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Medical Technology

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James Snyder

on 14 December 2012

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Transcript of Medical Technology

2009 HITECH ACT Financial incentives for "meaningful use" of Electronic Health Records (EHRs) Cost Access Quality Savings Defining Medical Technology History of Medical Technology Technology in Treatments and Procedures Technology in Diagnostics Technology in Personalized Medicine Quality-Adjusted Cost Increasing Costs of Medical Care Proportion of Growth Attributable to Medical Technology Industry Cost Factors The Cost Problem Geographic Variation / Market Size
Competition amongst hospitals to attract physicians / patients
Demand Inducement Insurance Medical Malpractice Anything that assists providers in improving or maintaining the health of their patients. Over time:
decreasing reliance on subjective patient desciptions of ailments
increasing reliance on mechanical and chemical means for diagnostics
increasing physician specialization & delegating tasks to technicians Annual in income per capita around 1.5%, whereas HC spending per capita is ~3.5-7% annually (Goyen 2009)
Today health care spending accounts for ~ 16% of annual US GDP (Phelps 2010) A matter of technology diffusion.
New advancements get approved for a high-risk population in which there's a proven benefit, its use then expands to lower-risk group.
Development of new treatments for previously untreatable conditions.
Expansion of the indications for a treatment over time, increasing the patient population to which the treatment is applied As coinsurance rates drop, demand for medical care increases, and with it research & development spending on new technologies.
~47% of Med Tech / capita growth 1960-1993 attributed to insurance - lower coinsurance R&D spending, both inducers of Tech, so by proxy 70% of growth attributable to Tech (Peden & Freeland 1998)
Research budget of National Institutions of Health from $26 mil in 1945 to $7 bil in 1990
Ave. out-of-pocket proportion paid by customers from 55% in 1960 to 14% in 2007 (Smith et al 2009)
% of US population with insurance from 10% in 1940 to 82.5% in 1980 (Weisbrod 1991)
$111 bil spend on R&D in 2005, 55% from private industry (Rettig 1994) Physicians fear that if every possible test isn't provided, they will be liable if a diagnosis is missed. Technology is overused in an effort to guard against costly litigation while simultaneously offering potentially highly quality of care Geographic Factors Surgeries Define medical technology
History of technical advancement
Examples of technology improving quality
Quality-Adjusted Cost 1900 1850 1800 1950 2000 1816: Stethoscope Invented 1590: Microscope Invented
1592: Thermometer Invented 1796: Small Pox Vaccine 1859: Local Anesthetic 1895: X-rays 1928: Discovery of Penicilin 1897: Aspirin Isolated 1952: Polio Vaccine 1905: First Corneal Transplant 1954: First Kidney Transplant 1942: Early Chemotherapy 1840: Successful Whole Blood Transfusion 1990 Human Genome Project 1960 Oral Contraceptives Approved 1963 Insulin Pump Invented 1952 Open Heart Surgery 1952: First MRI Image 1980 Nanotechnology Emerges 1998 Stem Cells Isolated Eric Marshall, Alex Risberg, James Snyder, Allison Warner How Technology Affects Quality of Medical Care
Analysis of Costs
Technology's Influence on Access to Medical Care
Health Information Technology Medical Technology Nearly every human illness has a genetic component
Human Genome Project, completed in 2003
Focus on 0.1% of variation among human genes
Current Applications
Pre-natal genetic testing
Genetic-typed Diets
Future Applications
A large set of technologies that help providers manage patient care

Outline:
1) History
a) HITECH Act
2) Types
3) Economics
2) Spread
3) Cost
4) Quality History Quality 1) Better adherence to care:
*Diabetes: improvements indicators; change from 30% to 50% with BP <130/80 mgHg
*Reminders = improved blood pressure control elderly
*Reminders = improved renal examination rates
2) Increased Patient Safety:
*Avoidance of benzodiazepine use among patients with depression
*Medication errors 14.0%
*Captured immunization: from 78.2% to 90.3%
3) Duplication of Services
*prevent duplication imaging/laboratory tests by 20%
*Decreased utilization of unnecessary care
4) Better Care Coordination
*Decreased adverse events (medical errors) because of info exchanging between hospitals Types Spread (EHRs) Most Common:
*Electronic health record (EHR)
Computerized Physician Order Entry (CPOE)
Clinical Decision Support System (CDSS)
E-Prescribing

