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147 Pages·1988·4.861 MB·English
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HEALTH SYSTEMS RESEARCH Edited by K. Davis and W. van Eimeren EEH. Rutten S.l. Reiser (Eds.) The Economics of Medical Technology Proceedings of an International Conference on Economics of Medical Technology With 8 Figures and 21 Tables Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Frans F. H. Rutten, Professor Dr. Department of Health Economics Rijksuniversiteit Limburg P.O. Box 616, 6200 MD Maastricht The Netherlands Stanley J. Reiser, M.D., Ph.D. Griff T. Ross Professor of Humanities and Technology in Health Care The University of Texas Health Science Center at Houston P. O. Box 20708, 6431 Fannin, Suite 1.500 Houston, Texas 77225 USA ISBN-13: 978-3-540-17984-9 e-ISBN-I 3: 978-3-642-72785-6 001: 10. I 007/978-3-642-72785-6 Library of Congress Cataloging-in-Publication Data International Conference on Economies of Medical Technology (1985 : Valkenburg, Lim burg, Netherlands.) The economics of medical technology. (Health systems research) Held at Valkenburg, Limburg, Netherlands, Sept. 2-4, 1985. 1. Medical technology-Economic aspects-Congresses. 2. Technology assessment-Economic aspects-Congresses. I. Rutten, F.F.H. II. Reiser, Stanley Joel. III. Title. IV. Series. [DNLM: 1. Biotechnology-econo mies-congresses. 2. Economics, Medical-congresses. 3. Technology Assessment, Biomedi cal-economics-congresses. W 74 15ge 1985] R855.2.I58 1985 338.4'766'06 87-23499 This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, re-use of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provi sions of the German Copyright Law of September 9,1965, in its version of June 24, 1985, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. © Springer-Verlag Berlin Heidelberg 1988 The use of general descriptive names, trade marks, etc. in this publication, even if the former are not especially identified, is not to be taken as a sign that such names, as understood by the Trade Marks and Merchandise Marks Act, may accordingly be used freely by anyone. Product Liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 2119/3145-543210 Table of Contents 1 Introduction..................... 1 2 The Early Assessment of Health Care Technology: Introducing the Artificial Heart S. J. Reiser. . . . . . . . . . . . . . . . . . . . . . 3 3 The Marketplace for Medical Technology B. Abel-Smith . . . . . . . . . . . . . . . 10 4 The Transfer of Medical Technology in Developing Countries: The Case of Brazil H. D. Banta . . . . . . . . . . . . . . . . . . . . . 16 5 Public Control of the Diffusion of Health Technology F. F. H. Rutten, J. M. Greep, and G. H. M. G. Haan . . 25 6 Diffusion of Medical Technology: A Case Study of Policy in Europe and the Netherlands L. M. J. Groot . . . . . . . . . . . . . . . . . . . 33 7 Economic Techniques for Technology Assessment M. C. Weinstein . . . . . . . . . . . . . . . . . . 44 8 Technology Assessment in Europe: Its Present and Future Roles A. J. Culyer . . . . . . . . . . . . . . . . . . . . . 54 9 A Working View of Technology Assessment: The Case of Digital Substraction Angiography E. Jonsson, L.A. Marke, and S. Olsson ........ 80 10 Changing Environment: Decentralized Use of Medical ' Technology J. E. Blanpain . . . . . . . . . . . . . . . . . . . . . . 90 11 The Birth and Development of an Innovation: The Case of Magnetic Resonance Imaging A. L. Luiten . . . . . . . . . . . . . . . . . . . . . . .. 99 VI Table of Contents 12 Economics and the Rational Use of Medical Technology A. Williams . . . . . . . . . . . . . . . . . . . . . . .. 109 13 Ethical Aspects of Medical Technology P. Riis ................. . 121 14 Educational Aspects of the Economics of Medical Technology G. Mooney .. . . . . . . . . . . . . . . . . . . 127 15 General Conclusions B. Jennett ..... . 135 List of Contributors Abel-Smith, Brian, Professor London School of Economics, Houghton Street Aldwych, London WC 2A 2AE, United Kingdom Banta, David H., M. D. Health Council, P.O. Box 90517,2509 LM The Hague, The Netherlands Blanpain, J., Professor Dr. Centrum voor Ziekenhuiswetenschap, Vital Decosterstraat 102, 3000 Louvain, Belgium Culyer, A. J., Professor Department of Economics, University of York, Heslington, York Y015DD, United Kingdom Greep, J. M., Professor Dr. Algemene Heelkunde, Academisch Ziekenhuis Maastricht, P.O. Box 1918, 6201 BX Maastricht, The Netherlands Groot, L.M.J., Professor Dr. Roerzicht 22,6041 XZ Roermond, The Netherlands Haan, G.H.M.G., Drs. Department of Health Economics, Rijksuniversiteit Limburg, P.O. Box 616,6200 MD Maastricht, The Netherlands Jennett, Bryan, Professor M. D. Dean Faculty of Medicine, University of Glasgow, Glasgow G12 800, United Kingdom Jonsson, Egan, Professor The Karolinska Institute and Spri, P.O. Box 27310, 102 54 Stockholm, Sweden Luiten, A. L., Jr. Philips Medical Systems, P.O. Box 218,5600 MD Eindhoven, The Netherlands VIII List of