Monday, June 30, 2008

Medical Technologies - Notes of a Medical Technology Realist

I’m a realist about technology use in American health care. Given the American culture and its belief that solutions to complex problems lie in technology just beyond the next horizon, I believe it's difficult, indeed, nearly impossible, to effectively suppress technology use.

Those in power tend to believe they can control medical technologies, bring in experts to figure out what needs to be done, conduct large scale studies to assemble evidence to decide what to pay for, set pre-authorization standards to rein in abuses, and limit available technological installations.

This belief sounds logical. But in America these approaches may not work. Why not? The problem is that complex technologies and their uses and abuses are…..well, complex.

At the market level in a complex capitalistic society that believes in innovation and entrepreneurship and choice, there are simply too many interacting variables, vested interests, market-driven forces, permutations and combinations among interacting individuals and entities, connections at the edges of practices and inside and outside organizations, financial and emotional incentives and considerations, hospitals and doctors who see technologies as a means to increase marketing clout, bring in more revenues, enhance prestige, and improve care: and too much pressure to generate additional sources of money to compensate for decreased reimbursements, patient desire to access the best and the latest, hype and hope generated by ubiquitous media.

Complexity doen’t end there. Once the technological genie is out of the bottle, and hospitals, specialists, and supply chain companies taste fruits of technology, there’s no going back, no way to stop, step back, and re-assess hard evidence whether a technology actually works to improve outcomes..

Take the case of imaging. Once CT and MRI scans hit the marketplace in the early 1970s and doctors recognized computerized imaging was a superior technology that allowed doctors to look inside brains, hearts, body cavities, and joints, there was no retreat. Marketing forces were simply too powerful.

Howard Hiatt, MD, dean of the Harvard School of Public Health, wrote in 1976 in the Wall Street Journal that there was far too much medical technology, and there ought to be a National Technology Assessment Institute to establish irrefutable proof that medical technologies improved care before they hit the market. His idea never got off the ground. Imaging flourished. Indeed, by 2001, a survey published by Fuchs and Fox in Health Affairs, among 225 internists indicated the number one innovation over the previous decade was CT and MRI scanning.

Consequently, imaging, in all of its variations and configurations, has become the fastest growing single cost component of the health system, with growth rates
of 16% to 18% per annum.

Health plans and Medicare have tried to contain imaging growth without avail. This year Medicare drafted a proposal saying it would only pay for CT angiograms if a large scale study proved their worth in improving care. The proposal met with fierce resistance from cardiologists and industry CT suppliers and lobbyists.

Medicare backed down. Two comments on why Medicare blinked, cited in a June 29 New York Times piece, “Weighing the Costs of a Look Inside the Heart,” are worth quoting and tell the technology tale..

• Said Barry Straube, MD, Medicare’s chief medical officer, “There are a lot of technologies , services, and treatments that have not been shown to improve health outcomes in a definite manner,” in announcing Medicare had changed its mind and would pay for CT angiograms, designed but not proven to rule out heart disease and to identify calcified arterial plaques.

• Noted Dr. Redberg, University of California San Francisco cardiologist, “Once the train leaves the station, once the technology gets into the marketplace, we don’t get the evidence. We’re spending a lot of money on technology with unclear benefit and risk.” And so CT angiograms are destined to continue, in ever increasing numbers.

The Web of Ideas to Limit Technology Costs

Here, briefly, are pros and cons of a web of ideas, many based on the Web itself, to reduce and untanglesoaring costs of technologies and to curtail the thirst and dependence of American health providers and consumers on technologies.

• Place doctors on salaries to end incentives to use medical technologies for personal gain from self-referral. This is so-called Mayo Model. It has two problems – one, only 10% to 12% of American doctors practice in Mayo type environments; two, the economic success and growth of hospitals employing doctors depends of ordering technologies offered by the hospital, thereby increasing costs.

• Reward only technologies that are “evidence-based.” Sounds good, but evidence-based research is in its infancy and “evidence” too often rests in the eyes and spins of beholders, outcomes based on patient behavior and compliance, not on actions of doctors. Few treatments have “absolute” evidence of cost effectiveness and reside in that “vast gray void” devoid of scientific proof and more on incentives of doctors and expectations of consumers. Besides where is the evidence to pay for "social visits," which account of about half of patient visits to the doctor.