*HIT is often intertwined. (use EHR to e-prescribe; CDSS integrated into EHR) Spread (E-prescribing) (Mukamel, Glance, Weimer, Pearson, Massey, Gold, Greenfield & Jackson, 2007) (Vaughan-Sarrazin, Hannan, Gormley & Rosenthal, 2002) (Shrank, Etner, Slavin, Kaplan, 2005) Imaging
Endobronchial ultrasound (EBUS)
Improves yield of sampling 58-84%
Reduces # of tests required
Molecular Breast Imaging (MBI)
Detects 2-3 times more cancer
Can be used for hard to screen breasts
Positron Emission Tomography (PET)
Reduced tracer activity & side effects
Improved visualization & detection of cancer Prosthetic
Improvements in materials, engineering, microprocessors, EEG
Results: prosthetic mimic lost limbs better, quality of life improves for amputees
Lathroscopic (keyhole) surgeries
Minimally invasive surgery, often can enter through natural orifice
Results: reduces recovery time, blood loss, scarring, and other negative effects
Brain surgery for drug-resistant conditions
Deep brain stimulation (DBS) for treatment-resistant depression
Results: 60% had positive response
Stereostactic Radio Surgery for trigeminal neuralgia
Results: 80% had significant pain relief Categories of Technology Significant quality increases in
Diagnostics
Treatments & Procedure Potential for quality improvements
Genetics & Personalized Medicine Increasing medical care expenditures.
Large portion of expenditure growth can be attributed to Medical Technology growth.
Factors that affect the consumption of Medical Technology (Herth et al. 2004) (O'Connor et al. 2009) (Sugawara et al. 1998) ~65% of real HC spending growth / capita 1940-1990 (Newhouse 1992) (Buckley 1999) (Zecca et al. 2002) (Dev et al. 2010) (Kondziolka et al. 1998) (Lozano et al. 2008) All of these results were found using the Residual Approach of quantifying impact: It's difficult to measure Tech impact directly.

RA quantifies impact of changes in other factors (prices, income, population growth and demographic changes, and utilization) and the residual not accounted for is attributed to changes in technology.

Only a rough, indirect estimate. Factors that affect the Consumption Medical Technology Insurance
HC Industry Factors
Medical Malpractice
Consumer Demand Med Tech utilization with market size (Smith et al 2009)
Strong correlation found between ratio of physician/population and Tech utilization (Gelijn 1994)
Institutions with high competition 166% more likely to offer coronary angioplasty & 147% more likely to offer bypass surgery (Robinson et al 1987)
The rate of technology utilization in a given area is correlated with the quantity of specialists (Gelijn 1994) Competition & Induced Demand Cutting edge tech is a way to attract patients and physicians.
Ex. MRI. A tool to attract referring physicians, and hence patients larger share of the local market.
By using MRI to get patients “in the door,” hospitals hope to “capture” them for other services (Hillman 1992)
Ownership of imaging tech by non-radiologist physicians 4x utilization frequency compared to physicians who refer to a radiologist . Imaging Technology in the US MRI & CT scans 15% annually between 2000-2004
Cardiologist revenue from imaging services to 36% of total revenue in 2006, up from 23% in 2000 (GAO 2008) Defensive Medicine 6-9% in cost / cardiac patient due to defensive Med (Kessler & McClellan 1994)
Annual cost of defensive Cesarean deliveries for women ages 30-39 is ~$8.7 mil (US OTA 1994)
Annual cost of defensive radiological procedures for ages 5-24 arriving with apparently minor head injuries ~$45 mil (US OTA 1994)
Patients in hospitals with high frequency of physician obstetric malpractice claims are 32% more likely to undergo C-section (Localio et al 1993)
Positive correlation between C-section rates and malpractice insurance premiums (Localio et al 1993)
Median time for malpractice claims without payment ~17 months (US GAO 1987) 1973: begins with managed care
80s-90s: spreads
96: privacy concerns: HIPAA
09: HITECH Act (CDC 2012; HealthIT.gov 2012) Variables in Spread 1) Age
2) Firm Size
*larger firms costs; small
3) Ownership
4) Specialty
*non eligible for Fed $ use
5) Geography
*Urban vs Rural: costs urban hospitals 3 years after EHR; costs rural
*IT/Research Intensive: 3.4% costs 3 yrs adopting EHR (high); 4% costs low (NHCS 2012; Menachemi, Perkins, van Durme, and Brooks 2006;Yaylacicegi and Mitchell 2012; DesRoches, Worzala, Joshi, Kralovec, and Jha 2012) (Joszt 2012) Examples of cost-effectiveness for technology Heart attacks (1984-98)
∆ treatment cost = $10k
∆ value = 1 year of life = $70k
Net benefit = $60k
Breast cancer treatment (1985-96)
Net benefit = $0 (Cutler & McClellan 2001) (Collins & McKusick 2001) (Shannon 2001) (Grierson 2003) HEALTH INFORMATION TECHNOLOGY HIT SPREADING FAST (2009 HITECH Act) (RAND, 2005) (Dranove, Forman, Goldfarb, and Greenstein 2012) (Dranove et al. 2012) (Zlabek, Wickus, Mathiason 2011) (Linder, Ma, Bates, Middleton, & Stafford 2007) (Linder, Ma, Bates, Middleton, & Stafford 2007) (Health IT 2012) (Ciemin, Coon, Fowles, Min 2009; Hunt JS et. al 2009) (Agha 2011) (Ciemins EL, Coon PJ, & Fowles 2009) (Grundmeir, Biggs, Locallo, Alessandrini 2009) (Couch 2008) (Cohn 2009) (IEEE-USA 2011) Key concept behind increasing costs Just because a new advancement may reduce costs on an individual basis, total med spending may still increase.
Cost savings obtained at a per patient level are sometimes more than offset by the increased utilization of a new technology.
Also, surviving one condition means you have a chance of incurring greater med expenses in the future. Surgeries
Imaging
Hospitalization Age
The highest percentage of cataract surgeries were performed among individuals 65 and older
The elderly (ages 70 and older) had the most coronary artery bypasses
Gender
Approx. two thirds of cataract surgery are performed on women
Men undergo more open heart surgeries, although women have more complications
The rate of tonsillectomy is nearly twice as high in girls than in boys Total value of increases in life expectancy annually (1970-90) =$2,777,360 (Murphy & Topel 1998) Cost vs Quantity In treating heart disease:
Coronary bypass developed led to costs/surgery, but quantity, thus total expenditures
Then coronary angioplasty cost/surgery and quantity again.
New contrast dye adopted, at cost/surgery as well as quantity, again total expenditures (Murphy & Topel 1998) International (pre '09 HITECH ACT) Spread (CDSS) (GE 2012) Barrett et al 1992 (Bollinger, 2008) Lewallen, 2009 (RAND 2005) (Zaroukian 2003) (Williams, Sloan & Lee, 2006) Nationwide:
$32.4 billion savings/year (90% adoption rate by 2020)

