During the 1940's, medical practices were very different than today. Syphilis was treated with bismuth and aresenic rather than penicillin. Pneumonia was treated with pneumococcal serum rather than antibiotics. Pernicious anemia was treated with liver extract injections. Heart failure was treated with ground up foxglove (digitalis) and with injections of mercury, which we know today are toxic. Oxygen was given in an oxygen tent.  The iron lung was a major advance for the treatment of polio, which had reached epidemic proportions. Sulfa drugs were used for infections but were highly toxic. Penicillin was available in limited amounts to members of the armed forces and research facilities, but not to the general public. Ulcers were treated with milk and "white diets" which consisted of eggs, fish, pureed foods, and cream of wheat). Heart attack patients were hospitalized for up to 8 weeks. Severe hypertension was treated with a radical nerve cutting operation since there were no available effective drugs. Tuberculosis was treated with a minimum stay of 9 months in a sanitorium. World War II marked the beginning of changes. It was discovered that syphilis and rheumatic fever could be successfully suppressed by penicillin. Researchers began to develop drugs to treat hypertension and cancer, as well as anticoagulants. Several antibiotics became available prior to 1950.

Diagnostic and treatment potential improved considerably during the 1950's. Multiple antibiotics were developed. Hospital stays for heart atttacks were shortened to 3 weeks. Advances occurred in the diagnosis of heart disease, X-ray diagnosis, and surgical techniques. Open heart surgery was introduced. Polio vaccines were developed and made widely available. Health insurance became a growing industry through the coverage of surgical and diagnostic procedures, however office visits and testing done outside of hospitals were reimbursed at greatly reduced fees or not at all. The struggle between insurance companies and physicians began. The cost of a hospital room was under $20 a day. General practices were slowly diminishing as specialty practices began increasing. Hospitals began developing quality assurance programs.

The 1960's paved the way for further advances in technology with even sharper cost increases.  Transplant surgery was moving out of the experimental stages.  Birth control pills were widely used. New cancer treatments were being tested. Medicare and Medicaid became law in 1966. Medical schools became specialty oriented causing a lack of role models wiwth broad clinical skills for medical students. Their main exposure was to highly technical subspecialitists and researchers, not general practitioners. Advances in research led to students learning to intervene without learning how to evaluate the need for intervention. The general way of thinking became technology was available, so use it. However, lost in the shuffle was the question of whether an appropriate use of technology was occurring.

During the 1970's, the social and economic side of health care gained more attention. Health care costs were out of control.  Family practice began to expand. Prepaid health plans surged in popularity.

During the 1980's, many of the gains of the past decades were becoming less available because of escalating costs and the inability to pay.  This was the decade where managed care blossomed because of the lack of success in controlling health care costs.

The United States uses more medical technology than most other countries in the world. For example, use of MRI is eight times greater in the US than in Canada, and four times greater than in Germany.  Open heart surgery and cardiac catherizations are more available in the United States than anywhere else in the world. In 1995, the US consumption of health-related equipment was estimated to be $43 billion.

Technology is credited with 33-75% of health care cost increases. Equipment is expensive, as is training, salaries of qualified personnel to operate the equipment, and construction of new spaces to house new equipment or services. The increase cost may also be the reason why some procedures or services are overused.

Technology also can help decrease costs. Examples are readily accessible information and communication systems (telemedicine) and electronic technology now being used to process insurance claims.

Americans have grown accustomed to sophisticated equipment. A 1992 Gallup Poll found 57% of Americans would rather pay more for health care and the latest technology than pay less by traveling to regional centers. Physicians also want easy access to the latest equipment and technology. Hospitals want to purchase the most high-tech equipment to attract patients and physicians.

Intense competition for the latest equipment and technology has been going on for years. In the 1980's, there were no incentives for hospitals to watch their purchases. Many eagerly bought state-of-the-art equipment which quickly became obsolete. These problems have led to current emphasis on technology assessment.

Judging the value of technology is extremely difficult. Do we consider costs to a health care facility or costs to society?

When evaluating costs, rationing of health care services and technology could become an issue. Should all patients have access?  If not, who makes the decision as to who receives the service.

Another issue is the cost of purchasing the equipment versus the cost of using the equipment, which include labor and other expenses associated with putting the technology to work (set-up, training, etc). The purchase price of health care equipment represented only about 5% of all health care costs in 1992.

