An Interventional Cardiologist’s (brief) View on the Health Care Debate

I wonder how many people reading this have the same mixed feelings that I do with regards to the current health-care coverage debate. There are clearly some tremendous advantages which could be realized by making health care available to the currently uninsured, and by making insurance available to people with pre-existing conditions. I have worked at county hospitals directly or indirectly for most of my career, so I have seen the impact of our current lack of universal health care on many members of our society. I have been struck how many employed, hard-working members of society have not been able to afford health insurance, and then being stuck with medical bills that overwhelm them. We have all heard about individuals with devastating health issues who have lost their savings and declared for bankruptcy due to their massive medical bills. These stories, and the recognition that there are ~30 million Americans without health insurance, cry out for reforming our system. Furthermore, although this needs to be paid for, it is nice to think that the health-care industry will receive payment for taking care of people who are currently uninsured. Undoubtedly the cost of caring for these people earlier than we are now (when things are desperate), will offset many of the costs inherent in providing for their health-care coverage.

The amount of “newsprint” currently being expended to cover the ins-and-outs of health care reform is vast, and there are many, many issues to debate, discuss and question. I am concerned (like many) about the costs, especially the costs which are clouded by smoke and mirrors. It sounds great that the current House and Senate bills propose to limit the insurance companies’ ability to avoid offering insurance to individuals with pre-existing conditions, or to establish caps on health care-coverage. But I wonder what we will see from the insurance industry when it is time for their voices to be heard in the marketplace. I don’t think anyone will have a true grasp on the implications of healthcare reform until we know how they will react. I don’t see the insurance companies standing idly by and accepting limits on their profits. They will undoubtedly find ways to make up for these limitations on their profitability. I would guess this will be in the form of health care rationing, with premium policies to be offered with the attraction of lower degrees of rationing. I suspect that much of the behind-the-scenes wrangling over the “public option” was due to intensive health insurance lobbying, as the public option would curtail the insurance industry’s ability to ration healthcare, in addition to the obvious intense competition for paying customers with which a public option would represent.

So what is the impact of health care rationing on interventional cardiology? As a field which impacts many people, and uses much expensive technology, it is highly likely that we will be at the cutting edge of this social experiment. I mentioned in my previous blog that we have an image problem, and that may play an unfortunate role in how our role or contribution to the well-being of our patients is going to be impacted during the upcoming health care upheaval. For example, how many active interventional cardiologists don’t think that drug-eluting stents are having a favorable impact on our patients’ well-being, despite the fact that the studies don’t show a clear impact on mortality or myocardial infarction? I believe that it is the general experience that drug-eluting stent usage has considerably reduced the need for recurrent interventions. They have largely abolished much of the “frequent-flying” to which we became accustomed prior to their availability, yet this does not appear to be widely appreciated outside of the interventional cardiology community. Instead, we are challenged for embracing more expensive technology.

Another tidbit in the Senate proposal that is little talked about, but which concerns me is a tax on pharmaceutical and medical device companies. Perhaps I have a bit of a vested interest in this area (full disclosure: I have part time employment with a start-up medical device company), but it immediately strikes me that this type of tax sounds good in the newspapers, but is unlikely to have much of an impact on health care economics. In fact, I suspect it will have the opposite of the desired effect – it may in fact increase costs. After all, a company with a successful product will likely increase the costs to pay for the increase in taxes, thus passing on these taxes to the consumers. However, my fear is that what this type of tax will do is create a disincentive for innovation, as this will make it less attractive to invest in medical devices. And as interventional cardiologists, we are acutely involved in the importance of innovation, and devices. This has been the cornerstone of our field, and it is clear there is much more to do. So why is additional taxation on pharmaceutical and medical device companies in the Senate proposal? I think it goes back to image, again. The costs of drugs and of devices are at the forefront in many people’s minds as to why healthcare costs so much. But there are not quite the same provisions against other groups who might make “too much profit” from the current or future health-care economic environments, so why single out the groups which have to assume a great deal of long-term financial risk to bring a commodity to market, to apply a specific tax? Why not instead simply tax any entity which is “too successful” in making money in health care? I think because the consumers see the costs of the drugs or the devices, which seem so high, leading to a frustration and a belief that these costs need to be curtailed. However, it is less transparent how much financial success there might be for an insurance company, or a hospital, or trial lawyers. Once again, interventional cardiology, and our patients, may be paying the price for a problem with image.

Steven L. Goldberg, MD is the Director of the Cardiac Catheterization Laboratory at the University of Washington Medical Center in Seattle, where he is a Clinical Associate Professor of Medicine. He also serves as the Chief Clinical Officer for Cardiac Dimensions, Inc., a small biotech company in Kirkland, Washington.

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