Important modifications to technology assessment, diffusion, adoption, and utilization must take place if the United States is to better employ medical technology and save resources so as to assure access for the uninsured and underinsured. The United States can learn from other health systems that are more successful in achieving these goals. The author selects for comparison the health systems of France and Quebec. The discussion focuses on the differences between the three systems in the management of medical technology on a range of policy-relevant dimensions, including health system structure, attitudes about planning versus market competition, government regulation, the balance between decentralization and centralization, the needs of the individual and those of the society, linkages between technology assessment and policy-making, and the importance of medical technology assessment for medical practice. Seven specific recommendations are made for better managing medical technology in the United States, drawing on what can be observed from the experiences of Quebec and France.
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References
1.
World Health Organization. Health for All by the Year 2000—Strategies. Geneva, 1980.
2.
NewhouseJ. P., An iconoclastic view of health cost containment. Health Aff. 12(Suppl.), 152–171, 1993.
3.
AldhousP., Research and health care costs. Science261: 416–418.
4.
U.S. Congress, Office of Technology Assessment. Medical Technology and the Cost of the Medicare Program. OTA-H-227. Government Publishing Office, Washington, D.C., 1984.
5.
FriesJ., Reducing health costs by reducing the need and demand for medical services. N. Engl. J. Med.329: 321–325, 1993.
6.
BodenheimerT.GrumbachK.Understanding Health Policy. Appleton & Lange, Stamford, Conn., 1995.
7.
LetschS. W., National health expenditures, 1991. Health Care Financ. Rev.14(2): 1–30, 1992.
8.
HellanderI., The growing epidemic of uninsurance: New data on the health insurance coverage of Americans. Int. J. Health Serv. 25: 377–392, 1995.
9.
HughesJ., How well has Canada contained the costs of doctoring?N. Engl. J. Med.324: 1253–1258, 1991.
10.
DuriezM.SandierS.The French Health Care System: Organization and Functioning translated by WilsfordD., Editions du Service de l'Information et de la Communication (SICOM), France, 1994.
11.
WeillC., Health care technology in France. Health Policy30: 123–162, 1994.
12.
CatalaC.L'offre et la demande dans le domaine de la santé. In La Protection Sociale en France, edited by De MontalembertM., Secretariat general de Government, Nancy, France, 1995.
13.
Organization for Economic Cooperation and Development. OECD Health Systems, Facts and Trends, 1960–1991. Paris, 1993.
14.
RedelmeierD.FuchsV., Hospital expenditures in the United States and Canada. N. Engl. J. Med.328: 772–778, 1993.
15.
BlendonR.Satisfaction with health systems in ten nations. Health Aff., Summer 1990, pp. 185–192.
16.
BlendonR., Who has the best health care system? A second look. Health Aff. 14(4): 220–230, 1995.
17.
RubleeD., Medical technology in Canada, Germany, and the United States. Health Aff. 8(3): 178–181, 1989.
18.
WennbergJ. E.The Dartmouth Atlas of Health Care. American Hospital Publishing, Chicago, 1996.
19.
PerryS.ThamerM., Health technology assessment: Decentralized and fragmented in the US compared to other countries. Health Policy40: 177–198, 1997.
20.
PerryS.GardnerE. M.HongR.Directory of Health Technology Assessment Organizations Worldwide. Medical Technology and Practice Patterns Institute, Washington, D.C., 1998.
21.
BantaH. D.AndreasenP. B., The political dimensions in health care technology assessment programs. Int. J. Technol. Assess. Health Care6: 115–123, 1990.
22.
BakerL. C.WheelerS. K.Managed care and technology diffusion: The case of MRI. Health Aff. 17(5): 195–207, 1998.
23.
ChernewM.FendrickA. M.HirthR. A., Managed care and medical technology: Implications for cost growth. Health Aff. 16: 196–206, 1997.
24.
NewhouseJ., Are fee-for-service costs increasing faster than HMO costs?Med. Care23: 960–966, 1985.
25.
LuceB. R.BrownR. E., The use of technology assessments by hospitals, health maintenance organizations, and third-party payers in the United States. Int. J. Technol. Assess. Health Care11: 79–92, 1995.
26.
NobleH. B.Linking technology and health groups to find best cure. New York Times, September 24, 1995.
27.
GabelJ. R., On drinking with your competitors after five: Research collaboration in the real world. Health Aff. 17: 123–127, 1998.
28.
BryceC. L.ClineK. E., The supply and use of selected medical technologies. Health Aff. 17: 213–224, 1998.
29.
WatzmanN.YoungclausJ.ShecterJ.Cashing In: A Guide to Money, Votes and Public Policy in the 104th Congress. Center for Responsive Politics, Washington, D.C., 1997.
30.
U.S. Government General Accounting Office. Medicare: Excessive Payments Support the Proliferation of Costly Technology. GAO/HRD-92-59. Gaithersburg, Md., 1992.
31.
U.S. Government General Accounting Office. Medical Technology: Quality Assurance Needs Stronger Management Emphasis and Higher Priority. GAO/PEMD-92-10. Gaithersburg, Md., 1992.
32.
BattistaR., Lessons from the eight countries. Health Policy30: 397–421, 1994.
33.
KahnC. N., The AHCPR after the battles: To overcome Congressional opposition, the Agency for Health Care Policy and Research has had to refine its role. Health Aff. 17: 109–110, 1998.
34.
RussellL.SiskJ., Medical technology in the U.S. Int. J. Technol. Assess. Health Care4: 269–286, 1988.
