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| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
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OCR for page 269
Index
Access to care, 9, 26, 79
determinants of, 87
egalitarian and libertarian views, 87-91
financial barriers,237
women's, 171
Adelstein, S. James, 226
Adrenal transplants, 129
Agency for Health Care Policy and
Research, 29, 31, 59, 145, 156, 213
Agranulocytosis, 70
AIDS, 116 n.l4, 171, 172, 173, 174
Airway/esophageal obstruction by foreign
object, 69
Alcoholic liver disease, 70, 236
Aldose reductase inhibitors, 209, 214-215
All-payer model, 30, 128-129
Alpha 1-antitrypsin deficiency, 70
Alzheimer's disease, 112, 171, 173, 174, 209
Alzheimer's Disease and Related Disorders
Association, 171
Ambulatory dialysis, 143
American Cancer Society, 55
American Hospital Association, 176
American Medical Association, 101 n.4
Anemia, 205
Anencephaly, 69, 71
Anesthesiology, gas monitoring technology,
224, 227
Angina pectoris, 5, 18, 21, 69, 181, 190
269
Angioplasty, 224
Angiotensin-converting enzyme inhibitors,
209
Ankylosing spondylitis, 173
Antibiotic therapy, 70, 187
Antisecretory agents, 235
Aplastic anemia, 69, 70
Appendectomy, 66, 69
Arizona, regulation of new technology, 137
Arteriography, 143
Arthritis of hip and knee, 18, 21
Arthroplasty, 69, 71, 72
Atherosclerosis, 18
Automatic blood pressure cuffs, 225
Automatic infusion pumps, 131
Baby boom generation, 170
Back operations, 25
Back pain, 18, 21, 24, 27; see also Low back
pain, 22
Barnett, Lauren, 176
Barry, Michael, 59
Bay State Health Care, 192
Benefit coverage
universal, 98, 251
variation in, 202
Benefit-utilization curve
alternative interpretations of, 11
OCR for page 270
270
benign prostatic hyperplasia treatment,
14-17
common conditions for which shape is
unknown, 18-19
diminishing marginal returns and, 12-13
under micromanaged care, 21, 47
outcomes and preference research and, 14
patient preferences and, 16-18
physician as decision maker and, 10, 12
13
under preventive theory of surgery, 14-15
under quality of life theory of surgery, 14,
15, 16
and rationing of care, 9-10
resource supplies and, 27, 47
shape of, 12-17
Benefits of treatment, measurement of, 83
Benign prostatic hyperplasia (BPH)
benefit-utilization curve, 14-17, 18
interactive computer videodisc on, 59
patient preferences for treatment, 16-18,
180
percent of men having a prostatectomy, 16
ranking in Oregon priority list, 69
shared decision making on, 21, 31, 46, 59
surgery rates, 18, 59, 235
Bergner, Marilyn, 183
Beta-blockers, 5
Beth Israel Hospital, 181
Bile duct anomalies, 71
Biliary atresia, 70
Blendon, Robert, 192
Blue Cross/Blue Shield Association, 49, 128,
139, 215, 222
Bone marrow transplants, 27, 47, 64, 70, 71,
129
Boston, Massachusetts, hospital beds, 21, 23,
24, 26-27
Brain hemorrhage, 168
Brain stem infarct, 165
Breast cancer
adjuvant chemotherapy, 158-159
assessment of treatments, 235
autologous bone marrow transplantation,
49
clinical advisory, 158
costs of care, 55
incidence, 55, 57
patients' predicaments, 154-157, 160
risk factors, 56
screening, 54-58, 157-158
treatment choices, 158, 235
INDEX
British National Health Service, 4
access to care, 79
advantages over U.S. system, 29
American views of, 91
budget, 79-80
competition in, 84
cost containment, 80, 102-103
diffusion of technology in, 86-87, 251
exemptions from restrictions, 84
gatekeepers, 80, 82
hospital service expenditures, 80
ideology, 79
incentives for innovation, 7
micromanagement of clinicians, 94
physicians, 80, 81-82
political support for, 80
priority setting in, 74, 81, 84-85, 94
private treatment, 79
problems of, 80-83
reallocation of resources, 31, 80-81
reforms, 7, 83-85, 94
reimbursement of providers, 80
waiting lists, 83
Bundled care, 144-145, 146
Bunker, John P., 181
Calcium channel blockers, 209
California, regulation of new technology,
137
Canadian health care system, 4
benefit coverage, 103-104
