A Follow-Up on Health Savings Accounts

Thanks for the compliment! Health Savings Accounts are brand-new high-deductible health insurance accounts. Essentially, the insurance doesn't kick in until you've paid $1,000 worth of medical expenses out of your own pocket if you're single, or a total of $2,000 if you have family coverage. But you get to set aside the money to cover these out-of-pocket expenses via tax-deductible contributions. If you have individual coverage you can set aside as much as $2,600; the maximum contribution for a family is $5,150. These amounts will be adjusted every year for inflation.

Now here's where some folks get pretty jazzed about an HSA: If you don't spend all of the money you've set aside in your account, it remains there, growing on a tax-sheltered basis. In other words, as you clearly understand, Peter, these accounts can be a substitute retirement savings vehicle, similar to a nondeductible IRA.

Martha Priddy-Patterson, a director with Deloitte & Touche, says you're "absolutely right" to consider not dipping into your HSA to cover medical bills if you don't have to. "You're under no obligation to pay your medical bill out if the HSA account. If you can afford not to, it's smart." If nothing else, leaving the money in the account allows you to build up a kitty in the event you do have a major medical expense, whether planned (braces for your two kids) or unplanned (you're in a car accident).

Keep in mind that withdrawals before age 59 1/2 for expenses that are not health-related will result in a 10-percent penalty, plus ordinary income tax on the gains. However, provided the money is used for medical bills ? at any age ? your withdrawal is tax-free. And once you're past the 59 1/2 milestone, you can even take withdrawals for non-health expenses without a penalty (you'll still owe income tax on the gains, though). If you're planning to use your HSA for retirement purposes, stay abreast of current IRS regulations ? it is not inconceivable that the rules for these accounts could change once they come into widespread use.

Hopefully, this explanation will help clear some misconceptions about these accounts. I love the control that these accounts provide. They make sense financially.

They should also make many people think carefully about their health care expenditures. As I have said repeatedly, this thought process should lead to less demand for high cost procedures and medications. If that is true, we might actually get physicians and patients to become more cost effective.

Implementation of Guidelines Sharply Reduces Post-MI Mortality

A formal system designed to ensure implementation of standards of care can reduce 1-year mortality in Medicare patients admitted with myocardial infarction by 23%, researchers announced here Wednesday during late-breaking clinical trial sessions at the American College of Cardiology Annual Scientific Session 2004.

The results, from the ACC's Guidelines Applied in Practice (GAP) Project in southeast Michigan, were reported by Dr. Kim A. Eagle of the University of Michigan Health System in Ann Arbor.

The project findings included approximately 2800 Medicare patients admitted with acute MI and followed until discharge. The objective was to determine if the ACC's GAP guidelines were being implemented and how effective implementation would be. Average patient age was 76. The study group was roughly half men and half women. Between one third and one half had comorbidities on admission.

GAP tools included visible standard orders for the AMI patient, the use of pocket guidelines, patient information sheets and patient discharge contracts, among other tools to trigger GAP use.

During the study, use of the discharge tool increased from about 2% to more than 30%. As a result, a significantly greater number of patients were discharged on what Dr. Eagle called the "Fab Four," beta blockers, ACE inhibitors, lipid lowering agents and aspirin, all proven to improve survival after MI.

Changes in discharge practices as a result of GAP implementation resulted in a 26% reduction in mortality at 30 days and a 23% reduction in mortality at 1 year compared with pre-study rates.

Just another piece to the implementation puzzle. We know what to do for many conditions and many patients. Now we need to continue to study how to make certain that we give the most appropriate care to the most patients.

This study suggests a strongly positive result - good news for postmenopausal breast cancer patients. Research: Breast cancer drug switch cuts recurrence

A drug for advanced breast cancer prevents localized tumors from returning after surgery better than the current mainstay drug, according to a large, international study that promises new hope and treatment strategies for many patients.

Recurrence of such early cancer was reduced by one-third in women who started on the gold standard treatment, tamoxifen, then switched after 21/2 years to the newer drug, exemestane, compared to those who took tamoxifen the whole time.

The women switching to exemestane, a hormonal drug sold under the brand Aromasin, also had less serious side effects, were 56 percent less likely to get cancer in the other breast and were half as likely to develop unrelated cancer in other body areas.

Dr. Jeff Abrams, the National Cancer Institute's associate chief of clinical research, said a recent study on exemestane "cousin" letrozole showed important advantages over tamoxifen for their class of drugs, called aromatase inhibitors. Abrams was not involved in the new study.

Lead researcher Dr. R.C. Coombes, professor of cancer medicine at Imperial College School of Medicine in London, predicted doctors will give exemestane to many women at high risk for recurrence, such as those whose breast cancer spreads to multiple lymph nodes.

"More work needs to be done to understand what's going on" at the molecular level, he said.

