact than anything real!
4. The patient now must take Aspirin and a branded drug called Effient for at least a year. The combination of these two potent drugs that inhibit the ability of your platelets to help stop bleeding, and in this case clotting of the artery which the trauma of the stent placement just damaged, also increases the risk of bleeding to death, especially if you need some type of emergency surgical procedure in the next year or you suffered some form of trauma. Stop the drug too early, especially in the first few months, and now, though not the case before the stent was placed, you have a very real chance of having a devastating heart attack! Need your gallbladder taken out in an emergency and you’ve got a big problem!
5. Mr. Brown’s doctors decided to place him on a drug called Effient. This is a drug that I consider a more potent Plavix, now available under its generic name, Clopidogrel. More potent means that Effient seems to reduce the risk of heart attacks in some patients who have stents but, since it is more potent, increases the risk of devastating bleeding. In the end, if you consider death a reasonable end-point, Effient is no better than Clopidogrel for Mr. Brown.
I like to use Costco for comparison of prescription drug pricing since they have very competitive pricing and also have a price checker on their web site. A two month supply for Clopidogrel at Costco is $14.68, while a two month supply of Effient is $498.83. Mr. Brown must take this medication for at least one year (some doctors leave their patients on it for even longer) so it will cost him, or our healthcare system, about $3,000 dollars for Effient instead of the $88 dollars for Clopidogrel (assessing the cost for Effient is a bit complicated since some insurance companies provide some coverage for this, but someone is going to be paying for this drug).
I wish I could say that I am exaggerating here, that what I just described is not commonplace and only found in smaller, non-academic centers, but our healthcare system has become so tarnished by greed and dishonesty that even the biggest and the best hospitals, including many in New York, are allowing just about any doctor to bring patients to their cath lab. While in the past big institutions shunned duplicitous operators and provided great oversight, some are providing little supervision now. The fact is that heart procedures make big hospitals hundreds of millions of dollars a year and the people in charge — the administrators — are driven by profit. Just a simple angiogram, with less than a few hours at a hospital can generate over $8,000 in revenue. Do more, make more. Do more stress tests, find more reasons to do angiograms, find more reasons to place stents or perform cardiac surgery.
Still think it’s the best healthcare system?
About the author: Dr. Evan S. Levine is a cardiologist in New York and a Clinical Assistant Professor of Medicine at Montefiore Medical Center – Albert Einstein College of Medicine. He is also the author of the book “What Your Doctor Won’t (or can’t) Tell You”. He lives in Connecticut with his wife and children.