• Compel health consumers to pay for a growing portion of costs using health savings accounts, high copays, and high deductibles in a consumer-driven environment using health savings accounts, with unspent tax-free money carrying over to subsequent years in a 410J type of arrangement. Consumers spending their own money will spend it widely, conventional wisdom says. The trouble is it’s hard to wean paternalistic pundits, politicians, and policy wonks, and consumers off idea that health care ought to be essentially “free.”

• Develop sophisticated algorithms using artificial intelligence and predictive modeling and aggregate pricing techniques to identify those technologies that offer proof of value and avoids unnecessary duplications and medical expense. Requires widespread computer systems, “fully operative” electronic medical records and personal health record systems that talk to one another and are trusted and used by physicians and hospitals.

• Introduce a single-payer system, as in Canada or the United Kingdom, that minimizes administrative expense and controls technologic use and installations by fiat and command and control methods. In America, socialism and capitalism don’t always mix, particularly when they restrict freedom to choose and exercise options.

• Modify the malpractice environment to end practice of “defensive medicine” so doctors are not punished for failure to diagnose using advanced medical technologies . Believe this will happen, and I will be glad to sell you a time-share in North Dakota in January.

• Have physicians spend more time with patients and pay them well to patiently to explain risks and benefits and options of technologies versus less expensive and more conservative wait-and-see approaches. This is difficult in our fast-paced society looking for immediate answers and gratifications, often for life-style enhancement and advancement rather than diagnosis and treatment of life-threatening disorders.

Oh, what a tangled web we weave then we try medical technology costs to relieve.


Andrew Whitman said...

What struck me in The New York Times article “Weighing the Costs of a CT Scan Inside the Heart” was what the story omitted: peer-reviewed and emerging clinical trial data showing that CTA scans produce cost savings and improve patient outcomes. Also, for a story of this length to leave out any discussion of appropriateness criteria – even though cardiology and radiology medical societies already have programs in place, and both criteria are part of the current policy discussion – is curious. In my estimation, it fails to offer readers balanced information to help inform their decisions.

There are numerous peer-reviewed studies demonstrating that CT scans detect heart disease and help patients avoid cardiac catheterization. For example, the article could have cited a 2007 study in the Journal of the American College of Cardiology, which found that multi-slice heart scans significantly reduced diagnostic time and produced cost savings. It could have also cited a recent study demonstrating how CT heart scans are an effective and cost-saving tool in selecting patients for cardiac catheterization. The selective catheterization resulted in average cost savings of $1,454 per patient.

Proper utilization of any medical technology is important, and the majority of doctors do use medical imaging appropriately, without standing to realize any financial gain from doing so. In fact, according to 2005 Medicare claims data, an average of 94% of CT, MRI, PET and SPECT referrals are made to physicians who do not order the tests, and that percentage is even higher for cardiac imaging. To address the small minority of instances when imaging is improperly used, policymakers and medical societies are embracing appropriateness criteria and accreditation requirements as effective solutions that allow health decisions to remain in the domain of physicians and patients rather than insurance companies. Unfortunately, The Times story made no mention of this either.

CT heart scans eliminate the need for an invasive and expensive procedure to diagnose coronary artery disease by providing precise and comprehensive information on heart ailments without surgery and within seconds. Yes, a CT heart scan may seem expensive when viewed in isolation, but compare the price tag of a one time scan to the cumulative, long-term costs that will come with its regrettable alternatives: repetitive consultation and progression of disease and inappropriate treatment. Talk about penny wise and pound foolish—especially considering that coronary artery disease is the most common type of heart disease, and the number one killer for both men and women.

Thankfully, Medicare’s recent heart CT scan coverage decision allowed continued patient access to these tremendously valuable scans, which have revolutionized the way doctors diagnose heart disease, and become the standard of care for cardiac disease throughout the country and the world. I am certain that patients across America are benefiting as a result, and in this vein, it is incumbent upon us and our healthcare system to ensure that physicians are continually armed with improved resources for diagnosing and treating disease more precisely, effectively and efficiently – not restricted in their ability to save lives.

Andrew Whitman
Vice President, Medical Imaging & Technology Alliance

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