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COLUMN ONE : A Second Opinion on Tools of Medical Trade : Medical technology is a prime suspect in the case of runaway health-care bills. Cost concern is gaining on the 'spare nothing' approach to treatment.


LOUISVILLE, Ky. — When the federal government in 1984 approved a futuristic shock wave machine that could pulverize kidney stones, doctors nationwide saw new hope that hundreds of thousands of Americans could be helped without surgery.

What Darrell Lewis saw was a gold mine--enormous profits for his employer, Humana Inc., which owns 81 hospitals from California to Florida. "The demographics were great," said Lewis, who is in charge of assessing new technologies for Humana.

As a preemptive strike against competitors, the hospital chain immediately bought six of the big machines, called lithotripters, at $1.6 million each.

Humana's rush was understandable. America was in the middle of what one health economist calls "a me dical technology arms race" in which few questions were asked about a new technology's effectiveness or cost.

But no more.

A consensus is emerging that medical technology is a major driving force behind runaway health-care costs, now approaching 12% of the gross national product.

And government regulators, employers, insurers and health care providers are proclaiming an unprecedented resolve to assess emerging medical technologies more closely and to encourage more appropriate use of existing ones--all with an eye on constraining costs.

"Tests are frequently ordered just because they are available, not because anyone's ever thought about whether they are useful or not," says Dr. Frank Meyskens, director of hematology and oncology at UC Irvine's College of Medicine. "There's probably more CAT scanners in Orange County than in all of Britain and it still hasn't helped medical care at all."

Meanwhile, other health-care providers in Orange County blame increasing malpractice suits for inappropriate use of medical technology.

"I think the issue that is always lurking in the back of a physician's mind when he orders a test is whether it will provide the best care available but also if it will protect him from litigation," said Richard Butler, administrator of Fountain Valley Regional Hospital. "He has to provide the community standard of care, and that increases with new technology."

In the past, some health-care providers said, technology developed without a lot of questions being asked about it's usefulness and effect on patient health.

But now, said Wayne I. Roe, a Washington-based health-care consultant, "the squeeze is on."

"The issue with medical technology is not necessarily whether it is good or bad," added Sanford Schwarz, a University of Pennsylvania internist and health economist. "Most technologies are good--under selected circumstances. The challenge is to define the clinical conditions under which a technology is appropriate."

Yet with few guidelines and little agreement on usage, experts see no sign that doctors or patients are ready to abandon the spare-nothing approach to treatment.

"Even now, I think the old philosophy still prevails, by and large," Roe said. "If you can make something that works, it's still very difficult for it not to be developed and used."

"That's the basic problem," Schwarz agreed. "Nobody is willing to control costs when it's them or their relatives involved. The major component missing right now is a lack of consensus or political will to face what is appropriate medical care."

Experts say there could be no better time than now to begin performing more rigorous technology assessment. A veritable flood of products is poised to enter the marketplace in the next decade.

"Ideally, technology should lower costs, but it doesn't," said Dr. Ralph W. Schaffarzick, retired vice president and medical director of California Blue Shield. "Technologies themselves are usually expensive. And utilization of them is often very great because doctors and the public want access to all the newest things."

Schaffarzick said a new product seldom replaces an older one. Instead, doctors often use both the new and the old.

For instance, the CT scanner or the magnetic resonance imager may be much more accurate than X-ray at detecting blood clots in the skull, but Schaffarzick said that physicians "more often than not" use all three. The expenses mount quickly--up to $500 for each use of a CT scanner, $900 for a magnetic resonance image and $60 for an X-ray.

"Some doctors still are not confident with the newer technologies," he said. "And there's always the lurking fear of malpractice--or at least, the excuse of it."

Unquestionably, technology has done much to prolong lives and improve the quality of life.

Yet as Americans live longer, their changing medical needs are dictating more and newer types of treatments, especially for the afflictions of aging. For instance, a person today with heart disease might live long enough, thanks to new medications, to develop Alzheimer's Disease or other ailments.

"It's going to cost more per capita. No question," said William McGiveny, director of the American Medical Assn.'s division of health care technology.

A 20-Year Boom

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