Using technology better
Is Technological Change In Medicine Always Worth It? The Case Of Acute Myocardial Infarction
By Jonathan S. Skinner, Douglas O. Staiger, Elliott S. Fisher
Health Affairs
February 7, 2006
Abstract:
We examine Medicare costs and survival gains for acute myocardial infarction (AMI) during 1986-2002. As David Cutler and Mark McClellan did in earlier work, we find that overall gains in post-AMI survival more than justified the increases in costs during this period. Since 1996, however, survival gains have stagnated, while spending has continued to increase. We also consider changes in spending and outcomes at the regional level. Regions experiencing the largest spending gains were not those realizing the greatest improvements in survival. Factors yielding the greatest benefits to health were not the factors that drove up costs, and vice versa.
From the Discussion:
Dramatic progress has been made in the treatment of heart attacks among the elderly during the past two decades. Between 1986 and 2002 the average one-year survival rate following AMI increased by nearly 10 per 100 elderly AMI patients at an estimated cost of less than $25,000 per life year saved. But underlying these numbers is tremendous heterogeneity across time and space: There was little improvement in survival after 1996, despite continued growth in costs, and there was much variation in survival gains across regions and over time, with regional gains that were (if anything) negatively related to costs. These facts and others like them have generated a debate over the value of additional medical care spending. On the one hand, aggregate trends in patient outcomes suggest that the technological innovations were “worth it.” In contrast, the apparent lack of any strong association between costs and patient outcomes or quality of care across regions suggests that aggressive cost-control policies might benefit society by eliminating unnecessary medical care for patients in high-cost regions.
A key assumption is that uneven diffusion of cost-effective innovations is a key factor driving differences in patient costs and outcomes. Support for this view comes from Paul Heidenreich and McClellan, who concluded that the vast majority of the increase in thirty-day survival following AMI between 1975 and 1995 was the consequence of low-cost treatments such as aspirin, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, and thrombolytics. Furthermore, both observational and clinical trial evidence suggests that use of these noninvasive treatments reduces the incremental benefit of more-expensive treatments such as invasive surgery.
It is important to note that our new view does not apply solely to “low-tech” effective treatments such as aspirin and beta-blockers, but rather it applies equally to any highly effective treatment, whether high-tech or low-tech.
The benefits of health care technology are often substantial. However, as health care costs continue to rise, squeezing consumers, producers, and the federal budget alike, principles of accountability-that each incremental dollar should provide something of real value to patients-become increasingly important. That some regions could implement technological innovations at remarkably low cost is a reminder that waste and inefficiency are not inevitable by-products of technological growth. Thus, efforts to develop measures of quality and efficiency that can encourage hospitals or provider groups to adopt low-cost, highly effective care, while discouraging incremental spending with no apparent benefits, might allow us to keep the golden goose of technological progress alive and well nourished.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.
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And…
To Use Technology Better
By Alan M. Garber
… their findings suggest that we should reexamine our approach to biomedical innovation. In nearly every disease area, we could use better treatments and better diagnostic approaches. For some diseases, like most cancers, dramatic improvements in outcomes are unlikely to occur without major investments in the development of new drugs, devices, and biotechnology products. As much as we would like new tools, though, Skinner and colleagues show that we haven’t mastered the tools that we already possess. The gains from more effective, efficient approaches to heart attack care, without using any medications or procedures that are not already available, would be enormous.
We have much to learn about promoting better medical care, and we should not underestimate the difficulty of the task. But in comparison to the money spent to develop new technologies, we spend a paltry sum on finding ways to improve the use of technologies we already have. According to a widely cited estimate, the average cost of developing a new drug-an average drug, not a breakthrough-was $802 million in 2000, or about $900 million in 2005 dollars. The entire 2005 budget for the only federal agency responsible for research on more effective care delivery, the Agency for Healthcare Research and Quality (AHRQ), was less than $320 million.
Encouraging both innovation and access to new technologies is the central challenge facing the U.S. health care system. If the cost of medical innovations is too high, only the well-insured-such as today’s Medicare beneficiaries-will have access to them. But as health spending rises, fewer and fewer people will have insurance, and swelling out-of-pocket payments will place some new treatments out of the reach of even the insured. A shrinking number of patients will then benefit from advances in care. New technologies can improve health, but unless we learn to use them better, we cannot expect to harness their value.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.
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Comment: By Don McCanne, M.D.
Should we continue with our current fragmented system of funding care that results in ever more costly expansion of both mediocre and valuable high-tech services? Or should we change to a single, integrated system of funding care that would make better use of what we have, while rewarding new technology that truly improves health care value?
With dedicated public stewards, a single payer system would be much more effective in achieving the latter goal.