The study, which included 4,742 postmenopausal women in 37 countries, focused on women with breast cancer in which the hormone estrogen fuels tumor growth -- the type causing about 70 percent of breast cancer. The results do not apply to premenopausal women or those with tough-to-treat breast cancer not driven by estrogen.

This study does give great promise to the majority of breast cancer patients. As scientists learn more about the biology of breast cancer, we may see even more advances. Great news!

Texas Company Removes Web List of Malpractice Plaintiffs

Yes I continue to listen to my tapes on existentialism. Currently, the lecturer is focusing on Sartre. Sartre's philosophy is quite complicated, but does include the concept of no excuses. I found this quotation particularly interesting.

"Freedom is what you do with what's been done to you."

Extra-Low Cholesterol

A cholesterol-lowering study whose results were announced this week has a wealth of important implications. The findings could certainly presage a significant change in the way heart disease patients are treated. It should also start a careful evaluation of whether normally healthy people could benefit from a sharp drug-induced reduction in their cholesterol levels. There may also be major side effects for the economy: the potential health benefits could drive up the use of high-cost drugs in a nation that is already struggling to pay its medical bills. Finally, the study should send a message to Congress and federal regulators about the value of comparative testing of prescription drugs.

The NY Times has a few issues right, and one or two that may not be right. Clearly, this study does make us reconsider how we treat coronary artery disease patients. The study does show that. My blogging colleague, Sydney Smith, disagrees - The Love Affair Continues. She and I have previously agreed that we can and should disagree on issues. I believe she is wrong on this one.

She minimizes the benefit

The results are more notable for what they don't tell us than what they tell us. Rather than following patients over a given period of time and tallying the number of events each group had, they stopped the study when they had 925 events, then relied on statistics to estimate the rates. As a result, the paper deals not with actual event rates but with Kaplan-Meier event rates. A far better study would have been to look at the actual rates. But then, the significance of the findings might not have been as impressive. That is, it would have been harder to present their statistically significant findings as equally clinically significant.

Sorry Sydney, but Kaplan-Meier event rates are actual event rates. Kaplan-Meier curves allow one to evaluate the entire curve over time, rather than just comparing rates at one arbitrary endpoint. Therefore they are much more informative. If anyone wants to read the nitty-gritty on this subject - Survival Curves: Accrual and The Kaplan-Meier Estimate. As I read this study, the results are dramatic (and just in the first 2.5 years). As I wrote yesterday, the curves suggest that the results would become even more dramatic over longer time frames.

The NY Times has no reason to suggest using higher doses as primary prevention. Primary prevention really is a different problem than secondary prevention. Extrapolating these data to the primary prevention problem does not make sense in 2004.

The NY Times suggests that the cost of the higher dose (a difference of ~$600/year) would "drive up the use of high-cost drugs in a nation that is already struggling to pay its medical bills". They should consider the possibility that the decrease in mortality and hospitalizations could overcome the medication costs. We err when we look at medication costs without analyzing the benefits of decreased hospitalizations, decreased development of congestive heart failure, decreased bypass surgery, and decreased mortality. These costs are all important.

Finally the NY Times is correct to point out the importance of head-to-head drug trials (a process which I have championed here over the past 2 years). Interestingly, and supportive of the results:

Bristol-Myers sponsored the study and expected it to prove that its drug was just as effective as Lipitor when it came to reducing disease and preventing deaths. Bristol-Myers was disappointed. But the effort did underline the great benefit in comparing the performance of two prescription drugs. Traditionally, drugs are only tested against placebos. From now on, the value of head-to-head competitions should be obvious to everyone.

Yes, Bristol-Myers makes Pravachol - not Lipitor. Kudos to Bristol-Myers for sponsoring this important study!!

Since posting last night, I have had a couple of interesting questions concerning this article. I would also like to link on today's news stories concerning this article. Finally, I would like to more explicitly give my own interpretation.

Who should receive the high dose strategy? Why not just use pravastatin (Pravachol) at a higher dose?

We must always remember that the patients in this study already had known, active coronary artery disease. This is a secondary prevention study. That being said, if one carefully reads the NCEP guidelines - Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) you will note that patients with adult onset diabetes mellitus are treated as if they already have coronary artery disease. One can (in my opinion) extrapolate the data to diabetic patients, but not patients with pure primary prevention (and no other major risk factors).

Reading the study carefully, they used the highest dosage of each medicine which currently has FDA approval. Certainly, pravastatin at 80 mg might work, but we have no data, either on efficacy or safety.

Today's news stories: New Conclusions on Cholesterol from the NY Times and Striking Benefits Found In Ultra-Low Cholesterol from the Washington Post.

