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Appendixes
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A
Workshop Agenda
Improving the Translation of Research Findings into Clinical Practice:
Workshop III
THE CHANGING HEALTH CARE ECONOMY:
IMPACT ON PHYSICIANS, PATIENTS, AND INNOVATORS
April 18, 1991
8:00 a.m. Registration and Continental Breakfast
8:30 a.m. Welcome and Opening Remarks
William Hubbard, Committee on
Technological Innovation in Medicine
8:45 a.m. Keynote Address: The Changing Health Care Economy
John Wennberg, Chair of Workshop III,
Dartmouth College
257
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258 APPENDIX A
9:15 a.m. A Reaction Uwe Reinhardt, Princeton University
9:30 a.m. Discussion
9:45 a.m. Break
Session I: Changes in the Financing and Delivery of
Health Services
Moderator: Susan Bartlett Foote,
Robert Wood Johnson Fellow
10:15 a.m. The Growth of Managed Care in the Private Sector
Michael Soper, CIGNA
David Ferriss (co-author), CIGNA
10:45 a.m. A Reaction- The Experience with HMOs
Edward Wagner, Group Health Cooperative of Puget Sound
11:00 a.m. Managing Care and Capacity in the Public Sector:
The United Kingdom
Alan Williams, York University, United Kingdom
11:30 a.m. The Meeting of the Twain: Managing Health Care
Capital, Capacity, and Costs in Canada
Morris Barer, University of British Columbia, Canada
Robert Evans (co-author), University of British Columbia,
Canada
12:00 a.m. A Reaction-Public-Sector Mechanisms in Medicaid:
Oregon's Priority List
Gilbert Welch, Dartmouth College
12:15 p.m. Discussion
1:15 p.m. Lunch
Session II: Changes in the Diffusion of New Technology:
The Provider's Perspective
Moderator: Jerome Grossman, New England Medical Center
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APPENDIX A
2:00 p.m.
2:30 p.m.
3:00 p.m.
3:15 p.m.
5:00 p.m.
April 19, 1991
The Hospital and Changes in the Adoption of
New Technology
Paul Griner, Strong Memorial Hospital
Physicians' Acquisition and Use of Technology
Bruce Hillman, University of Arizona
Break
Provider Panel Discussion:
Alan Nelson, Memorial Medical Center,
Salt Lake City, Utah
Paul Barrett, Kaiser Permanente, Denver, Colorado
Mary Mundinger, Columbia University
Arnold Aberman, University of Toronto
Discussion
Adjournment and Reception
8:00 a.m. Continental Breakfast
8:30 a.m. Opening by John Wennberg, Chair of Workshop III,
Dartmouth College
Session III: Changes in the Diffusion of Technology:
The Patient's Perspective
Moderator: John Wennberg, Dartmouth College
8:45 a.m. The Patient's Stake in the Changing Health Care
9:15 a.m.
9:45 a.m.
10:30 a.m.
259
Economy
Albert Mulley, Massachusetts General Hospital
What Is It Like to be a Patient in the 1990s?
Charles Silberman, New York City
Discussion
Break
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260
Session IV: Changes in the Development of New Medical
Technology
Moderator: Gerald Laubach, Chair, Committee on
Technological Innovation in Medicine
10:45 a.m. Industrial Strategies for Pharmaceutical
Research and Development
Frederick Telling, Pfizer Pharmaceuticals
Barry Bloom (co-author), Pfizer Pharmaceuticals
APPENDIX A
11:15 a.m. Industrial Strategies for Medical Device Development
Ben Holmes, Hewlett-Packard
11:45 a.m. Discussion
12:15 p.m. Lunch
1:00 p.m. Surgical Techniques Originating in Academic
Health Centers
Frank Moody, University of Texas Health Science Center,
Houston
1:30 p.m.
