Overuse of technology is a major factor in runaway health costs. Any effort to limit the use of technology immediately raises the threat of rationing, which opponents of health-care reform use relentlessly in their campaigns.
An analysis of inpatient and outpatient itemized medical bills typically shows that technology -- blood tests and imaging -- is a major component of expenses. Use of technology varies widely across the United States. High-use states do not have better health outcomes. Further analysis of practice patterns in high-use states shows patterns of overuse of technology.
Four factors drive excessive use of technology: defensive medicine, influence of training programs, profit motives, and consumer demand.
* Defensive medicine: The total amount of money awarded in medical malpractice suits is a tiny fraction of the nation's medical costs. Fear of litigation with its hefty financial and emotional burdens pushes physicians to investigate every possible cause of a particular symptom. The resulting costs are huge.
Medicine, in the popular view, should be fail-safe with no diagnosis, even very rare conditions, ever missed on initial evaluation. The diagnostic workup is driven by the fear of how the patient's chart might be interpreted in a court of law. Every test is imperfect, producing false-positive and false-negative results. Multiple tests can produce more questions than answers. To protect against lawsuit, no stone, no matter how improbable, is left unturned.
* Training programs: Medical students and residents train in sophisticated medical centers that pride themselves on being at the forefront of technology. Students and residents prepare their cases for presentation at rounds and conferences with the same intensity as if they were defending themselves in court.
In many training programs, they are expected to obtain multiple consultations and employ a full range of testing for each patient. The costs of tests and consultations are seldom mentioned. In this environment, low-tech investigations such as history, physical examination and simple tests are not sufficient. Technology builds its own justification. Bad habits acquired during training are hard to break.
* Easier profits: Cynics speak of the need to have a "gimmick" to succeed in medical practice. The gimmick can be any diagnostic device that can generate substantially more income than histories and physical examinations. If a medical office possesses a diagnostic tool, the temptation is to use it, even in situations where it is unlikely to be helpful. A similar temptation exists when the physician is an investor in a diagnostic enterprise, such as an imaging center.
* Patient demands: Media barrages of ads and reports about the latest technical innovation influence patients to insist upon that test. Pressure to use a new test builds before the worth of that test can be determined. Refusal of demands to use a new test may lead patients to go elsewhere for their medical care. In a busy day, it is easier to order the test than try to explain why it is not indicated.
Medical technology can be contained by adherence to national, evidence-based clinical guidelines. Many guidelines already exist. They are based upon considerations of safety, accuracy and cost-effectiveness. Unfortunately, adherence to guidelines is limited at best. Health systems that routinely use existing guidelines demonstrate their effectiveness in reducing costs and improving quality of care.
Courts must consider clinical guidelines in determining if a lawsuit alleging malpractice is justified.
Training programs for physicians must emphasize cost-effectiveness at every stage of education.
In establishing payment schedules, health insurers must re-evaluate the worth of technical services. Cognitive services--medical histories and physical examinations--save money and deserve higher reimbursement.
Limits must be placed on direct-to-consumer advertisements of medications and medical devices.
Without rational boundaries, medical technology will continue to drive medical costs ever higher with no additional benefit to patients. Guidelines can show us how to use valuable, finite resources to serve the needs of sick and injured people. This does not constitute rationing.
E-mail Clif Cleaveland at firstname.lastname@example.org.