My interpretation of the data at this time:

• This study, and its results are only definitely important for secondary prevention
• The results are, to me, striking at 2.5 years. Since atherosclerosis progresses over time, it seems logical that the benefits will increase over time (although that is theory).
• The costs for Lipitor 80mg ($3-4 per day) are significant, but given the benefits not unreasonable.
• I am converted, and plan to work on giving post ACS patients the new dose
• We have no data on Crestor at high doses. I would not use a new statin until I better know the risk profile

Study: Lower Cholesterol Helps Save Lives

Lowering heart attack victims' cholesterol to levels dramatically below current standards appears to be an important strategy for saving lives and preventing new heart problems, a major new study shows.

Drugs called statins are already standard medicine for people recovering from heart attacks. But the study suggests newer, more potent varieties work best for these high-risk patients.

``The message for these people going home from the hospital is they should be on a high-intensity regimen,'' said Dr. Christopher Cannon of Boston's Brigham and Women's Hospital. ``For everyone else, treating cholesterol and getting it down is very important.''

The much-anticipated study helps answer one of the most discussed questions in cardiology: How low should cholesterol go? For those getting over recent heart attacks, at least, the answer appears to be very low indeed.

Those who did best in this study saw their levels of LDL, the bad cholesterol, plunge in half to an average of just 62. The goal in current federal guidelines is to get LDL below 100.

The study was to be presented Monday in New Orleans at the annual scientific meeting of the American College of Cardiology. It also will be published in the Apr. 8 issue of the New England Journal of Medicine.

The latest work reinforces the conclusion of another head-to-head comparison of statin drugs released last November. In that study, doctors found the more intensive treatment resulted in less artery clogging. The new report is considered even more persuasive because it looks for differences in the risk of death and other clearly measurable misfortunes of heart patients.

Both studies compared 40 milligrams daily of Pravachol to 80 milligrams of Lipitor, the highest approved doses of both drugs when the research started. Pravachol is an older statin made by Bristol-Myers Squibb, while the newer and more potent Lipitor is made by Pfizer. Last fall's study was financed by Pfizer, and this one was paid for by Bristol-Myers Squibb. Lipitor came out on top in both comparisons.

For those who want to read the article from the NEJM - Comparison of Intensive and Moderate Lipid Lowering with Statins after Acute Coronary Syndromes and the editorial - Intensive Statin Therapy -- A Sea Change in Cardiovascular Prevention

Several caveats for everyone. First, they did use a higher dose in the Lipitor group - the group that we call intensive (rather than standard) therapy. Second, all patients had acute coronary syndrome. We should not extrapolate the use of intensive therapy to primary prevention. Third, we must understand cost (sentence quoted from the Wall Street Journal) -

Dr. Topol noted that the dose of Pravachol used in the study costs about $900 a year, while the dose of Lipitor costs $1,400.

Given all these caveats, I would take the higher Lipitor dose (@$4/day) if I had an acute coronary syndrome.

Whoever fights monsters should see to it that in the process he doesn't become a monster.

Friedrich Nietzsche

While most watchers have not picked this up on their radar, I have been ranting about this issue for months. We do not have enough physicians going into primary care - because primary care physicians are treated poorly, both financially and with relationship to worklife balance. Apparently DO students are figuring that out also. Fewer new DOs picking primary care

Tort reform debate best served by truth

Here's another e-mail: "Peer review may be one part of the solution, but it should be serious, responsible peer review of doctors and hospitals. ... Shining the light of investigation on negligence incidents would do more to reduce medical errors, thereby reducing malpractice claims."

The Institute of Medicine and the Health and Human Services Dept. say most medical errors are not failures of physicians, but failures of the system. Even when doctors do their jobs correctly, most errors would still occur.

A better approach to fixing the problem of system errors would be to dispel the fear of physicians, hospitals and nurses that open discussion on adverse events would be discoverable in lawsuits.

That's why we support the Patient Safety and Quality Improvement Act (S 720), a proposed federal law that would allow the voluntary, confidential reporting of errors to patient safety experts. The result would be advice on how to improve the system and therefore patient safety. This system fix would be shared with all in a de-identified manner. This model works for the Aviation Safety Reporting System. It would work in the health care field, too.

The AMA also helped launch the National Patient Safety Foundation in 1996 and has supported it since with more than $6.5 million dollars. Despite our repeated public challenges to match our donations, the Assn. of Trial Lawyers of America has not contributed a dime.

If this excerpt whets your appetite, go read the entire article.

Thanks for all the comments. As I have thought through the issues, I would like to be more explicit in my dislike of the web site.

My problem relates to diagnostic test performance. Of all the people (lawyers, unethical testifying physicians, and litigious patients) that one might conceivably like to exclude from ones practice, they would all be there. However, many people on the list do not deserve the scorn that one would give to anyone on the list. Thus, the list is sensitive, but not specific.

This listing sets a danger precedent. I am against similar lists of physicians have been sued, for exactly the same reason.

If one could look at each case, and classify the lawyer, testifying physician and patient as legitimate or not, then they might have a decent argument. However, in the absence of complete information this list does not meet my fairness test.