Published 2020.1.22
Although healthcare coverage predominates most policy coversations, healthcare costs may be a larger threat to the American economy. Multiple researchers have suggested that it is difficult to identify savings within the American healthcare system beyond the “administrative overhead.” Here are three different ways to think about approaching high healthcare costs:
Medical conditions that cost less/DALY over time
The National Pharmaceutical Council sponsored a study published in Health Affairs in early 2019 suggesting that some medical conditions became less expensive to manage over time. They used World Health Organization US-specific condition-specific DALYs to identify the seven conditions with the greatest morbidity and mortality (ischemic heart disease, lung cancer, breast cancer, HIV/AIDS, cerebrovascular disease, chronic obstructive pulmonary disease and diabetes). They then used CDC and Global Burden of Disease data to estimate age-standardized death rates and disability-adjusted life-years for each of the seven conditions. Finally, they used the Medical Expenditure Panel Survey (MEPS) 1996 and 2015 responses to estimate dollars spent managing these conditions.
| Condition | Per-Person Change in Total Costs (adjusted) | Per-Person Change in DALYs | $/DALY gained |
|---|---|---|---|
| Lung cancer | -$12,310.63 | 2.44 | Dominant |
| Ischemic heart disease | -$5,496.74 | 1.89 | Dominant |
| Cerebrovascular disease | -$1539.94 | 0.47 | Dominant |
| HIV/AIDS | -$1465.32 | 9.00 | Dominant |
| Breast cancer | $173.37 | 1.25 | $138.38 |
| COPD | $519.39 | -0.05 | Dominated |
| Diabetes | $713.56 | 0.13 | $5,687.94 |
The authors acknowledge the study’s limitiations including:
- Public health interventions and lifestyle changes could account for some of the gains, but those improvements could not be distinguished from the gains due to medical interventions,
- The methodology does not account for earlier diagnosis, potentially reducing the resources required to manage the earlier stage disease, and
- Only a small fraction of MEPS respondents had lung cancer, breast cancer or HIV/AIDS diagnoses, limiting the study’s findings for those conditions.
Medical conditions amenable to healthcare
In an article published in mid-2018, the Global Burden of Disease researchers identified 32 causes of death that should not occur in the presence of effective healthcare to approximate personal healthcare access and quality:
| Cause | Amenable age range (years) |
|---|---|
| Tuberculosis | 0-74 |
| Diarrheal disease | 0-14 |
| Lower respiratory infections | 0-74 |
| Upper respiratory infections | 0-74 |
| Diptheria | 0-74 |
| Whooping cough | 0-14 |
| Tetanus | 0-74 |
| Measles | 0-14 |
| Maternal disorders | 0-74 |
| Neonatal disorders | 0-74 |
| Colon and rectal cancer | 0-74 |
| Squamous-cell carcinoma | 0-74 |
| Breast cancer | 0-74 |
| Cervical cancer | 0-74 |
| Uterine cancer | 0-44 |
| Testicular cancer | 0-74 |
| Hodgkin’s lymphoma | 0-74 |
| Leukemia | 0-44 |
| Rheumatic heart disease | 0-74 |
| Ischemic heart disease | 0-74 |
| Cerebrovascular disease | 0-74 |
| Hypertensive heart disease | 0-74 |
| Chronic respiratory diseases | 1-14 |
| Peptic ulcer disease | 0-74 |
| Appendicitis | 0-74 |
| Inguinal, femoral and abdominal hernia | 0-74 |
| Gallbladder and biliary diseases | 0-74 |
| Epilepsy | 0-74 |
| Diabetes mellitus | 0-49 |
| Chronic kidney disease | 0-74 |
| Congenital heart abnormalities | 0-74 |
| Adverse effects of medical treatment | 0-74 |
The study authors suggest countries or sub-national geographies can use this index to better direct their healthcare investments.