distinctions from U.S. system, 29, 97
capital management, 98, 106-110, 113
114
cost-control succes s, 102- 103, 115
differences from U.S. health care systems,
97, 98-103
environmental context of operation, 101
102
funding of, 98, 104, 105, 114-115, 243
future of, 115-117
hospital funding and bed supply, 105-106,
109-110, 113
macromanagement of care in, 100, 105,
108, 112-113, 115
micromanagement in, 101, 111-112, 115,
116
operations management, 100, 103-106
out-of-pocket costs to patients, 104
physician peer assessment programs, 101
physician reimbursement rates, 30, 104
105
OCR for page 271
INDEX
plan management responsibility, 100
pricing of services, 104
private employer-based insurance, 97, 104
quality assurance programs, 101
reallocation of excess capacity to
research, 30, 115, 116
reimbursement policies, 104-105, 113
supply of physicians, 105, 107, 108, 113
and taxation rates, 104
technological innovation and diffusion in,
102, 110, 111-113
transition from macro- to
micromanagement, 111-115
user charges, 104, 114
utilization rates, 105
Cancer, 22, 173, 174, 231
Cancer Surveillance System, 57
Capital, see Health care resources
Capital markets, and health care costs, 11
Capitation, 73, 128
Cardiac arrhythmias, 5, 69, 181
Cardiac surgeons, 106
Carotid artery surgery, 25, 74, 235
Case Western Reserve Medical School, 189
Cataracts, 18, 21, 69, 72, 233
Cerebral ischemia, 69, 71
Cerebral palsy, 71
Certificate of need
and adoption of new technology, 125,
127, 221
defined, 136 n.1
and MRI diffusion, 136-138
for outpatient facilities, 127
and resource supply, 46
Charity care, 126, 140
Chart review, 100
Cholecystectomy, 69, 73, 239
Chronic bronchitis, 22, 27
Chronic obstructive pulmonary disease, 69
Chymopapain, 156, 185
Cineangiography, 223
Cirrhosis of the liver, 70
Clinical competence assurance activities, 116
Clinical information systems, 224
Clinical practice
biopsychosocial model, 183-184
guidelines, 52, 100, 116
and innovation, 5
MRI diffusion into, 134-142
technology acquisition in, 5, 133-148,
191
271
see also Doctor-patient relationship;
Physicians
Clinical reminders, 52
Cochlear implants, 129
Coinsurance, 40, 44
Common cold, 72
Competition/competitivene s s
among providers, 84, 127-130
and information availability to patients,
161
in pharmaceutical industry, 210, 213-215
and technology adoption, 127-130, 140-
141, 146-147
Computed tomography, 110, 138, 139, 140,
156, 166, 220, 223, 224, 226, 240
Computerized catheterization laboratories,
220, 224
Congestive heart failure, 173
Connecticut
adoption of new technology in, 129
teaching hospitals, 126
Consumerism, and technological change,
169-174
Continuous quality improvement, 6-7, 178
Cooley, Denton, 103
Copayments, 43, 44
Coronary bypass procedure, 5, 106, 171,
231, 238
Corticosteroids, 186
Cost-benefit analyses, 67-68, 236-237, 239
Cost containment
and access to care, 40
capacity limits and, 12
"cafeteria" plans, 39
coinsurance, 41
deductibles, 40
dependent coverage, 39
eligibility restrictions, 64
employee cost sharing, 39-40
by employers, 39~0
and growth of managed care, 39
by HMOs, 51, 203
incentives for, 40
innovation and, 4, 102, 216, 227
limitations on optional services, 64
macromanagement of care and, 19, 21
Medicaid strategies, 63-64
micromanagement of care and, 12, 21, 31,
45, 64
public-sector efforts, see Oregon cost-
containment strategy
OCR for page 272
272
reduced fees to providers, 64
and shared decision making, 7, 21, 45
status of, 25
universal coverage and, 98-100
Cost-effectiveness
analyses, 4, 66, 72, 86, 175, 243
cutoff ratios, 85-86
rationing of care based on, 10
of surgical innovation, 238-239
Cost shifting
and managed care, 41-42, 44-45
Medicare reimbursement, 38, 222
and technology adoption, 137, 140, 143
Costs of health care
for breast cancer screening, 55-56
factors contributing to growth of, 11
growth of, 38
measurement of, 74
Current Procedural Terminology codes, 69,
236
Dartmouth Coop Charts, 183