Inpatient:
*Laboratory tests per hospitalization 18%; monthly transcription costs 74.6%
*VA hospitals savings ($4.64 bil.);
*need to see multiple specialists (Williams, Sloan & Lee, 2006) Economics of EHRs
Nationalized health care: EHR software monopoly (public utility)
*homogeneous software; send EHR anywhere
USA: Private: many EHR companies
*hospital "share" agreements (Meriter/St. Marys; VA hospitals)
*software may not be compatible
*network effect (Microsoft); Epic? (Williams, Sloan & Lee, 2006) (Bresnahan 2012) Surgeries Race
Black individuals were less likely to undergo cataract surgery than white individuals
Coronary Artery Bypass:
83.7% White/non-Hispanic....................................23.0% off-pump
5.6% Black/non-Hispanic........................................31.0% off-pump
4.3% Other/non-Hispanic.......................................20.7% off-pump
4.1% White/Hispanic..............................................25.3% off-pump
2.0% Other/Hispanic..............................................11.6% off-pump
0.3% Black/Hispanic................................................26.5% off-pump Income Level
Income level was insignificant when determining the likelihood of cataract surgery
Insurance
Patients with Medicare parts A and B coverage underwent more cataract surgeries than those with primary private employer-based coverage or the uninsured
Cataract procedures under fee for service insurance types were twice as prevalent as those under contact capitation insurance types
Coronary Artery Bypasses - Certificate of Need Regulations
States with intermittent regulations had 4.97 procedures per 1000 beneficiaries
States with continuous regulations had 4.75 procedures per 1000 beneficiaries
States without regulations had 4.23 procedures per 1000 beneficiaries Surgeries (Wright 2012) (Wright 2012) (Loop, Golding, MacMillan, & Cosgrove, 1983) (Smith & Bindman, 2008) MRI MRI CT Scan CT Scan Evidence suggests an overuse of MRI examinations
Between 1997 and 2006, the number of scans in the United States increased dramatically while the occurrence of illnesses has remained constant Evidence suggests an overuse of CT scans
Between 1997 and 2006, the number of scans in the United States increased dramatically while the occurrence of illnesses has remained constant (Smith & Bindman, 2008) Availability
On-site MRI was available for 66% institutions, and mobile MRI for 20%
Smaller, rural, and critical access hospitals had lower MRI availability
Insurance
Medicare coverage
Part A - MRI diagnostic test performed on an inpatient
Part B - covers an MRI performed on an outpatient, in any setting, to diagnose an illness or injury (Ginde, Foianini, Renner, Valley & Camargo, 2008) (Ginde, Foianini, Renner, Valley & Camargo, 2008) Availability
CT scanners were present in 96% institutions
94% had 24/7 access for patients.
CT scanner resolution varied: 28% had 1-4 slice, 33% had 5-16 slice, and 39% had a more than 16 slice
Smaller, rural, and critical access hospitals had lower CT and MRI availability and less access to higher-resolution CT scanners (Ginde, Foianini, Renner, Valley & Camargo, 2008) (Ginde, Foianini, Renner, Valley & Camargo, 2008) MRI and CT:
Private Insurance MRI and CT:
Medicare Inpatient Hospitalization Age
The elderly, ages 65 and older had 33 percent of all hospitalizations
Infant hospitalizations increased to 4.7 million in 2007, a 21-percent increase since 1997
Gender
Females accounted for more stays than males—18.2 million stays for females compared to 16.2 million stays for males

Race
Across respondent hospitals, 38% white, 29% black, 24% Hispanic/Latino, and 3% Asian or Pacific Islander
Insurance
In 2007,
56% Medicare and Medicaid
35% Private
6% uninsured (Levit, Wier, Stranges, Ryan & Elixhauser, 2007) (Levit, Wier, Stranges, Ryan & Elixhauser, 2007) (Levit, Wier, Stranges, Ryan & Elixhauser, 2007) (Regenstein & Sickler, 2006) Outpatient Hospitalization Outpatient Hospitalization Outpatient Hospitalization
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