Healthcare “shoppable” services
In November 2019, CMS (page 65603 of this issue of the Federal Register) defined a shoppable service as “a service that can be scheduled by a healthcare consumer in advance.” The Health Care Cost Institute recently suggested that 36% of 2017 total spending (including prescription medication spend) and 43% of out-of-pocket spending was attributable to shoppable services. I’ve listed the DRGs and CPT/HCPCS the group included below:
| Code | Name | CMS-specified shoppable service |
|---|---|---|
| DRG 005 | Liver transplant and/or intestinal transplant with Major Complication or Comorbidity (MCC) | N |
| DRG 009, 014, 016, 017 | Bone marrow transplant | N |
| DRG 023 | Craniotomy with major device implant or acute complex CNS PDX with MCC or chemotherapy implant or epilepsy | N |
| DRG 025, 026, 027 | Craniotomy and endovascular intracranial procedures without Complication or Cormorbidity (CC)/MCC; with CC; and with MCC | N |
| DRG 039 | Extracranial procedures without CC/MCC | N |
| DRG 101 | Seizures without MCC | N |
| DRG 163, 164, 165 | Major chest procedures without CC/MCC; with CC; and with MCC | N |
| DRG 166 | Other respiratory system operating room procedures with MCC | N |
| DRG 190, 191 | Chronic obstructive pulmonary disease with CC & with MCC | N |
| DRG 216, 217 | Cardiac valve and other major cardiothoracic procedure with cardiac catheterization with CC & with MCC | Y (216) |
| DRG 219 | Cardiac valve and other major cardiothoracic procdure without cardiac catheterization with MCC | N |
| DRG 227 | Cardiac debrillator implant without cardiac catheterization without MCC | N |
| DRG 228, 229 | Other cardiothoracic procedures without MCC & with MCC | N |
| DRG 233, 234 | Coronary bypass with cardiac catheterization without MCC & with MCC | N |
| DRG 237, 238 | Major cardiovascular procedures without MCC & with MCC | N |
| DRG 246 | Percutaneous cardiovascular procedures with drug-eluting stent with MCC or 4+ vessels or stents | N |
| DRG 247 | Percutaneous cardiovascular procedure with drug-eluting stent without MCC | N |
| DRG 249 | Percutaneous cardiovascular procedure with non-drug-eluting stent without MCC | N |
| DRG 251 | Percutaneous cardiovascular procedure without coronary artery stent without MCC | N |
| DRG 253, 254 | Other vascular procedures without CC/MCC & with CC | N |
| DRG 266, 267 | Endovascular cardiac valve replacement without MCC & with MCC | N |
| DRG 268, 269 | Aortic and heart assist procedures except pulsation balloon without & with MCC | N |
| DRG 270, 271, 272 | Other major cardiovascular procedures without CC/MCC; with CC; and with MCC | N |
| DRG 273, 274 | Percutaneous intracardiac procedures without MCC & with MCC | N |
| DRG 286, 287 | Circulatory disorders except acute myocardial infarction, with cardiac catheterization without MCC & with MCC | N |
| DRG 310 | Cardiac arrhythmia & conduction disorders without CC/MCC | N |
| DRG 314 | Other circulatory system diagnoses with MCC | N |
| DRG 326, 327, 328 | Stomach, esophageal & duodenal procedure without CC/MCC; with CC; and with MCC | N |
| DRG 329, 330, 331 | Major small and large bowel procedures without CC/MCC; with CC; and with MCC | N |
| DRG 392 | Esophagitis, gastroenteritis and miscellaneous digestive disorders without MCC | N |
| DRG 405, 406 | Pancreas, liver and shunt procedures with CC & with MCC | N |
| DRG 454, 455 | Combined anterior/posterior spinal fusion without CC/MCC & with CC | N |
| DRG 457 | Spinal fusion except cervical with spinal curvature/malignancy/infection or external fusion with CC | N |
| DRG 460 | Spinal fusion except cervical without MCC | Y |
| DRG 462 | Bilateral or multiple major joint procedures of the lower extremity without MCC | N |
| DRG 466, 467, 468 | Revision of hip or knee replacement without CC/MCC; with CC; and with MCC | N |
| DRG 469 | Major hip and knee joint replacement or reattachment of lower extremity with MCC or total ankle replacement | N |
| DRG 470 | Major hip and knee joint replacement or reattachment of lower extremity without MCC | Y |
| DRG 472, 473 | Cervical spinal fusion without CC/MCC & with CC | Y (473) |
| DRG 483, 484 | Major joint & limb reattachment procedure of the upper extremity without CC/MCC | N |