Discussion
2:30 p.m. Summing Up: Medical Technology and the Changing
Economics of Health Care
Harvey Fineberg, Harvard University
3:00 p.m. Adjournment
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B
Contributors
MORRIS L. BARER is director of the Centre for Health Services and
Policy Research and a professor in the Department of Health Care and
Epidemiology at the University of British Columbia. He is also an associ-
ate of the Centre for Health Economics and Policy Analysis at McMaster
University and an associate of the Canadian Institute for Advanced Re-
search, Program in Population Health. He presently serves as the senior
editor for health economics of Social Science and Medicine. Dr. Barer has
conducted research and published widely in the areas of physician resource
policy; trends in health care utilization, particularly among the elderly in
British Columbia; comparative health care system funding and organiza-
tion; and comparisons of health care costs and use in Canada and the United
States. Recent papers have appeared in The Milbank Quarterly, New En-
gland Journal of Medicine, Journal of Health Politics, Policy and Law,
International Journal of Health Services, Health Services Research, Inqui-
~y, and the Canadian Medical Association Journal. He is also a co-author
of two recent research monographs-The Growth in Use of Health Services,
1977/78 to 1985/86, published by Saskatchewan Health, and Australian Pri-
vate Medicare Care Costs and Use, 1976 and 1986, published by the Aus-
tralian Institute of Health-and a major policy report, Toward Integrated
Medical Resource Policies for Canada, published by the Canadian Confer-
ence of Deputy Ministers of Health.
261
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262
APPENDIX B
ROBERT G. EVANS is an internationally known expert on the eco-
nomics of health care, an active participant in developing policies for the
Canadian health care system, and a health care consultant in Europe, Asia,
and the United States. A graduate of the University of Toronto in political
economy, he earned a Ph.D. in economics from Harvard University in 1970;
he is currently professor of economics at the University of British Colum-
bia, Vancouver, where he has been a faculty member since 1969. He was a
member of the British Columbia Royal Commission on Health Care and
Cost, which has recently issued its final report, and is currently a member
of the main advisory committee for the National Health Research and De-
velopment Program. He is also a faculty member of the Centre for Health
Services and Policy Research at the University of British Columbia and an
associate member of the Centre for Health Economics and Policy Analysis
at McMaster University. He was president of the Canadian Health Econom-
ics Research Association from 1983 to 1986 and is a fellow of the Canadian
Institute for Advanced Research and director of the Institute's Program in
Population Health.
DAVID M. FERRISS, .IR. is associate national medical director for
the CIGNA Employee Benefits Division. Dr. Ferriss earned his M.D. from
Tulane Medical School in 1976 and his M.P.H. in health services from the
University of California, Los Angeles, in 1981. He is a diplomate of the
American Board of Family Practice and the American Board of Preventive
Medicine. Dr. Ferriss joined CIGNA in 1985 and served for three years as
the medical director of CIGNA Healthplan of Colorado. He assumed his
present position in CIGNA's National Medical Department in 1990, follow-
ing a two-year leave of absence during which he was a postdoctoral fellow
in health services research at the Johns Hopkins University School of Hy-
giene and Public Health.
HARVEY V. FINEBERG received his A.B. degree from Harvard Uni-
versity in 1967, his M.D. from Harvard Medical School in 1972, and his
Ph.D. from the John F. Kennedy School of Government in 1980. Dr. Fineberg
is dean of the Harvard School of Public Health; prior to his appointment to
that post in 1984, he was a professor in health policy and management at
the Harvard School of Public Health. Dean Fineberg has been a leading
figure in the health policy field. As a member of the Public Health Council
of Massachusetts from 1976 to 1979, he participated in decision making on
matters of hospital investment and health policy. From 1982 to 1985, he
served as chairman of the Health Care Technology Study Section of the
National Center for Health Services Research. Dean Fineberg's past re-
search has focused on several areas of health policy, including the process
of policy development and implementation, assessment of medical technol-
ogy, and dissemination of medical innovations. He helped found and has
served as president of the Society for Medical Decision Making.
