The new $2 billion, 368-bed, hi-tech Stanford Hospital opened November 17, 2019, prompting thought about technology and health care costs.
Stanford aside, I have deep concerns about technology and accelerating health care expense. The concerns are not with the responsible and specific use of technology but with its irresponsible and excessive use. The influences motivating this irresponsible and excessive use are powerful and diverse.
One set of these influences is economic, wherein new technologies are implemented primarily as an asset in the competition among health care systems. Once acquired
- The cost of the initial installation must be recovered.
- The cost of upkeep and maintenance contracts on the technology must be recovered.
- The short lifetime to obsolescence of many new technologies accelerates cost increases by shortening the time in which cost can be recovered.
- The cost of promoting and featuring the new technology as an asset in the competition among health care systems, must be recovered.
- The above costs to health care multiply as the competing health systems respond to and possibly duplicate (the first health system’s introduction of) the technology.
Another set of these influences is cognitive, wherein there is a systematic inclination to excessively demand and to overuse the new technologies.
- The availability bias impels physicians to utilize first the technology most widely promoted.
- The novelty bias influences patients and physicians to consider the newest technology as being, always and everywhere, the best.
- The action bias influences physicians to execute an action when active surveillance (“watchful waiting”) would be more appropriate.
- The conformity bias impels physicians to simulate the practice patterns of their colleagues.
- Litigation fear influences physicians to utilize all the functionalities available to them.
Finally, excessive use of a technology, once embraced, increases costs methodologically.
- As the new technology is used beyond its specific indications, the proportion of false positives to true positives rises as the technology is applied to an ever-increasing base population with an ever-decreasing rate of pathology. The increased false positives increase costs by requiring additional follow-up studies and patient procedures.
- Excessive use of the new technology often leads to decreasing rates of reimbursement. This, in turn, motivates attempts to keep ahead of the decreasing reimbursement by further increasing volume of the technology’s use or moving to a newer technology and repeating the cycle.
In conclusion, the adoption of a new technology should be guided by legitimate need as demonstrated by the existence of a sufficiently large, specific population of pathology. Its continued use should be guided by specific, evidenced, indications. Existence of a technology should not justify its acquisition. Acquisition of a technology should not justify its use.
Dr. Thomas Falasca, Author of Physician’s Guide to Better Medical Decision Making