You get what you pay for? If only...

David Brown is part physician, part journalist. Usually that makes his coverage of health matters in the Washington Post  first-rate. But the internist in him got the jump on the reporter in his article Sunday on the impressive drop in death rates from heart attacks since the 1970s. 

He mentioned aspirin, but mainly wrote about the big-ticket items such as corony bypass surgery and angioplasty. He said:  "The evolution of heart attack treatment over the past three decades is a story of doing more things to more people at greater expense with better results. It is a portrait in miniature of medicine in the United States." 

Brown seemed to be making a dose-response argument for health-care spending. Indeed, the headline writer penned: "A case of getting what you pay for."

By lunchtime, New York Times economics reporter David Leonhardt had posted a column  pointing out holes in the Brown article. He said that progress in treating heart attacks is indeed a great success story, but that doesn't mean the more you spend the better the results. 

"What the story leaves out is that some aggressive, expensive treatments for heart-attack patients are also now commonly being used on people who have not had heart attacks," Leonhardt wrote. "This trend has raised health spending — potentially without much, if any, health benefit."

Leonhardt wrote that several leading cardiologists, including one whom Brown had quoted, say that today there is more angioplasty, stenting and bypass surgery being done than there needs to be. In other words, some who undergo the expensive treatments are getting risk without benefit.

As the economics reporter noted, other countries that have advanced heart care are spending less and gaining longer lifespans than we are. 

I had some problems with the Post story, too. For example, Brown wrote:

"Providing health insurance to the 47 million Americans who don't have it -- the key feature of the bills before Congress -- is likely to expand heart attack treatment and increase spending on it, not pare it back and reduce the cost."

 But elsewhere Brown says death rates for the insured and the uninsured from heart attack are the same, presumably because when people collapse with a heart attack they're shipped off to the hospital in an ambulance, where they begin the high-tech care whether they have insurance or not.

So if they're already getting the treatment, it's being paid for by taxpayers and those who pay inflated insurance premiums.  Therefore, as a matter of logic and economics, extending health coverage to the uninsured shouldn't increase the cost of heart-attack care. 

Brown makes another questionable assumption in saying the improved results on heart attack would not have occurred without these interventions. Maybe, maybe not.

There might have been equally effective techniques, devices or drugs that cost less that were never tried because there was no financial incentive for companies to look for them. That's especially true for drugs that have gone off-patent.

Also, using money for one thing takes away the opportunity to spend it on something else. Might there not have been just as great a drop in deaths from heart attack if the United States had invested in public-education campaigns to change behaviors? If it spent money rearranging the way cities and suburbs are laid out, with walking and bike paths making it safe and convenient to get more exercise? 

What If cigarettes had come under FDA regulation long ago? What if food ads aimed at children had been barred from the airwaves? What if non-disabled school kids had to pass a physical-fitness test to progress to the next grade? 

If money were spent on such things instead of on stents, would there be as great an effect? We'll never know.

--Carol Gentry can be reached at 727-410-3266 or by e-mail.