Healthcare reform is now the law of the land. And while we do not know for sure the final form this new law will take (since the final form depends on the outcome of the ongoing reconciliation process), there are a few clear inferences we can make about our new healthcare system that are relevant to anyone concerned about heart disease. Some of these are:
Expensive Cardiac Treatments Will Be Subject To New Scrutiny
One complaint everyone is making about the new healthcare law is that it does not sufficiently control costs. But the new law does, in fact, establish mechanisms by which various cost controls can occur. Panels of experts will be established, for instance, to find ways to measure "quality." Measuring quality means establishing standards, standards which will rely (whenever possible) on the application of "evidence-based medicine" (i.e., the practice of medicine strictly according to the results of well-conducted clinical trials). While the strict application of evidence-based practice standards is not always a good thing for individual patients (since the standards are invariably based on the average response to a therapy among a very large group of people), it does help to maintain a certain overall level of quality, and, when judiciously applied, can reduce costs.
Chief among the cardiac procedures which will be subject to new scrutiny by such panels of experts will be the use of stents to treat stable angina. There can be little doubt that stents are greatly overutilized by cardiologists. Stable angina, randomized trials tell us, can be safely managed primarily by the use of anti-anginal drugs, resorting to stents only when a sufficiently aggressive period of trial-and-error with medication has failed. Cardiologists (and, some cardiologists insist, their patients) have been reluctant to adopt this approach. The application of "regulatory muscle" will undoubtedly convince cardiologists to re-examine their treatment of angina.
Other expensive cardiac therapies which are likely to be targeted for scrutiny include implantable defibrillators (and possibly pacemakers), and ablation therapy for cardiac arrhythmias.
Expensive Cardiac Diagnostic Tests Will Be Subject To New Scrutiny
The notion that "preventive medicine" reduces healthcare costs has been reduced to near dogma, and the government and various interest groups (such as the American Heart Association and the American Cancer Society) have spent decades teaching all of us this "fact." However, the government (at least) knows better. Preventive medicine, in truth, often greatly increases the cost of healthcare, and in the interest of achieving cost reduction under our new healthcare law, our government is going to have to figure out how to "unteach us" this dogma. (Their first attempt to do so - last fall's attempt to roll back screening mammography in women under 50 - was pretty much a disaster.)
Preventive medicine - specifically, screening for disease in apparently healthy people - almost always greatly increases the cost of healthcare. First, the screening tests are often expensive. Second, there are invariably a lot of false positive tests, requiring further, more definitive (and more expensive) tests. Third, such screening tests almost by definition discover "occult" disease (disease at an early stage and which, at the moment, is not causing obvious problems), and in some cases (such as with some prostate cancers and - apparently - some breast cancers, and with some coronary artery disease) it has never been demonstrated that early diagnosis leads to better oucomes. But early diagnosis always leads to immediate expenditures of healthcare resources.
In the case of heart disease, it is almost a certainty that expensive screening studies - specifically, cardiac calcium scans, cardiac MRI scans, nuclear scans such as stress/thallium studies and MUGA scans, and even echocardiograms - will become subject to new quality controls that will significantly reduce their usage. On average, this may be a good thing. For specific individuals, not so much.
What You Can Do
It seems inevitable that people who have heart disease - or who might have heart disease - will, in the future, have to fight a little harder or wait a little longer for diagnostic tests and certain therapies. In some cases, and perhaps even in the average case, this might not be such a bad thing. In any case such restrictions, if they occur, will not happen overnight. It will likely take several years for panels of experts to meet, deliberate, and promulgate, and even longer for regulators to reduce their "recommendations" to enforceable rules.
In the meantime, there are several things you can do if you have, or are concerned about, heart disease:
- If you and your doctor have decided it would be a good idea for you to be screened for coronary artery disease (for instance, with a calcium scan), you might want to do so in the next year or two, before possible new restrictions come on line.
- Get yourself a good primary care physician, and do it quickly. In many cases, PCPs will become the formal "gatekeepers" to cardiologists (and other specialists). So having a PCP you trust may turn out to be very important. Furthermore, there is a dire shortage of PCPs already, and when 32 million Americans suddenly become insured, PCPs will become much, much harder to find. So find a good one now. Make it a priority.
- Don't get heart disease. And if you have heart disease, do everything you can to keep it from progressing. To a large extent, coronary artery disease is preventable and controllable. (This is not true for everyone, but it is true for the majority.) Getting heart disease is a bad thing whether we have healthcare reform or not. But to the extent that our new healthcare system will make it more difficult to receive the diagnostic and therapeutic procedures you and your cardiologist might like to use, avoiding heart disease altogether makes that much more sense. So assess your risk for heart disease, and do everything humanly possible to reduce that risk.
Do the things you can do yourself; relying on the healthcare system to bail you out if you fail to live a healthy lifestyle has never been a great idea, and it is probably going to be even a worse idea in the future.
ouch.