Contributors Mooney, Gavin H., Professor Institute of Social Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3, DK-2200 Copenhagen N, Denmark Reiser, Stanley J., M. D., Ph. D. Griff T. Ross Professor of Humanities and Technology in Health Care The University of Texas, Health Science Center at Houston, P.O. Box 20708,6431 Fannin, Suite 1.500, Houston, Texas 77225, USA Riis, Povl, M. D. Professor of Internal Medicine, University of Copenhagen, Panum Institute, Blegdamsvej 3, DK 2200 Copenhagen N, Denmark Rutten, Frans F. H., Professor Dr. Department of Health Economics, Rijksuniversiteit Limburg, P.O. Box 616,6200 MD Maastricht, The Netherlands Weinstein, Milton c., Professor Institute for Health Research, Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachusetts 02115, USA Williams, Alan, Professor Department of Economics, University of York, Heslington, York Y015DD, United Kingdom 1 Introduction Technological development has created major possibilities for the treatment of disease and for the disabled. The cost of new technologies has added considerably to health care cost intlation, which still exceeds the growth rates of most national economies. The share of national resources devoted to health care is still rising, although at a lesser pace than in the seventies. -Therefore, the use of medical technology confronts us with some of the major dilemmas in society today. The routine and intensive use of technology has transformed the most basic interpersonal and social features of medicine. It has altered the means through which patient and doctor communicate about illness as well as the content of this communication, changed the doctor's relationship to medical colleagues by increasing his dependence on them, altered the place and form of practice by creating advantages for the centralization of medical care in complex organizations, and created for society new responsibilities and powers to influence the context and scope of medical practice. Economics as a discipline and the application of more 'economic thinking' in medical practice may contribute to properly addressing the major questions with respect to resource allocation in health care. A continuous commitment to evaluate and identify the appropriate use of medical technology is needed. In this effort economists should combine forces with other disciplines such as medicine, ethics, law, sociology, epidemiology, psychology, and engineering. In this volume the focus will be on the economic aspects of the use of medical technology. Other approaches corresponding to other disciplines will also be taken into consideration. A multi- disciplinary approach seems essential for tackling problems in this area. Given the opportunities of communication and transport today, innovation and the diffusion of innovative technologies is not only a national issue, but poses challenges to the international community with regard to directing fundamental and applied research and controlling the diffusion of medical technology. This volume contains the proceedings of an international conference held in Valkenburg, 2-4 September 1985, at which experts from various countries were invited to react to these challenges from different viewpoints. A number of international aspects such as the transfer of medical technology between countries and the international orientation of partici pants in the market for health technology are given special attention. The contributions to this volume are clustered around five topics. The first two contributions are placed under the heading 'medical technology and society.' The first contribution by Reiser describes the first phase of the development of a new technology, taking the case of the artificial heart as an example, and addresses the 2 Introduction kind of questions to be tackled in that phase. In the second, Abel-Smith provides an overview of the main characteristics of the market place for medical technology. The next section on the transfer and diffusion of medical equipment contains the contributions by Banta, Rutten, Greep, Haan, and Groot. Banta identifies a number of problems in relation to the transfer of medical technology in developing countries by focusing on the situation in Brazil. Rutten, Greep, and Haan consider the options for public control of the diffusion of health technology and discuss the experience in some countries. Some of the mechanisms underlying the diffusion of medical technology in Europe are set out by Groot. Technology assessment as a discipline is considered by Weinstein, Culyer, and Jonsson. Weinstein sets forth an agenda for future methodological challenges to be tackled, while Culyer identifies a number of practical problems in technology assessment as derived from a critical assessment of current literature. Jonsson provides a working view of technology assessment using digital subtraction angiogra phy as an example. Considering advanced medical technologies at home and in the hospital, Blanpain