Is medical technology the villain?
Taming the Beloved Beast: How Medical Technology Costs Are Destroying Our Health Care System by Daniel Callahan. Princeton, NJ: Princeton University Press, 2009, 288 pp.
Daniel Callahan’s Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System is both more and less than the title implies. More, in that it is a blunt, thought-provoking view of medical culture that raises difficult but essential questions about our values and public policy. Less, in that it lacks depth and nuance in its treatment of technology, limiting its utility in evaluating short-term policy issues. It is a particularly interesting read in this time of acrimonious health reform debate.
Callahan’s main focus is not technology per se but rather the evolution and prospects of the U.S. health care system as a whole. The challenge is formidable because the starting point is “a messy system, one ill-designed for reform because of the accretion of assorted interest groups with different agendas and vested interests, an ideologically divided public, and a steady stream of new and expensive technologies added to those already in place.”
At the heart of the book is the belief that health care is at a level of unsustainable cost growth and resource consumption. When Callahan examines health care costs, he gravitates toward technology, which by various estimates accounts for up to half of cost growth. By extension, his policy imperative becomes how to manage technology costs.
Technology is the beloved beast: “It saves and improves our lives with its undoubted power to diagnose and treat but, in its unrestrained lumbering about in the house of medicine, increasingly wreaks financial havoc.” Callahan attributes that unrestrained lumbering in large part to a medical culture that assumes innovation to be a “central and untouchable value” so that “nothing is allowed to stand still in health care; it is always supposed to get better.” He characterizes much of the industry as focused on innovation and scientific advancement with little or no concern for escalating costs or resource consumption at a national level.
One of the most interesting discussions in the book is Callahan’s description of how innovation, research, business interests, and medical education meld into a self-reinforcing culture of continuous innovation and development. Although many would call this a treasured asset, he views it as a dynamic that creates untenable social risk. At the same time, he has a fine sense of realpolitik and pursues his case in the context of this question: “What if it is crucial for the long run that the golden-haired favorite not win, that the despised or dismissed contender—the one who looks a bit grim and hardly as pleasing as the crowned champion—is actually the most deserving?”
What is this despised or dismissed contender? Philosophically, it is a culture in which health care moves from an “infinity model” with open-ended medical progress and technological innovation as core values to one that is more limited in aspiration. In practical terms, this becomes a universal health system with global budgeting, conscious limits on the development and use of technology, and policies that distribute care resources based on an age-stratified, quality-adjusted life year (QALY)–mediated cost-effectiveness model. Callahan is particularly enamored of the European social health insurance (SHI) model as demonstrably superior in both health outcomes and cost management. Although he rightly notes the role of national policy, he fails to point out underlying characteristics of these systems—much smaller size, homogenous demographics and culture, better-established social support systems—that contribute to their success but do not exist in the United States. The resulting sea change embodied in his proposals will require “fewer new technologies, especially those with marginal benefits, slower diffusion of expensive ones, a reduced dependence upon technology by physicians, and a willingness of patients to change their expectations and lower their demands.”
The upshot, and in many ways the most controversial element of Callahan’s policy framework, is the severe limiting of the use of expensive technologies and interventions to treat those who have lived a “full life,” nominally at or around age 80. Callahan summarizes the argument thus: “The baby boomers should know that if in their 80s they come to want the same level of technological care they received in their earlier years, they will simply not get it.” That view, writ large, becomes the driving force for a series of age-, condition-, and expense-based proposals at the heart of resource allocation in his proposed national health system. Callahan lays out preliminary ideas on how the logic of such a system might work; less time is spent on the process or politics of implementation.
The urgency behind the words is based in large part on the author’s philosophical bent and reflections. However, there are two other elements in play. The first is his belief that current approaches to cost containment and technology assessment are grossly insufficient, individually and collectively, to generate progress. Callahan devotes a very small fraction of the book to considering, and largely summarily dismissing, a wide range of initiatives. These include reduction of waste, inefficiency, and geographic variation; evidence-based medicine; reduction of medical errors; disease management; better management of chronically and critically ill patients; and information technology. In each case, the intervention is deemed too small, not politically grounded, not focused strongly enough on costs, or in some other way not up to the task.
However, as Callahan exposes his schema for public policy, in particular his “conciliatory” reform track, he allows that some of the above would be appropriate elements. More important, aside from a high-level description of cost-effectiveness evaluation utilizing QALYs (drawn in large part from the UK model employed by the National Institute for Clinical Excellence) and the constraints of a global budget, he proposes no other specific approaches, thus suggesting a decided preference for the saw over the scalpel.
The lack of depth in the discussion of technology is noticeable, and surprising given the title. With a few exceptions such as the discussion of left ventricular assist devices, Callahan spends little time defining the technology arena except in broad categories such as critical care, hospital care, high-cost pharmaceuticals, and biologics. Noticeably absent is any discussion of areas in which technology can truly be transformative, in which it can reduce costs and improve clinical quality on a scale that will have a major impact on U.S. health care. Callahan’s implicit conclusion appears to be that no such examples exist.
The combination of few or no perceived effective policy levers and no transformative technologies leads to a very simple and blunt technology policy: make it unavailable or permit it only when it passes a rigorous “sufficient evidence” test. In short, desperate times require painful measures.
One can, however, hold a fundamentally different and more positive view of both proposed initiatives and present and future technologies. With respect to current initiatives, Jack Wennberg, Donald Berwick, and many others have made a compelling case for the clinical and cost benefits of reducing practice variation and errors. Sean Tunis, identified by Callahan as a leading thinker in the area of comparative effectiveness, is making excellent progress on methodology and application with the Center for Medical Technology Policy. Although no single initiative will resolve the cost issue, it is equally true that their combined potential is powerful.
There are current and emerging technologies that also show early results and even greater promise for transformative performance. Technologies such as telemedicine, remote patient monitoring, medication optimization, computerized provider order entry, and electronic health records offer significant advantages in cost and quality of care. It is particularly important to note that the European SHI systems that Callahan most admires have been early and continuous investors in these very technologies as part of their own strategies. Likewise, the most aggressive use of, and compelling results from, these same strategies and technologies in the United States are coming from systems such as the Veteran’s Health Administration and Kaiser Permanente that are recognized as leaders in cost management and care of large populations.
The root causes of the nation’s long-term dilemma—an aging population, growth in chronic diseases, and persistent shortages of caregivers—that Callahan takes as his imperative to constrain technology may in fact be the most persuasive argument for technology. If one thing is clear, it is that we cannot expect to provide anything approximating reasonable capacity if we continue down a path of highly person-intensive, disease- and institution-based care models. Although it is unarguable that technology has contributed to cost escalation, it is also clear that technology can and will play an important role in redefining our care processes and resulting delivery system. Forcibly constraining R&D will make delivery system transformation more, not less, difficult.
This is a book well worth reading. It raises important and difficult questions and deals with them directly and unflinchingly. Its greatest strength is in identifying and expounding on important philosophical and social issues that underlie much of our national reform debate. Its greatest weakness is in underestimating the potential utility of current industry initiatives aimed at quality improvement and cost management, and the contribution of specific technologies to the transformation of health care. In total, Callahan performs a valuable service for all who think about and must shape the future of our delivery system.
Steven DeMello ([email protected]) is the Director of Health Care at the Center for Information Technology Research in the Interest of Society (CITRIS) at the University of California, Berkeley.