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.