35.
KamerowD. B., Before and after guidelines. J. Fam. Pract.44: 344–346, 1997.
36.
Personnel in the Communications Division of the AHCPR. Telephone interview conducted by the author, April 27, 1998.
37.
38.
LintonA.NaylorC. D., Organized medicine and the assessment of technology. N. Engl. J. Med.323(21): 1463–1467, 1990.
39.
DeberR.ThompsonG.LeattP., Technology acquisition in Canada. Int. J. Technol. Assess. Health Care4: 185–206, 1988.
40.
EvansR. G.Technology: The case of Canada. In Resources for Health: Technology Assessment for Policy Making, edited by BantaH. D., Praeger, New York, 1982.
41.
Price Waterhouse. Evaluation du Conseil d'évaluation des technologies de la santé. Final report of evaluation of the Conseil d'évaluation undertaken for the Quebec Government by Price Waterhouse. Ministère de la Santé et des Services Sociaux, Quebec, 1991.
42.
LaPointeD., Le conseil d'évaluation des technologies de la santé du Quebec; l'instrument privilégié d'évaluation. Bulletin32(5): 44–45, 1992.
43.
JacobR.BattistaR. N., Assessing technology assessment: Early results of the Quebec experience. Int. J. Technol. Assess. Health Care9: 564–572, 1993.
44.
AltenstetterC., Regulating healthcare technologies and medical supplies in the European economic area. Health Policy35: 33–52, 1996.
45.
ArmogatheJ.-F.Pour le Développement de l'évaluation médicate. La Documentation Francaise, Paris, 1989.
46.
Durand-ZaleskiI.ColinC.Blum-BoisgardC., An attempt to save money by using mandatory practice guidelines in France. BMJ315: 943–946, 1997.
47.
MitchellP., France gets smart with health à la carte. Lancet351: 736, 1998.
48.
CrossM., Putting health on the cards. Health Serv. J.108(5590): 24–25, 1998.
49.
LacroniqueJ. F., Technology in France. Int. J. Technol. Assess. Health Care4: 385–394, 1988.
50.
GoldbergA. J., Home care for life-supported persons: The French system of quality control, technology assessment, and cost containment. Public Health Rep. 104(4): 329–335, 1989.
51.
FieldingJ. E.LancryP.-J.Lessons from France—‘vive la difference.’JAMA270: 748–756, 1993.
52.
RosenauP. V., Market structure and performance: Evaluating the U.S. health system reform. J. Health Soc. Policy13(1), 2001.
53.
TunisS.GelbandH., Health care technology in the United States. Health Policy30: 335–396, 1994.
54.
PoullierJ.-P.Public health strategies in Europe—Doing better and feeling worse. In Oxford Textbook of Public Health, edited by DetelsR., Oxford University Press, Oxford, England, 1997.
55.
Budget bill gives states what they wanted on Medicaid, but they lose out on DSH. State Health Watch4(8): 1, 4, 1997.
56.
U.S. Government General Accounting Office. Health Insurance Regulation: Wide Variation in States' Authority, Oversight and Resources. GAO/HRD-94-26. Gaithersburg, Md., 1993.
57.
KassierJ. P., Managed care and the morality of the marketplace. N. Engl. J. Med.333: 50–52, 1995.
58.
World Health Organization, European Region. Evaluation of the Strategy for Health for All By the Year 2000, Vol 5. Geneva, 1986.
59.
JeffreyN. A.GentryC.Some insurers put coverage for Viagra on hold until they decide on a policy. Wall Street J. April 29, 1998, p. B3.
60.
WeillC., Attitudes professionnelles et diffusion de la connaissance scientifique: Les conférences de consensus sont-elles susceptibles de modifier les comportements des praticiens?Sci. Soc. Sante8(4): 91–114, 1990.
61.
FuhrerR.Policy for medical technology in France. In The Management of Health Care Technology in Nine Countries, edited by BantaH. D.KempK. B., Springer Verlag, New York, 1982.
62.
Ray-CoquardP., Impact of a clinical guidelines program for breast and colon cancer in a French cancer center. JAMA278: 1591–1595, 1997.
63.
LevyF.DoanB. D., New technological equipment and their economical impact in ambulatory care. Cahiers de sociologie et de démographie médicales33(1): 5–106, 1993.
64.
MathewsJ. E., The physician self-referral dilemma: Enforcing antitrust law as a solution. Am. J. Law Med. 19: 523–546, 1993.
65.
MitchellJ. M.SunshineJ. H., Consequences of physicians' ownership of health care facilities. N. Engl. J. Med.327(21): 1497–1501, 1992.
66.
MitchellJ. M.ScottE., Physician ownership of physical therapy services: Effects on charges, utilization, profits and service characteristics. JAMA268: 2055–2059, 1992.
67.
HillmanB. J., Physicians' utilization and charges for outpatient diagnostic imaging in a Medicare population. JAMA268: 2050–2054, 1992.
68.
SofaerS., Informing and protecting consumers under managed competition. Health Aff. 12(Suppl.), 76–86, 1993.
69.
ImersheinA.EstesC. L., From health services to medical markets: The commodity transformation of medical production and the nonprofit sector. Int. J. Health Serv. 26: 221–238, 1996.
70.
SimonC.BornP., Physician earnings in a changing managed care environment. Health Aff. 15: 124–133, 1996.
71.
RosenauP. V., The impact of political structures and informal political processes on health policy: Comparison of the United States and Canada. Policy Stud. Rev.13: 293–314, 1994.
