Correspondence
Cardiovascular Risk Factors and Medicare Costs
N Engl J Med 1999; 340:813-814March 11, 1999
- Article
To the Editor:
The article by Daviglus et al. (Oct. 15 issue)1 on the relation between the presence of risk factors for cardiovascular disease at 40 to 64 years of age and later Medicare expenditures has important implications for public health and national policy. Traditionally, insurers, particularly private insurers, have had a short-term view of the risks and benefits of health care, because they must balance their budgets annually. This short-term emphasis has made it difficult to extend funding for efforts at disease prevention because, although we know such efforts have great benefits and are cost effective, the results are not seen for many years, by which time the member who benefited may no longer be with the health plan that incurred the costs. Thus, that health plan may not reap the financial benefits of decreased health care costs.
The data in the article by Daviglus et al. may serve as an impetus for the Health Care Financing Administration to join with private insurers and managed-care plans, which are generally insuring persons in the 40-to-64-year-old age group, in an effort to decrease health care expenditures and improve the nation's health by focusing on prevention. Some of the most effective preventive factors — eating a healthful diet and exercising regularly — cost nothing, require minimal intervention on the part of a physician, and have no costly adverse effects.
This point was overlooked in Dr. Russell's editorial,2 which accompanied the article. In addition, Russell notes that smoking cessation has been shown to be one of the most cost-effective interventions available today, costing less than $5,000 per quality-adjusted life-year gained. Yet she advocates screening for elevated homocysteine levels, which many regard as unnecessary and not cost effective, especially given the current widespread practice of fortifying breads and cereals (for the benefit of pregnant women).
I commend Daviglus et al. for bringing these exciting new data to light. I hope their findings will serve as the impetus for forward-looking health care policy focusing on preventive efforts that would benefit all Americans while decreasing Medicare expenditures — a true win–win strategy.
2 ReferencesRita F. Redberg, M.D.
University of California, San Francisco, Medical Center, San Francisco, CA 94143-02141
Daviglus ML, Liu K, Greenland P, et al. Benefit of a favorable cardiovascular risk-factor profile in middle age with respect to Medicare costs.N Engl J Med 1998;339:1122-9.
2
Russell LB . Prevention and Medicare costs. N Engl J Med 1998;339:1158-1160
Full Text | Web of Science | Medline
To the Editor:
Daviglus et al. report the benefit of a favorable cardiovascular risk-factor profile with respect to Medicare costs, focusing on three established major risk factors: a high cholesterol level, hypertension, and smoking. Recently, the Nutrition Committee of the American Heart Association, in its “call to action,” strongly suggested that obesity should be upgraded from the status of a contributing risk factor to that of a major risk factor for coronary heart disease.1 It is well established that the economic burden of obesity is enormous.2
In the study by Daviglus et al., Medicare costs arising from a high cholesterol level, hypertension, and smoking are very high, with smoking leading the list. We note that the body-mass index (the weight in kilograms divided by the square of the height in meters) is available for all study subjects. Therefore, the data base of this trial appears to provide an excellent opportunity to calculate the adjusted average annual charges arising from obesity and, in this way, allows a comparison of the costs of obesity with those of the three established risk factors.
2 ReferencesHannes Gaenzer, M.D.
Guenther Neumayr, M.D.
Josef R. Patsch, M.D.
Innsbruck University Hospital, Innsbruck 6020, Austria1
Eckel RH ,Krauss RM . American Heart Association call to action: obesity as a major risk factor for coronary heart disease. Circulation 1998;97:2099-2100
Web of Science | Medline2
Rosenbaum M ,Leibel RL ,Hirsch J . Obesity. N Engl J Med 1997;337:396-407
Full Text | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: We agree with Dr. Redberg's comments. Although much effort has recently been directed toward controlling health care costs,1 little attention has been given to prevention as a method of cost containment. Our findings indicate the potential for preventive measures to increase the proportion of the population with favorable cardiovascular risk-factor profiles, thereby preventing cardiovascular disease and lowering health care costs. Such a result requires population-wide early prevention of all major risk factors (rather than merely the treatment of existing risk factors and disease). This critical conclusion was overlooked in the editorial, which focused on expensive drug treatments for persons at high risk.
