Raise your hand if you’ve never undergone a CT or MRIÂ scan, never taken a statin to lower your cholesterol or never had a joint replacement. If your hand isÂ still in the air after reading this, you’re either in a healthy minority or just haven’t caught up yet with the odds.
American health care is very good – a world leader, in fact – at developing and using technology. Just how prevalent our technologic interventions have become is demonstrated in a report recently issued by theÂ National Center for Health Statistics, whichÂ takes a look atÂ this technology boom by the numbers.
The findings are rather eye-opening. Take, for instance, the report’s summary of the growth of medical imaging over the past couple of decades:
Despite the significant costs of acquiring advanced imaging capability, the availability and use of imaging technologies in the United States has substantially increased since their introduction in the early 1980s. In 2006, there were more than 7,000 sites offering MRI, with an estimated 27 million MRIÂ procedures performed. In 2007, more than 10,000 CT units were in operation at more than 7,600 hospital and nonhospital sites, and the availability of PET and other imaging modalities has been steadily increasing. The site of imaging services has diffused from hospital inpatient and outpatient settings to nonhospital settings such as physician offices or radiology centers. During the past decade, the number of freestanding diagnostic imaging centers owned by radiologists, other specialists, private investors, or for-profit companies has more than doubled.
The report found that from 1996 to 2007, the number of advanced imaging scans ordered during outpatient office visits tripled in number. In emergency rooms, the use of advanced imaging grew fivefold between 1996 and 2007 for patients under the age of 65 and quadrupled for patients 65 and older.
The number of joint replacement surgeries has grown substantially. At least one analysis estimates the demand for total hip replacements could grow by 175 percent in the next 20 years, while the demand for knee replacements could increase sixfold.
The rate of kidney transplantation increased 31 percent between 1997 and 2006. Liver transplants increased 42 percent during this same period. The use of assisted reproductive technology has risen, especially among women younger than 35. From 1988-1994 to 2003-2006, the use of statins to treat high cholesterol rose almost 10-fold, while the use of antidiabetic medications as a replacement for insulin rose by 50 percent.
None of this is necessarily bad. As the report points out, it’s “almost inconceivable to think about providing health care in today’s world without medical devices, machinery, tests, computers, prosthetics or drugs.” Joint replacement surgery has enabled countless people to remain mobile, independent and pain-free. Angioplasties and organ transplants save lives. Drug therapies have staved off illnesses that might otherwise have been fatal and allowed patients to return to normal life.
The flip side to this is that it costs money. A lot of money.Â Even interventions that are less costly can add up as they become more widely used. From the report:
Technologies applied to new populations and conditions generally come at a cost to individuals and to society as a whole. Technologies can be very expensive (e.g. heart transplants, chemotherapy) or very inexpensive (e.g. the Band-Aid). Total expenditures for a given technology, however, are determined by both use and cost; consequently, widely used inexpensive technologies can often have higher aggregate expenditures than rarely used expensive ones. Some new technologies can be cost-saving – for example, annual influenza vaccinations in high-risk children. Many technologies, however, contribute to increases in overall health care expenditures because they increase utilization (e.g. more doctor visits may be needed to monitor new drug therapies); they may be used on a larger number of patients; they may be more expensive than technologies they replace; or they may increase life expectancy in populations and thus their lifetime health care costs.
In one of the most telling sentences in the entire report, the authors point out:Â ”In general, Americans – both providers and consumers – appear to be more willing and eager to adopt and use new technologies than people in other countries.”
This whole issue came to mind when I recently read a New York Times article about robotic surgery. It costs more per patient – $1,500 to $2,000 more. It’s not clear if the results are any better than more traditional surgery. But, as the article explains, hospitals and surgery centers are marketing it and patients are asking for “the robot,” in some cases walking away from surgeons who don’t do robotic surgery.
Readers chipped in with comments. Several said they’d had robotic surgery and couldn’t be happier with the results. Others were more skeptical. “Follow the money,” one person scoffed.
Last weekendÂ my Sunday paper was accompanied by this article in Parade magazine: “Revealing the body’s deepest secrets.” It describedÂ several new forms of gee-whiz medical imaging technologies that are “transforming medicine.” One is the use of MRI for diagnosing heart attacks; another is a fiber-optic probe that can help detect oral cancer. To be fair, there could well be an appropriateÂ niche for these technologies – but at what cost, notÂ only in dollar terms but also in the ratcheting-up of people’s expectations? On some online message boards, I’ve seen people criticize their physician’s competence for not ordering a specialized test they felt they should have.
Finally, here’s yet another look at the issue, this time from Kaiser Health News, in an article titled “High-Tech Medicine Contributes to High-Cost Health Care”:
Just before Christmas, 41-year-old Michael Kelley decided he wanted a whole-body imaging exam, the heavily advertised service touted on television by celebrities like Oprah Winfrey. He didn’t smoke, wasn’t overweight, and didn’t have elevated cholesterol. “I’m pretty normal for a guy my age,” he said.
No matter. The electrical engineer scheduled a full-body X-rayÂ computed tomography or CT scan at Virtual Physical, a radiology clinic located in a glass-enclosed office building on a busy commercial strip not far from the headquarters of the National Institutes of Health. The clinic’s name, plastered in large red letters on the building’s exterior, served as a billboard aimed at cars exiting the high-end shopping mall across the street.
About an hour after checking in, Kelley left the clinic clutching a manila envelope with high-resolution 3-dimensional images of most of his major body systems, including the insides of the major coronary arteries pumping blood to and from his heart. “They said I was fine, no plaque,” he said. Kelley paid $1,400 for a CT scan to confirm what he and his doctor already knew – he was perfectly healthy.
The rest of the article delves into some of the difficult issues surrounding the use of medical technology. When does the technology genuinely benefit patients and when does it reach the point of diminishing returns? Is “better” always the best thing? How should we weigh the potential benefit to the patient vs. the risk of harm?
The article concludes that in the long run, technology will probably help save money, but we’re not there yet:
When robotic doctors are able to performÂ micro-surgeries; when arm and leg replacements function as well if not better than the original parts; when pharmacology replaces more expensive treatments and therapies, the U.S. may actually be able to use technology to bend the cost curve of health care downward. Until that time comes, we’re stuck with ever-increasing costs and left to wonder whether the investment is greater than the payoff.
What’s remarkable about this whole discussion is that it’s happeningÂ on a wider, more public stage. Ten years ago, maybe even five years ago, I’m not sure the average person was ready to contemplate the down side of technology. More and more, however, these questions are being asked and debated – not just within policy circles butÂ among theÂ public. We might not have the answers, but the sheer fact that we’reÂ willing toÂ acknowledge it and talk about itÂ is surely a sign of progress.
West Central Tribune photo by Anne Polta