Manufacturers of high-technology equipment, procedures, and devices struggle for funding.  Technology users struggle to find cost-effective procedures for diagnosis and treatment of patients. Researchers are pressured to find affordable methods of detecting and treating illnesses. Physicians are pressured to use expensive technology only when less costly techniques will significantly decrease outcomes.

Providers of health care are relying on technology outcomes assessment for reliable information on what devices and procedures work best, for whom, and at what cost. The concept of technology assessment has existed in the United States sin 1977, but has only recently come into practice.

The Office of Technology Assessment is a federal office responsible for evaluating the risks, benefits, and clinical effectiveness of new or current technologies.  The Office is limited in its ability to conduct investigations. Their mandate is to look at technology in the context of broad health care issues, such as AIDS or women's health, and to advise Congress on policy matters.  The Office is not responsible for investigating devices or equipment.

The Agency for Health Care Policy and Resarch is a federal agency responsible for determining the patient outcomes resulting from assorted uses of technology. The Agency prepares technology assessment reports primarily for the Health Care Financing Administration (HCFA), which are based on surveys of peer-reviewed medical literature and expert opinions. As of 1994, the Agency is allowed to accept technology assessment requests from the general public.

Patient Outcomes Research Teams (PORTs) examine outcomes of treatments and offer recommendations based on results of treatment. These outcomes include the physiological status of patients after treatment, assessments of functional capacity, and use of health care resources.

The United States Food and Drug Administration (FDA) is responsible for approving medical devices and diagnostic equipment. Manufacturers must prove only that a device or diagnostic test does what it is intended to do, and not be innovative. Because of this, the FDA approves 4000-5000 products every year that are considered nearly equivalent to products that already exist. The FDA does not require manufacturers to compare new products with other available methods of accomplishing the same goal. Therefore, only a few dozen products each year are new and innovative, trying to solve previously unsolved problems. Once a device or diagnostic test is approved, the FDA cannot control whether health care providers use it for its intended purpose.

Insurance companies rely on research conducted on the safety and effectiveness of procedures for reimbursement assignments.  Cost becomes a factor when two technologies appear to have the same level of safety and effectiveness.

Health equipment manufacturers recognize buyers want proof of product safety, efficacy, and cost effectiveness. In the past, performance was important and not much emphasis was placed on cost since manufacturers knew the customers would pay.  Today, new features must make a difference since customers are not as willing to pay.

Manufacturers of new technology must prove the product improves patient outcomes. In selling new products, comparison to other alternatives is required. The product should give the same outcome as others but at a lower cost or bring about improved outcomes if offered at a higher cost.

Hospitals and managed care organizations are asking physicians to justify their use of expensive technology. Today, more health plans and physicians accept fixed, prepaid fees for patient care. This limits the use of technology and influences decisions about when and under what circumstances high-tech diagnostic or treatment methods will be used. Manufacturers are faced with the task of developing more genuinely innovative products.

Telemedicine is a fast growing technology that fits well into today's cost-conscious health care environment. High speed computers and communication networks allow for long distance transmission of medical images and data among physicians and patients who may be miles apart. It is estimated that telemedicine could save as much as $36 billion annually in health care costs. Rural communities are expected to benefit the most from telemedicine.

The United States Department of Commerce Advanced Technology Program contributed $185 million over a 5 year period to the development of health care information technologies designed to reduce costs and errors.  Funds have been allocated for the development and interconnection of health information systems that transmit information via personal computers, global networks, or interactive video.

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References:

Fuller, B. (1994). American Health Care. Charles C. Thomas Publishers, pp 1-13.

Robbins, K. (1994). "Buyers of Health Care Equipment Are Demanding Evidence That Technology Improves Outcomes and That It Is Cost Effective," The State of Health Care in America. Business & Health Magazine 1994 Supplement, pp. 63-66.

Van Pelt, D. (1995). "Health Care Technology is Struggling to Balance the Promise of Innovation with the Reality of Affordability," The State of Health Care in America.  Business & Health Magazine 1995 Supplement, pp. 47-40.

Lassey, M.L., Lassey, W.R., & Jinks, M.J. (1997). Health Care Systems Around the World. Prentice Hall.