Davies, Allyson Ross, 178
Deductibles, 40, 43
Defibrillators, 131
Delegated decision model
awe of physician and, 188-189
benefit-utilization curve, 45
biomedical approach in, 185-186
and cost containment, 45
and doctor-patient relationship, 11-13,
15-17, 22, 180
flaws in, 180, 185-186
and hospitalization thresholds, 22-23
and micromanagement of health care, 11-
13, 15-17, 18, 21
and patient preferences, 25, 45
physician knowledge base and, 169-170
reform of, 45, 170
reinforcing assumptions, 169-170
Demand, supplier-induced, 10-11, 25
Dental care, 65, 66
Depression, 181, 209
Development, see Research and
development; Technology development
Deyo, Richard A., 183
Diabetes, 69, 181, 186
Diagnostic tests, substitution for information
from patient, 190-191
Dialysis, 69, 171, 205
Digital subtraction angiography, 143
Discography, 156
INDEX
Doctor-patient relationship
awe of physician and, 188-189
collaboration in, 187-188, 191-192
and costs of care, 238-239
delegateddecisionmodel,ll-13, 15-17,
22, 180, 189-190
ethical status of, 12
informed consent and, 179
knowledge base and, 153-154
managed care and, 46, 100, 203
micromanagement of, 11, 19-20, 21, 27-
28, 161-162
and patient compliance with treatment
regimen, 186
and placebo effect, 186-187
reform of, 7, 11-12, 19-21, 179-187
shared decision making, 7, 12, 20-21, 28,
31, 183
see also Physicians
Doll, Anne, 176
Drug Price Competition and Patent Term
Restoration Act, 203
Drugs
cost-containment strategies, 206
costs, pressures on, 203-204
enhanced delivery systems, 212
exclusion of nonapproved uses, 204
"fast follower," 211
generic copies, 203-204, 210
imitative, 211-212
well-differentiated, value-added, 211, 212
see also Pharmaceutical innovations
Duke Health Profile, 183
Ear oximeter, 226-227
Economics of health care
bureaucratic model, 154, 157, 161; see
also Micromanagement of health care
and innovation, 153
market model, 154, 161
optimization subject to constraints, 80-81
patient's stake in, 153-162
and surgical techniques, 231-244
see also Cost containment; Cost shifting
Eddy, David M., 169, 170, 180
Edgar, Harold, 173
Education, see Medical education
Electrocardiogram management systems, 220
Ellwood, Paul, 43, 169
Employer-provided health care benefits
"cafeteria" plans, 39
coinsurance, 40
OCR for page 273
INDEX
cost-containment strategies, 39-41, 71
costs of providing, 38
deductibles, 40
dependent coverage, 39
employee cost sharing, 39-40
from HMOs, 43, 44
individuals without, 26
mandatory, 39, 63
point-of-service products, 44
in United States, 37-41
Endarterectomy, 69, 71, 74, 235
Endoscopic retrograde cholangiography, 240
End-stage renal disease, 69, 70, 72, 238
Engel, George L., 180, 183, 184
Enteritis, regional, 71
Entitlement services, financing of, 11
Esophageal hemorrhage, 236
Ethical issues
in micromanagement of care, 20
physicians as gatekeepers, 82
in randomized clinical trials, 174
in rationing of health care, 87-95
shared decision making by patient and
physician, 7, 12, 184
Evaluative research, see Outcomes research;
Preference research; Technology
assessment
Extremely low birthweight, 69, 73
Family practitioners, 23
Fauci, Anthony S., 174
Feinstein, Alvan R., 180, 182
Fetal monitors, 220, 224
Fishman, Steve, 168
Food and Drug Administration
drug approval, 156, 171 - 173, 187, 225-
226
medical device approval, 220, 223, 228
MRI approval, 134, 135-136, 228
patient/caregiver input to, 215
reforms, 253
treatment IND, 173
Food, Drug, and Cosmetic Act, 135, 172, 220
Foraminotomy, 156
Foucault, Michael, 182
France, 7
Frank, Arthur, 167
Freud, Anna, 189
Freud, Sigmund, 168
Functional impairments, weighting of, 66
Gallbladder anomalies, 71
273
Gallstones, 18, 21, 69, 73
treatment innovations, 232, 239-241, 242
Gamma globulin, 124, 131
Ganglion of tendon or joint, 71
Gastric freezing, 190
Gastric restrictive procedure, 237
Gastroenteritis, 22, 24, 27
Gastroplasty, 237
Gatekeeper/gatekeeping
and health outcomes, 204-205
and innovation, 204
physicians, 80, 82, 176
and quality of care, 204-205
third-party payers, 203
General practitioners
British, 31, 80, 82, 83
Canadian, 104 n.7, 105
Germany, innovation and cost containment
in, 103
Goldwyn, Samuel, 192
Greenfield, Sheldon, 178, 190
Grossman, Jerome, 178
Group Health Cooperative of Puget Sound,
29
breast cancer screening, 54-58
Committee of Practice Efficacy, 59
Committee on Prevention, 55, 58
Consumer Board of Trustees, 57
cost-containment success, 51
innovation management, 53, 54
managing care at, 53-54
shared decision-making initiative, 46
Halsted, William Stuart, 158
Harvard Community Health Plan, 192
Health care
expenditures on, 9, 202, 238
two-tiered system, 10
see also Costs of health care; Economics
of health care; Rationing of care
Health Care Financing Administration, 59,
126, 139, 144, 175, 178, 187, 215
Health care reforms
and access to care, 9
challenges in, 32, 91
critical elements, 249
demand side separation from supply side,
83-84
innovation and, 4, 27-32, 249-253
principles and guidelines, 26-27, 32
in United States, 26, 250-251
OCR for page 274
274
see also Macromanagement of health care;
Micromanagement of health care
Health care resources
bureaucratic model of allocation, 154, 157
global limits on, 45, 52, 64, 73
human, 106, 107
intangible, 106, 107
management of, 106-110
physical, 106, 107
reallocation of excess capacity, 27, 28, 29,
80-81, 116
reserves, 27
see also Hospital beds; Medical
manpower; Supply of resources
Health care system
adjustment mechanisms, 90-91, 93
capacity determinants, 24
demand element, 90, 92
growth of, 21, 26
idealized libertarian vs. egalitarian, 90-91
limits on, 26
success criteria, 91, 93-94
supply element, 90, 92-93
Health insurance
universal coverage, 72, 73-74, 98-100
see also Employer-provided health care
benefits; Insurance companies; Third-
party payers
Health Insurance Association of America, 99
n.2, 215
Health Insurance Plan, breast cancer
screening trial, 56
Health Maintenance Organization Act of
1973, 42-43
Health maintenance organizations, 97, 125,
139
advantages of, 51
breast cancer screening, 54-58
characteristics, 51-52, 60
cost containment, 19, 51, 52, 203
defined, 42 n.5
as effectiveness laboratories, 58-59
elements important for managed care, 60
employee health care through, 43
enrollments, 43
group-model, 42 n.5, 43, 51, 53, 60
growth of, 43
independent-practice-association model,
42 n.5, 43
innovation management, 53-54
macromanagement of health care by, 4, 52
INDEX
managing care at GHC, 53-54
micromanagement of care by, 52
network model, 42 n.5
outcomes of care, 52
physician participation in, 144
point-of-service plan, 43-44
prescription drug use by enrollees, 205
reimbursement arrangements, 51-52
staff-model, 19, 29, 42 n.5, 43, 46, 51, 53,
60, 145-146
technology adoption by, 136
technology assessment, 53-54
Health Planning and Resources Development
Act of 1974, 136
Health Professionals Follow-up Study, 171
Health service categories, ranking of
condition-treatment pairs, 68-70
Health status
assessment, 183, 187
life extension and, 112 n.l2
Healy, Bernadine, 171
Heart attacks, 22, 167
Heart transplants, 64, 70, 72, 129
Hepatic cancer, 70
Hepatic necrosis, 70, 72
Herniated disc, 18, 21, 69, 156, 181
Hewlett-Packard telemetry, 224-225
Hip fracture, 22
Hip replacement, 71, 231, 233
Histamine H-2 receptor antagonists, 209,
235
Histiocytosis, 71
Hodgkin's disease, 66, 70
Holter monitors, 224
Hospital beds, 131
case studies of planning and construction,
24-25
and clinical thresholds for admission of
patients, 22-23
geographic variation in utilization, 21, 45
determinants of supply, 24-25, 46, 107
readmissions, 24
reallocation of excess capacity, 27, 98-99
supply of, 11, 21, 26-27
utilization, 109-100
Hospital Corporation of America, 178
Hospitals
accountability demands of payers, 175
adoption of new technology, 123-132,
137, 143, 188, 222
amenities, 176
OCR for page 275
INDEX
architecture and design changes, 176