identifies an important trend in that medical technologies are increasingly used outside of the traditional hospital setting. Luiten describes the birth and development of an innovation (magnetic resonance imaging) as seen from the perspective of the industry. The last section contains an assessment of the relevance of economics, ethics, and training in economics in relation to the rational use of medical technology Williams mentions a number of very important problems in using economics in resource allocation. Riis comments on the relation between medical ethics and economics and Mooney stresses the importance of training important health care decision-makers in economics. Jennett summarizes the contributions in the volume and tries to derive general conclusions from them. The conference in Valkenburg was held in honor of Professor Lou Groot upon his farewell from the University of Limburg and the Catholic University of Leuven. As he has been one of the leading patrons and advocates of appraisal in health care in Europe, his retirement seemed a splendid occasion to hold a conference on the economics of health technology. If the conference had not been associated with his farewell, it would certainly not have been possible to bring together so many well known experts in the field of medical technology, who paid their respects to Lou Groot through their presentations at the conference. Finally, the editors of this book, who were also the organizers of the conference, would like to thank two ladies whose contributions have been invaluable. Mrs. Fransje Hein and her staff from the University of Limburg should be congratulated for taking care of all administrative and technical details of the conference. Mrs. Brigitte Kerbusch of the Department of Health Economics of the University of Limburg deserves our highest esteem for very skillfully handling all technical details associated with the production of the manuscript. Stanley J. Reiser Frans F.H. Rutten 2 The Early Assessment of Health Care Technology: Introducing the Artificial Heart S.l. Reiser 2.1 Introduction The unfolding drama of replacing a human heart with a machine is one of the extraordinary spectacles of our century. It creates the hope that this will be a major step in overcoming heart disease, the most widespread affliction of developed nations. However, the hope is accompanied by troubling questions about the use of technology in its early phase of development. My discussion will focus on what the actions we have taken with respect to the artificial heart imply about the early stages in the development of an innovation. Work on the artificial heart program took a major step forward in 1964 when the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) in the United States approved approximately ten million dollars of yearly research support for it. Underlying this support was a view of the project as the development of a new therapeutic tool. The key issues discussed were conceived of as technical ones bearing on the question "Can it work?" Discussion centered around matters such as the power source: Which was better, battery or nuclear power? Electric batteries were safe, but required frequent recharging or replacement - not a desirable trait in a system which could not be stopped without great peril to its user. From this standpoint, a nuclear-driven engine seemed highly attractive. Fueled by a small amount of plutonium, the artificial heart would be able to run for very long times without replacement of its power source. Yet, its risks were considerable. Leakage of radioactive material, thought highly probable, would not only create a cancer risk for users, but also for relatives. The plutonium would also have to be recovered from the body after death to avoid atmospheric contamination. Thus absorbed in the critical issues of how to make a good device, both those who funded this research in 1964 and other federal officials in the United States health establishment failed to explore adequately another set of policy issues critical to evaluation at this early stage of development, a nearsightedness which continued into the next decade. As Harvey Sapolsky put it in 1978: Nowhere in government is there the clear recognition that the choice to go ahead with the artificial heart inherently is a multi-billion dollar decision, not just a question of year-by-year' funding allocations. At this moment there is no way to decide whether or not to make that choice ... Decisions affecting the conduct of medical research, the financing of health services, and the construction of medical facilities, although increasingly determined by government agencies, are made independently of each other, despite their interrelationships. As Sapolsky was writing this essay, there was in fact an entity just being established in the United States, one of whose missions was to promote such coordinative actions:

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