In her editorial, Dr. Russell casts doubt on our ability to achieve very early modification of risk factors, and she argues that intensive, multiple-intervention programs would be costly.2 In fact, during the past two decades, relatively inexpensive preventive efforts have achieved sizable reductions in the mean intakes of saturated fat and cholesterol, in serum cholesterol (from about 240 to less than 205 mg per deciliter), in blood pressure, and in the prevalence of smoking — resulting in a reduction of more than 50 percent in the mortality from coronary heart disease or other forms of cardiovascular disease.3 Our data also show graded increases in Medicare charges, with charges rising progressively with the level of each major cardiovascular risk factor.3 All these findings support the inference that public policy efforts to shift behavior toward favorable risk-factor patterns result in less disease and lower Medicare costs, even before large numbers of people achieve low-risk status (defined as freedom from all major risk factors).
With respect to the issue raised by Gaenzer et al., the mean annual Medicare charges — both total charges and those related to cardiovascular care — were significantly lower for people with a favorable body-mass index (<25) than for those with a higher body-mass index, after we controlled for all other risk factors ($531 vs. $557 for men, and $333 vs. $433 for women).
3 ReferencesMartha L. Daviglus, M.D., Ph.D.
Kiang Liu, Ph.D.
Philip Greenland, M.D.
Jeremiah Stamler, M.D.
Northwestern University Medical School, Chicago, IL 60611-44021
Schwartz WB . The inevitable failure of current cost-containment strategies: why they can provide only temporary relief. JAMA 1987;257:220-224
CrossRef | Web of Science | Medline2
Russell LB . Prevention and Medicare costs. N Engl J Med 1998;339:1158-1160
Full Text | Web of Science | Medline3
Lowe LP ,Liu K ,Daviglus M , et al. CVD risk factors and health care costs 20+ years later: the CHA Study. Can J Cardiol 1997;13:Suppl B:31B-31B abstract.
Author/Editor Response
Dr. Redberg may be right about insurers, but cost-effectiveness analyses take a long-term view and already account for the kind of future savings documented by Daviglus et al. These analyses also account for the costs of the interventions necessary to reap those savings, something done by neither Dr. Redberg nor Daviglus et al. Thus, their data do not change the problem or the information available to policy makers in the Health Care Financing Administration and elsewhere; since the cost effectiveness of the various interventions against heart disease (especially smoking cessation and medications to lower blood pressure and cholesterol levels) is highly variable, policy makers need to think carefully about the best ways to allocate resources for better health.
Dr. Redberg does not cite studies to support her statement that exercise and diet do not involve cost or risk, nor do I know of any that support that view. I have described elsewhere a framework for conducting an evaluation of exercise.1 It is important to keep in mind that interventions that may not involve costs to the medical sector usually have costs outside that sector. Time, for example, is a scarce resource, and exercise requires a regular amount of it over the course of many years. Such steady, repeated costs for large populations make interventions more expensive than they first appear. To support good decisions about the best ways to improve health, information about costs and health benefits should be comprehensive, not limited to the issues of concern to a single sector.
Although I did not, as Dr. Redberg asserts, advocate screening for elevated homocysteine levels, I did advocate a search for more cost-effective interventions against heart disease. Homocysteine has been identified as a significant risk factor for heart disease. If interventions aimed at lowering homocysteine levels are evaluated in clinical trials, their cost effectiveness should be evaluated at the same time.
It is unfortunate that public health advocates continue to point to the savings from interventions while ignoring their costs. Good health is so important that we need to spend our resources as wisely as possible in its pursuit. The false claim that no resources are really required does not contribute to good decisions by policy makers or by individual men and women.
1 ReferencesLouise B. Russell, Ph.D.
Rutgers University, New Brunswick, NJ 08903
