Roanoke Times
Copyright (c) 1995, Landmark Communications, Inc.
DATE: MONDAY, August 22, 1994 TAG: 9409270009
SECTION: EDITORIAL PAGE: A7 EDITION: METRO
SOURCE: KENNETH SHINE
DATELINE: LENGTH: Medium
Are we wrong to want the best technology money can buy? Or is there something about the way we use technology that unnecessarily drives up costs?
It's not obvious why new technologies should cost so much. Clearly, some innovations save money. According to a conservative estimate, vaccines against such childhood illnesses as polio and measles save $10 in future health-care costs for every $1 spent. Drugs such as lithium, used to treat manic-depressive disorder, reduce the need for costly hospitalization.
But even medical innovations that would seem to save money can paradoxically end up raising health-care expenditures. The reason: Physicians use them more often, thus swamping the effect of decreased unit prices.
For example, laparoscopic cholecystectomy, in which the gallbladder is removed through a small slit in the abdominal wall, is a splendid addition to the surgeon's armamentarium. The procedure costs up to 40 percent less than a laparotomy, the traditional surgical approach. But when researchers studied patient populations that were offered the new technique, aggregate expenditures increased 11 percent because doctors used the new procedure 60 percent more often.
Physicians also have a tendency to acquire the "Cadillac syndrome." If a patient needs a pacemaker, a doctor might put in the top-of-the-line model rather than a less costly alternative that would meet the patient's needs.
Costs can go up when physicians have an economic interest in the provision of services. In a study in Florida, physicians referred patients for diagnostic procedures significantly more often if the physicians had a financial interest in the diagnostic facility.
Unnecessary medical procedures also can drive up costs. Sometimes specialists ask that patients coming to see them undergo routine diagnostic procedures before the consultation. The result might be a magnetic resonance imaging scan that would have been avoided had the specialist consulted with the patient first.
Finally, easy access to technology encourages its use. The cardiologist who has an echocardiography machine or a treadmill in the next room is far more likely to use them for a stress test under borderline circumstances.
If new technologies lead to higher costs, shouldn't we just slow the development of new technologies? But that doesn't make sense. Biomedical research and clinical studies hold tremendous promise to prevent illness and cure disease. We want those benefits for ourselves and for our children. We also want U.S. companies to continue to be world leaders in these industries.
The problem lies not in new technologies but in the ways that we choose to use and pay for them. Today, new technologies are the medical equivalent of climbing Mount Everest: We use them because they are there. We need to move toward a system of paying for new technologies only when their benefits exceed their costs.
For example, "Cadillac" pacemakers should be used only when a heart patient needs the complex functions they offer. An expensive new antibiotic developed to kill a drug-resistant organism should be used only when that organism is likely to be present.
Assessment of new technologies would separate reimbursement policy from science policy. Scientists, engineers and developers could continue to produce the innovations that improve human well-being. Insurers and other major payers could gather the information needed to make reimbursement decisions rationally.
Some medical technologies are inevitably going to increase expenditures - and if the benefit is better health, maybe people will be willing to pay the cost. But we need a way to compare costs and benefits - which is very difficult under the current health-care system.
Kenneth Shine, a cardiologist, is president of the Institute of Medicine in Washington, D. C.
by CNB