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APPENDIX B
263
Dr. Fineberg is a co-author of two books: Clinical Decision Analysis
and an analysis of the controversial federal immunization program against
the swine flu in 1976, The Epidemic That Never Was. He is the author of
numerous journal articles, including the recent "Education to Prevent AIDS:
Prospects and Obstacles" in Science and "The Social Dimensions of AIDS"
in Scientific American. He is a member of the Institute of Medicine (IOM)
and served on the IOM committee that produced the report Confronting
AIDS in 1986. In 1988 he received the Joseph W. Mountin Prize from the
epidemiology section of the American Public Health Association. He is
also a member of the board of directors of the American Foundation for
AIDS Research and has served as a consultant to the World Health Organi-
zation.
ELLIOTT S. FISHER is an assistant professor in the Departments of
Medicine and of Community and Family Medicine at Dartmouth Medical
School and is part of the medical staff of the White River Junction Veterans
Administration (VA) Hospital. He is a graduate of Harvard College and the
Harvard Medical School. Dr. Fisher completed his residency training in
internal medicine at the University of Washington where he was also a
fellow in the Robert Wood Johnson Clinical Scholars Program. His princi-
ple research interests are in health policy and the use of large data bases for
research. His research includes comparisons of surgical outcomes in the
United States and Canada and comparisons of VA and private health care
system effectiveness.
ANNETINE C. GELIINS joined the Institute of Medicine (IOM) as an
international fellow and is now director of the Program on Technological
Innovation in Medicine. Before joining the IOM, she was senior researcher
for the Project on Future Health Care Technology, cosponsored by the Eu-
ropean office of the World Health Organization (WHO) and the Dutch gov-
ernment. From 1983 to 1985, Dr. Gelijns worked for the Steering Commit-
tee on Future Health Scenarios, where she helped develop models for long-term
health planning in the areas of cancer, cardiovascular disease, and aging;
she also had a joint appointment to the Staff Bureau for Health Policy
Development, Department of Health, the Netherlands. She has been a con-
sultant to various national and international organizations, including the
WHO and the Organization for Economic Cooperation and Development.
She is a member of the board of the International Society on Technology
Assessment in Health Care. Her research interests focus on medical inno-
vation, and she has authored a number of publications on the subject, in-
cluding a recent book on the dynamics of medical technology development.
She received the LL.M. degree from the University of Leyden and her Ph.D.
from the University of Amsterdam.
PAUL F. GAINER, who holds the academic title of Samuel E. Durand
Professor of Medicine at the University of Rochester School of Medicine,
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264
APPENDIX B
has been general director of Strong Memorial Hospital since March 1984.
A graduate of Harvard College, Dr. Griner received his M.D. degree, with
honors, from the University of Rochester School of Medicine and Dentistry.
He completed an internship and residency in medicine at the Massachusetts
General Hospital and served as medical chief resident at Strong Memorial
Hospital. In 1964, he was appointed instructor in medicine and a fellow in
hematology, and has been a member of the Rochester medical faculty since
that time. As the chief executive officer of Strong Memorial Hospital, Dr.
Griner is responsible for directing its activities and programs, including its
ambulatory services. He also directs the hospital's relationships with the
community and with local, state, and federal regulatory bodies. As a na-
tionally recognized authority on medical decision making and the delivery
of health care, Dr. Griner has published and lectured extensively on improv-
ing the efficiency and effectiveness of clinical practice, the relationship
between managerial and clinical decision making in the hospital, and future
directions in medicine. He is active in many professional organizations,
including the American College of Physicians, where he chairs the Board of
Regents. Dr. Griner is a member of the Institute of Medicine, the Associa-
tion of American Medical Colleges, and the Academic Medical Center Con-
sortium. He has also been appointed to the New York State Governor's
Health Care Advisory Board and chairs its Quality of Care and Regulatory
Review Committee.