| DRG 490, 491, 518, 519, 520 | Back & neck procedure excluding spinal fusion without CC/MCC & with CC/MCC or disc device/neurostimulator | N |
| DRG 493, 494 | Lower extremity & humer procedure except hip, foot, femur without CC/MCC & with CC | N |
| DRG 620, 621 | Operating room procedures for obesity without CC/MCC & with CC | N |
| DRG 627 | Thyroid, parathyroid and thyroglossal procedures without CC/MCC | N |
| DRG 641 | Miscellaneous disorders of nutrition, metabolism, fluids/electrolytes without MCC | N |
| DRG 708 | Major male pelvic procedures without CC/MCC | N |
| DRG 742, 743 | Uterine and adnexa procedure for non-malignancy without CC/MCC, & with CC/MCC | Y (743) |
| DRG 765, 766 | Cesarean section without CC/MCC & with CC/MCC | N |
| DRG 775 | Vaginal delivery without complicating diagnoses | N |
| DRG 795 | Normal newborn | N |
| DRG 847 | Chemotherapy without acute leukemia as secondary diagnosis with CC | N |
| DRG 945 | Rehabilitation with CC/MCC | N |
| CPT 00142, 00170 | Under anesthesia for procedures on the head | N |
| CPT 00300, 00320 | Under anesthesia for procedures on the neck | N |
| CPT 00400 | Under anesthesia for procedures on the thorax (chest wall and shoulder girdle) | N |
| CPT 00670 | Under anesthesia for procedures on the spine and spinal cord | N |
| CPT 00740, 00810 | Under anesthesia for gastrointestinal endoscopic procedures | N |
| CPT 00790 | Under anesthesia for procedures on the upper abdomen | N |
| CPT 00840 | Under anesthesia for procedures on the lower abdomen | N |
| CPT 00952 | Under anesthesia for procedures of the perineum | N |
| CPT 01400 | Under anesthesia for procedures on the knee and popliteal area | N |
| CPT 01402 | Under anesthesia for procedures on the knee and popliteal area | N |
| CPT 01480 | Under anesthesia for procedures on the lower leg (below knee) | N |
| CPT 01630 | Under anesthesia for procedures on the shoulder and axilla | N |
| CPT 01810 | Under anesthesia for procedures on the forearm, wrist and hand | N |
| CPT 01967 | Under anesthesia for obstetric procedures | N |
| CPT 11042 | Under debridement procedures on the skin | N |
| CPT 11100 | Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed | N |
| CPT 17000 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses) | N |
| CPT 17110 | Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), of benign lesions other than skin tags or cutaneous vascular proliferative lesions | N |
| CPT 19103 | Biopsy of breast, percutaneous, automated vacuum assisted or rotating biopsy device, using imaging guidance | N |
| CPT 19120, 19081, 19082, 19083, 19084, 19085, 19086 | Under excision procedures on the breast | Y (19120) |
| CPT 19125 | Excision of breast lesion identified by preoperative placement of radiological marker, open | N |
| CPT 19318 | Under repair and/or reconstruction procedures on the breast | N |
| CPT 20610, 20612, 20680 | Under general induction or removal procedures on the musculoskeletal system | N |
| 23412 | Under repair, revision, and/or reconstruction procedures on the shoulder | N |
| CPT 26055 | Under incision procedures on the hand and fingers | N |
| CPT 27130 | Under repair, revision, and/or reconstruction procedures on the pelvis and hip joint | N |
| CPT 27447 | Under repair, revision, and/or reconstruction procedures on the femur (thigh region) and knee joint | N |
| CPT 28296 | Under repair, revision, and/or reconstruction procedures on the foot and toes | N |
| CPT 29824, 29826, 29827, 29877, 29880, 29881, 29888 | Under endoscopy/arthroscopy procedures on the musculoskeletal system | Y (29826, 29881) |
| CPT 30520 | Under repair procedures on the nose | N |
| CPT 33240, 33249 | Under pacemaker or pacing cardioverter-defibrillator procedures | N |
| CPT 36415 | Under venous procedures | N |
| CPT 42820 | Under excision and destruction procedures on the pharynx, adenoids and tonsils | Y |
| CPT 43235, 43239 | Under esophagogastroduodenoscopy | Y |
| CPT 45378, 45380, 45384, 45385, 45391 | Under endoscopy procedures on the rectum | Y (45378, 45380, 45385, 45391) |
| CPT 47562, 47563 | Under laparoscopic procedures on the biliary tract | Y (47562) |
Although these DRGs and procedures meet the strict definition of a shoppable service, I doubt patients or caregivers would consider most of these services “shoppable.”