The Economics of Medical Technology: Proceedings of an International Conference on Economics of Medical Technology

147 Pages·1988·4.861 MB·English

by  Frans F. H. Rutten, Stanley J. Reiser M.D., Ph.D. (auth.), Frans F. H. Rutten, Stanley J. Reiser M.D., Ph.D. (eds.)

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
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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: