In previous blog posts, I shared with you the significant findings from CHRISTUS’ Futures Task Force I. As a result of our scenario planning, we determined that the two most significant drivers taking us into the first decade of this century would be declining reimbursement, particularly on the inpatient side, and the rapid introduction of new technology which would give us the ability to move more inpatient treatment to the outpatient arena. We also predicted that the introduction of this technology was accelerating at such a pace that it would be disruptive.
Traveling through this decade, we are comfortable that these are, and will continue to be, the major drivers of health care change in the foreseeable future. In a recent article in the New York Times entitled, “Weighing the Cost of a CT Scan’s Look Inside the Heart,” the authors discuss two major issues associated with the introduction of technology. These two issues, which tend to be on the negative side of the equation, are 1)The overuse of this technology and 2)The cost of the technology when compared to the incremental value it brings in relationship to less costly, more standard procedures. While these treatments undoubtedly improve the health status of some, the overall value of the treatments themselves are called into question.
It is interesting to note also, that in our Futures Task Force II process, which is utilizing “learning journeys,” that in countries we visited (including Canada and India), the availability of technology is highly regulated. Specifically, there are significantly less CAT scans available in Canada than there are in the U.S. And one statistic that is often reported is that there are more CAT scans in Texas than there are in the entire country of Canada in the same time period.
Clearly, the issues identified above have caused hospital-oriented systems to attempt to develop guidelines for the appropriate use of these costly technologies. However, adhering to these guidelines is often challenging because patients and their families will often demand them because of public marketing which is done by vendors to persuade them that they need these treatments. Clinicians may also find it easier and faster to do a study rather than spending the time doing an extensive and complete history and physical. When complete histories and physicals are performed--as physicians were taught to do in medical schools--the correct diagnosis can often be made by supplementing these exams with simple laboratory or X-ray examinations.
There is no question that this requires time and a maintenance of physical examination skills, but it is readily known that there is no better knowledge about what is occurring to a patient than that that is gained from direct observation.
Another reason why these studies are often over-utilized is that they are--at least at this time in the U.S.--significantly reimbursed. Therefore, the financial incentive to deviate from the guidelines is present. Also, these technologies are often purchased by physicians and placed in their offices, where again, the financial incentive to use the expensive technology such as a CAT scan rather than a simple chest X-ray or abdominal film would be adequate. Because of these clear incentives to over-use this technology, we strongly support the utilization of the balanced scorecard, which we have discussed also in prior blogs. The purpose of a balanced scorecard is to balance at all times the value received from a financial, clinical service and community perspective. Only then will the correct guidelines for the use of these expensive technologies be adhered to appropriately.
And finally, with the use of these new technologies, we are now also recognizing that there are side effects. (Honestly, there have always been side effects present with any technology that has been invented in health care since the beginning of time.) Both CAT scans and MRIs temporarily alter the alignment of tissue particles or expose these tissue elements to high doses of radiation. Although these tests are done in a rapid timeframe and therefore necessitate minimal exposure to these side effects in each instance, if they are replicated and overused on any one patient, the accumulative effects will become evident.
In summary, there is no question that the introduction of new technologies has been tremendous and has created life-saving opportunities for many patients who pass through our doors. Cataracts and gall bladders are removed much more safely today, and arteriograms done through catheters in the groin far surpass the dangerous situations that were created by the original needles that had to be inserted in the carotid arteries in the neck. The advantages of these technologies are clearly evident. However, the technologies that have been developed for diagnosis including CAT scans, are initially seen as extremely beneficial, but can quickly decrease in overall value because their ease of deliverance and their high financial reimbursement may cause them to become over-utilized. As this technological equipment becomes more affordable, their availability exceeds need and only accentuates the potential for their overuse.
So what is the answer? For CHRISTUS Health, we will continue to carefully monitor the development and introduction of new technologies. Through our capital allocation process, will make sure we are acquiring and locating appropriate numbers of these technologies in our various regions and business units which will provide adequate opportunities for these studies to be provided to our patients and families, utilizing appropriate guidelines and minimizing overuse.