Technology and health care reform

 

A couple of letters in this week’s Archives of Internal Medicine provide a picture of some of the more perverse incentives to overuse technology that are built into our current health care delivery “system.” One letter describes a study of proton beam therapy for treatment of prostate cancer. Proton beam therapy has never been shown to be superior to standard photon-based therapy for the treatment of prostate cancer; it is, however, novel, high-tech, “cool,” and way more expensive. The study showed that the mere availability of the technology, rather than any clinical indication, drove its utilization: “If you build it,they will come” (and spend!).

Another letter addressed the systemic factors that influence physicians to use more technology, whether clinically warranted or not: “The sheer amount of technology available may lead some [doctors] to look askance at the value of their clinical skill and bypass them in favor of testing. This can lead to a technological addiction that is every bit as difficult to break as a substance addiction.”  In the reply to this letter, the authors wrote of “several systemic factors that promote a ‘more is better’ approach: a reimbursement system that rewards diagnostic testing while failing to provide physicians enough time with patients to avoid it; performance measures that reward doing more with no attempt to measure doing too much; and a malpractice system perceived to expose physicians to legal punishment for doing too little but not for doing too much.”

The incentive to use more technology is not only inherent in the nature of technology itself (see Jacques Ellul’s The Technological Society), but is built into the fabric of our health care “system.” The cost of that technology is a large part of what is making health care unaffordable for all except the healthy. Any health care reform scheme that does nothing to change these structural incentives is so much wind. The reform schemes put forth by the two major political parties are pathetic, cosmetic band-aids that do nothing to get even close to the root of the problem (“Uh, let’s find different ways for people to buy insurance!”). Such band-aids amount to a joke; only it’s hard to laugh when so much is at stake.

 

Sources:  Aaronson et al., “Proton Beam Therapy and Treatment for Localized Prostate Cancer: If You Build It, They Will Come,” pp. 280-282; letter from Volpintesta, “Training in Uncertainty Has Value for Primary Care Physicians: Overreliance on Technology Can be Remedied,” p. 297; and the reply by Sirovich et al., p.297, Archives of Internal Medicine, Vol 172 (No. 3), Feb 13, 2012.

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Jon Holmlund
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A question and a few comments: First, the question, for Dr. Gibes or other readers: How much will Accountable Care Organizations help this, and are they properly configured at present by CMS? (I apologize if I am neglecting to note earlier posts on this.) Second, the comments: I agree that the “technology push” is challenging enough when doctors and patients just want to “try something else”–never mind when there are financial incentives added. I do think that more competition in insurance–not less–would allow more appropriate price signals than are at present. Look, Medicare overpays for those scooters, does it not,… Read more »

Joseph Gibes
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Joseph Gibes

Jon, I am no expert on ACOs, but the hope is that rewarding these organizations that keep health costs down will provide the incentive for everyone to keep the costs down. However, this seems to me to do nothing to put a dent in our voracious appetite for technology, the belief that more is better. Working as I do with multiple insurance companies, I have difficulty seeing how more competition between them will help other than in providing more work for bean-counting bureaucrats. I don’t know that this IS a government problem, except that it is a natural in all… Read more »