Technology is often pinned as the big villain or the benevolent cure-all in the world of healthcare. From one perspective, high tech innovation is responsible for the rising costs of treating diseases and medical conditions. Another perspective, however, argues that technology is the answer to all present and future medical problems.
Both of these views are common but are distractions from the real issue, which is value, said David Cutler, a Harvard economist who spoke on "Harnessing Technology in Healthcare" at the 5th Annual Alumni Healthcare Conference on November 5, 2004. Cutler, a former adviser to presidential candidate John Kerry and the author of a book called Your Money or Your Life: Strong Medicine for America's Health Care System, said that price increases are only a small part of the story.
Any conversation about the costs and benefits of technological advances in the medical system needs to hinge on the most effective way to treat a disease or condition, he said.
"To me, the single, fundamental, most important issue in healthcare is how to create a system that has higher valuenot one that spends more or spends less or does more or does less, but one that does stuff when the value is high," he said.
For a window into the state of the medical system as a whole, just look at changes in the treatment of cardiovascular disease, said Cutler. Almost fifty years ago, one of the most famous patients was President Eisenhower, who had a heart attack in 1955. The attack was misdiagnosed and Eisenhower's doctor thought he had indigestion. The President was ordered to bed. Ten hours later, he was still in substantial pain so he went to the hospital. There he was given morphine, which dulls the pain.
At the time, according to Cutler, standard therapy for severe heart disease was six weeks of bed rest in a hospital, after which the patient was gingerly transported home and told to stay in bed for six months.
"Not only is it not effective care, it's actually harmful care because this therapy leads to blood clots. If any patient did actually survive this therapy, he or she wasn't any better. But it was cheap."
More recently, patients might be treated with coronary artery bypass surgery (CABG) or angioplasty. CABG is a procedure that dates back to the late 1950s, and was used in about 1 in 100,000 people, Cutler explained. Up until the mid-1990s, CABG was seen as a procedure for severely ill patients: patients with multiple vessel disease or with a blockage in a place that was difficult to reach. Angioplasty didn't exist at all until the early to mid-1980s, he continued, and was used sparingly at first.
The most important issue in healthcare is how to create a system that has higher value. |
David Cutler, Harvard University |
"We're now reaching a point where we are substituting angioplasty for bypass surgery. Bypass surgery has crested and its use is declining in favor of angioplasty with stents," he said. "A basic fact about the medical system is that whenever a technology like this is developed, it may get used far greater than any wishful projection about its use."
"In both of these cases, they were initially seen as relatively specialized technologies that wouldn't be used on a wide variety of patients because they were imagined for particular kinds of conditions. In reality, they turn out to be used prophylactically and all over the place. That's more or less in a nutshell what happens to the medical care system."
Costs per person are ten times what they were in 1950, he said. Medical costs have doubled directly every twenty years as a share of GDP. There is more use of treatments which are more intensive and therefore reimbursed more heavily.
"Ironically, we have figured out how to control the prices," continued Cutler. "Medicare, private health insurers, Medicaideveryone has figured out how not to pay the doctor more for doing the same thing. That's why doctors are very upset. They're getting paid less, but we still spend more because we're doing more things."
More bang for the buck
Two overriding issues in high technology care are expense and effectiveness, said Cutler. Treatment with CABG costs around $30,000; angioplasty treatment with a stent is around $20,000. In comparison, medical managementmeaning treatment with pharmaceuticals such as beta-blockers, without any intensive therapiescould cost potentially about $10,000. So cardiovascular therapies overall have added considerably to the expense of the medical system, he said.
But these are also technologies where there is a lot of concern about the effectiveness, he continued. "People live a lot longer than they used to, but if you look at the literature, there is a lot of use in patients for whom clinical trials either have not been performed or in fact have been performed, but these procedures did not do better on average than other therapies that are out there. And yet [these procedures] are still used. These are expensive, but we are not really sure what we're getting. That's the conundrum."
"This actually characterizes most of medicine. If you ask, 'For what share of all the things that are done in the medical system is there good, hard evidence that in that patient it is an effective therapy?' nobody quite knows the answerbut it is probably about 20 percent."
A further hindrance to understanding true effectiveness of treatment, he said, is that the older population is almost always excluded from clinical trials because they often have multiple conditions. Clinical trials are easier to run on patients with just one condition.
What would Henry Ford do?
According to Cutler, there are three kinds of medical technology that could be ranked from least intensive to most intensive. A separate scale could be used to rate them according to how valuable they are to improving the health of patients.
To improve its own health, the medical system could take a lesson from the automobile industry. |
The first kind of technology falls under the umbrella of health promotion: devices for working with patients to make sure they are taking medications that they ought to, for instance. The second involves the "basic doctoring" of figuring out how to manage a patient's diabetes or some other chronic disease, for which the caregiver needs some kind of medical training but not particularly high tech training. The third encompasses very acute care using the types of treatments described earlier, such as CABG and angioplasty.
To improve its own health, the medical system could take a lesson from the automobile industry, suggested Cutler. The first big invention that got the car business into gear was the internal combustion engine. But the second invention was more important, he said. It was an organizational invention. Henry Ford figured out how to organizationally innovate on a big scale. "That involved a number of different things: a new approach to production. Different ways of paying workers. Different ways of thinking about the firm and what the firm was," said Cutler.
"The thing we're missing in healthcare is the organizational innovation that would lead us to get to have technology harnessed in a more useful way. What we need is a system that reimburses not for doing stuff, but for doing stuff that is effective in improving the care of the patients."
Here are Cutler's recommendations:
- An evidence base that supports good medicine that physicians actually know is effective. This could be drawn from profiling individual doctors, groups of doctors, hospitals, and insurance companies.
- A system that admits and learns from its mistakes. "Malpractice reform is important, I think, not because of what it does or doesn't do in the nature of how much additional defensive medicine doctors do," he said, "but because [at the current rate] you're never going to have a system that is focused on quality improvement if admitting that you made an error is harmful to you."
- A payment system that rewards quality. Doctors who do treatments that are indicated by the literature to be appropriate should get paid more than doctors who do treatments that are not.
- A system that covers everybody.
In his prognosis for the future of healthcare, Cutler summoned the ghost not of the ancient Greek physician Hippocrates, but German writer and philosopher Johann Wolfgang von Goethe. "If we do poorly" in treating sick people, predicted Cutler, "we will wind up where Goethe was a couple of centuries ago, when he wrote, 'Humanity might win in the long run, but the world will be one big hospital.'"