BRUCE 'l. HILLMAN attended Princeton University, receiving a B.A.
degree in 1969, and the University of Rochester School of Medicine, from
which he received the M.D. degree in 1973. After finishing radiology
training in 1978, which included a one-year research fellowship at the Shields
Warren Research Laboratories of Harvard University and specialization in
genitourinary radiology, Dr. Hillman became assistant professor of radiolo-
gy at the University of Arizona; he was promoted to associate professor in
1981 and full professor in 1985, and served as vice chairman of the Depart-
ment of Radiology from 1986 to 1991. Since 1992, Dr. Hillman has been
professor and chairman of the Department of Radiology at the University of
Virginia School of Medicine and senior scholar at the University of Virgin-
ia Center for Health Policy Research.
During his early career in radiology, Dr. Hillman was awarded George
Marshall and John A. Hartford fellowships to pursue his research in renal
microcirculation, applications of new technology, and radiologic decision
making. In 1984-1985, he was appointed a Pew Foundation Health Policy
Career Development Fellow at the RAND/University of California, Los An-
geles, Center for Health Policy. Since that time, Dr. Hillman has pursued
research dealing with the assessment and diffusion of new imaging technol-
ogy, competition in medicine, the development of research careers, and new
methods for developing practice standards. He is a research consultant to
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APPENDIX B
265
the RAND Corporation, the United Mine Workers Health and Retirement
Funds, and the American College of Radiology. Dr. Hillman is editor-in-
chief of the journal Investigative Radiology.
BEN L. HOLMES is a vice president of Hewlett-Packard Company, a
position to which he was appointed in September 1985, and general manag-
er of Hewlett-Packard's Medical Product Group, a position he has held
since February 1983. He holds a B.S. degree in applied physics from the
University of California, Los Angeles (1959~; he received his M.B.A. in
marketing from the University of Southern California (1966~. A 30-year
Hewlett-Packard veteran, Mr. Holmes has held various management posi-
tions with the Medical, Computer Systems, and Instruments groups. Previ-
ously, he was general manager of Hewlett-Packard's Waltham Division.
Currently, he has management responsibility for the design, manufacturing,
and marketing of monitoring instrumentation and systems for adults and
neonates, diagnostic instrumentation and systems, ambulatory monitoring
systems, fetal monitors, ultrasound imaging equipment, health care infor-
mation systems, and supplies. Mr. Holmes is chairman of the Health Indus-
try Manufacturers Association (HIMA) and a member of the executive com-
mittee and board of directors of HIMA and the Massachusetts High Technology
Council. He currently serves on the Board of Visitors for Boston Universi-
ty Medical School and is on the IOM Committee on Technological Innova-
tion in Medicine and the Committee on Clinical Evaluation.
GERALD D. LAUBACH holds a B.A. from the University of Pennsyl-
vania and a Ph.D. in organic chemistry from the Massachusetts Institute of
Technology. He is formerly president of Pfizer, Inc., and chair of the IOM
Committee on Technological Innovation in Medicine. Dr. Laubach is a
research chemist by training and served as a laboratory scientist in his early
years at Pfizer. He is a member of the Institute of Medicine and the Nation-
al Academy of Engineering, and served on the now disbanded IOM Council
on Health Care Technology. His current activities also include membership
on the executive committee of the Council on Competitiveness (successor
group to the President's Commission on Industrial Competitiveness), the
board of the Food and Drug Law Institute, the Corporation of the Rock-
efeller University Council, the Carnegie Institution of Washington, the Na-
tional Committee for Quality Health Care, the Medical Center Advisory
Board, the New York Hospital-Cornell Medical Center, and the Corporation
Committee for Sponsored Research at the Massachusetts Institute of Tech-
nology; he is a director of CIGNA Corporation of Philadelphia and the
Millpore Corporation of Bedford, Massachusetts. Previously, Dr. Laubach
served as chair of the Pharmaceutical Manufacturers Association from 1977
to 1978 and as a board member until April 1989. He has received honorary
doctorates in humane letters from the City University of New York, in law
from Connecticut College, and in science from Hofstra University.
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266
APPENDIX B
FRANK G. MOODY received his M.D. degree in 1956 from Cornell
University Medical College. Following a residency in general surgery (1956-
1963) at Cornell's New York Hospital, he pursued a research fellowship in
gastrointestinal physiology at the University of California Medical Center's
Cardiovascular Research Institute in San Francisco. He began his academic
career at the University of California Medical Center, followed by appoint-
ment to the faculty at the University of Alabama, Birmingham. In 1971, he
assumed the chair of surgery at the University of Utah, and subsequently
attained his current position as chairman of the Department of Surgery at
the University of Texas Medical School at Houston in 1982. Dr. Moody
has undertaken more than two dozen visiting lectureships, has been on the
editorial board of numerous major journals, is an author of more than 100
peer-reviewed articles, has authored or co-authored 60 chapters in major
texts, and has been editor-in-chief or co-editor of 13 books. He has also
been president of the American Pancreatic Association, International Bil-
iary Association, Society for Surgery of the Alimentary Tract, and Society
of Surgical Chairmen; director of the American Board of Surgery; and chairman
of the Council of Academic Societies of the Association of American Med-
ical Colleges.
ALBERT G. MULLEY, JR., is a graduate of Dartmouth College. Af-
ter receiving degrees in medicine and public policy from Harvard, he com-
pleted his residency training in internal medicine at Massachusetts General
Hospital. He has remained at Harvard, where he is currently associate
professor of medicine and associate professor of health policy, and at Mas-
sachusetts General Hospital, where he is chief of the General Internal Med-
icine Unit. He is the author and editor of Primary Care Medicine and of
many articles in the medical and health services research literature. Dr.
Mulley's research has included the evaluation of intensive care and the
cost-effectiveness of prevention strategies and other common clinical prac-
tices. Recent work has focused on the use of decision analysis, outcomes
research, and preference assessment methods to distinguish between war-
ranted and unwarranted variations in clinical practices. He recently served
on the Institute of Medicine Medicare Quality Assurance Committee and is
a member of the Clinical Efficacy Subcommittee of the American College
of Physicians.
CHARLES E. SILBERMAN is the author of five influential books:
Crisis in Black and White (1964), The Myths of Automation (1966), Crisis
in the Classroom (1970), Criminal Violence, Criminal Justice (1978), and A
Certain People: American Jews and Their Lives Today (1985~. He is
currently at work on Crisis in American Medicine, to be published by Pan-
theon Books in 1992. Trained as an economist, Mr. Silberman was a mem-
ber of the Department of Economics of Columbia University from 1948 to
1953, an associate editor of Fortune Magazine from 1953 to 1961, and a
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APPENDIX B
267
member of Fortune's board of editors from 1961 to 1971; he has been a
free-lance writer since 1971. Mr. Silberman was awarded the honorary
degree Doctor of Human Letters by Kenyon College in May 1972.
MICHAEL R. SOPER is national medical director for CIGNA's Em-
ployee Benefits Division, which includes CIGNA Healthplans. He was
previously the chief operating officer of AV-MED Health Plan, an indepen-
dent practice association (IPA)-model health maintenance organization (HMO)
in Florida, and the medical director of Prime Health, a staff-model HMO in
Kansas City. Dr. Soper has been active with the Group Health Association
of America (GHAA) since 1975. He is a past chairman of the Medical
Directors' Division of GHAA. Dr. Soper received the M.D. degree, magna
cum laude, from Harvard Medical School. His clinical specialty is internal
medicine, and he is a fellow of the American College of Physicians.
FREDERICK W. TELLING is vice president, planning and policy,
for Pfizer Pharmaceuticals Group. He joined Pfizer in 1977 and held a
variety of positions with Pfizer's U.S. pharmaceutical group and its world-
wide diagnostic products group, prior to becoming the director of planning
for pharmaceuticals in 1981. In 1986, Dr. Telling's responsibilities were
expanded to include groupwide public policy issues and medical communi-
cations for pharmaceuticals. Dr. Telling graduated from Hamilton College
in 1972 with a B.A. in history and economics; he completed a master's
degree in industrial and labor relations in 1974 and a Ph.D. in economics
and public policy in 1976, both at Cornell University.
EDWARD H. WAGNER is a general internist/epidemiologist and di-
rector of the Center for Health Studies at Group Health Cooperative of
Puget Sound. He is also professor of health services at the University of
Washington School of Public Health and Community Medicine. Previous-
ly, he was professor of medicine and epidemiology and deputy director of
the Health Services Research Center at the University of North Carolina,
Chapel Hill. He is a former member and chairperson of the Health Services
Research Study Section of the former National Center for Health Services
Research. His current research interests include the evaluation of health
promotion/disease prevention interventions, disability prevention in older
adults, and the organization of primary care practice.
H. GILBERT WELCH is an assistant professor in the Departments of
Medicine and of Community and Family Medicine at Dartmouth Medical
School and is on the medical staff at the White River Junction Veterans
Administration Hospital. He is a graduate of Harvard College and the
University of Cincinnati Medical School. Dr. Welch completed his residen-
cy training in internal medicine at the University of Utah and was a fellow
in the Robert Wood Johnson Clinical Scholars Program at the University of
Washington. He has a strong interest in how resources are best allocated in
health care and has authored a number of publications in the area. In
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268
APPENDIX B
particular, he has closely followed the proposed Medicaid expansion in the
state of Oregon. Dr. Welch has recently been awarded a Veterans Adminis-
tration career development grant to study resource allocation methodolo-
g~es.
JOHN E. WENNBERG is a graduate of Stanford University in Cali-
fornia and McGill Medical School in Montreal. He is director of the Center
for the Evaluative Clinical Sciences and professor of epidemiology at the
Dartmouth Medical School. Dr. Wennberg is a member of the Institute of
Medicine (IOM) and serves on a number of national committees including
the Health Sciences Policy Board of the IOM and the IOM Committee on
Technological Innovation in Medicine. He is the author of numerous publi-
cations and is particularly well known for his leading research in small-area
variations in health care. He is currently principal investigator for the
patient outcomes assessment team (PORT) on prostate disease established
under the new federal Agency for Health Care Policy and Research.
ALAN WILLIAMS is professor of economics at the University of
York in the United Kingdom. Although for most of his working life he has
been an academic economist interested in the appraisal of public expendi-
tures, he also spent two years working inside the Treasury on these same
problems, and was a member of the Royal Commission on the National
Health Service. He is also a former member of the Department of Health
and Social Services Chief Scientist's Research Committee, and the SSRC
Health and Health Services Panel. Dr. Williams is a founding member of
the United Kingdom Health Economists' Study Group and is director of
research projects concerning economic aspects of the care of the elderly,
orthopedics, computed tomography scanning, and magnetic resonance im-
aging. Dr. Williams just completed work on a book with European inten-
sivists that sets out guidelines for the improvement of intensive care in
Europe. His current interests are in the measurement of and valuation of
health and the economic appraisal of medical technologies; priority setting
in the National Health Service, especially the use of cost-benefit criteria;
lay concepts of health; the economics of intensive care medicine; the man-
agement of waiting lists; technology assessment in health with particular
attention to cardiology and radiology; the measurement of patients' quality
of life, particularly for patients with epilepsy or multiple sclerosis; the eco-
nomics of an aging population; and issues of ethical, economic, or clinical
freedom.
Representative terms from entire chapter:
british columbia