assessment of technology, 130
all-payer DRG system, 128-129
borrowing capacity, 125
capital reserves, 126
charity care, 126
competitiveness, 127-130, 137, 222, 251-
252
cost containment by, 128, 222
experimental payment systems, 127-128
funding in Canada, 105-106
global budget system, 127-128
length-of-stay reductions, 224, 235, 241
marketing of, 176
medical staff relationships, 130
operating margins, 126
operating surpluses, 125, 126
patient pressures on, 175-176, 187
pharmacy budgets, 131
physician joint ventures with, 141
physicians vs. patients as customers, 170,
176
readmissions, 24
regulation of, 125 n.l, 126, 143
teaching, 125, 126, 129, 180
Hutt, Peter, 214
Hypertension, 186, 210, 236
Hyperthyroidism, 235
Hypoxia, 227
Ibuprofen, 72
Illinois, regulation of new technology, 137
Imaging and laser technologies, 101, 106,
223; see also specific technologies
Immune stimulators, 209
Information technologies, 224
Informed consent, 179
Innovation
accountability demands of payers and,
175-179
and clinical practice, 5, 133-148
components of, 123-124
continuation of, following diffusion, 226-
227
and cost containment, 102-103
dynamics of, 242-243
economics of, 4, 31-32, 53-54
and health care reform, 249-253
incentives for, 7
introduction of, 85
and micromanagement, 27-32
and patient preferences, 187-192, 225
275
"perks" associated with, 86
and physician demand, 106
rational, 28, 31
regulation and, 7, 172
reimbursement constraints on, 7, 31-32
synergisms of, 241-242
see also Medical devices; Medical
technology; Pharmaceutical
innovations; Surgical innovation
Insomnia, 183
.
Insurance companies
cost shift to, 38
micromanaged care programs, 19-20, 38
Intellectual property, 203
Intensive care units, 5, 224
Interactive computer videodisc technology,
46, 59, 188, 189
International Summit on Health Care and the
Economy, 103
Internists, 23
Interstudy, 43
Intraocular lens implants, 224
Japan, 7
Kaiser Permanente Plan, 29, 207
Kaplan, Sherrie, 178
Katz, Jay, 179
Kessler, David A., 172
Kidney cyst, 71
Kidney transplant, 70
Kitzhaber, John, 64
Laetrile, 173
Laminectomy, 69, 156, 165
Laparoscopic cholecystectomy, 4, 187-188,
241, 242, 243
Laryngitis, 71
Lasagna, Louis, 172
Lasker, Mary, 171
Leukemia, 70
Liability, and medical device development,
224
Life expectancy
BPH treatment and, 14, 15
extension of, 112 n.l2, 243
Lithotomy, 239
Lithotripsy, 4, 239-241, 242
Liver anomalies, 71
Liver transplants, 64, 70, 72, 129, 236
Loss of consciousness, 65
Louis Harris & Associates, 177
OCR for page 276
276
Low back pain
hospitalization for, 22
information base, 155-157
patients' predicaments, 154-157
treatment choices, 155, 185-186
utilization management for, 47
Lucile Salter Packard Children's Hospital,
224-225
Lung cancer, 171
Lung transplant, 70
Lumbar disc disease, 156
Lupus, 168
Lutheran Hospital (La Cross, Wisconsin),
225
3M Corporation, 225
Macromanagement of health care, 3-4
and cost containment, 21
by HMOs, 4
national health system, see British
National Health Service
social insurance-based system, see
Canadian health care system
Magnetic resonance imaging
assessment of, 145
benefits of, 134, 143, 223
certificate-of-need regulations, 136-138
charges to patients, 135
competition over, 140-141
costs, 124, 220
diffusion into clinical practice, 134-142
FDA regulation of, 134, 135-136, 228
financing of acquisitions, 137- 138
marketing of, 135-136, 140
new applications, 131, 156
patient comfort, 224
and physician's views of illness, 166
RAND study of, 134, 137-141
referrals by physicians, 140-141
reimbursement for, 134, 138-140
Mahoney, Florence, 171
Maine, hospital beds, 24-25
Malpractice
and medical device development, 224, 227
priority lists and, 73
surgical innovation and, 233
Mammography units, costs of, 55
Managed care
advantages of, 41, 250
changes in, 42
collaborative process, 52
consumer involvement in, 52
INDEX
and cost containment, 45, 192, 203
cost shifting and, 41~2, 44-45
defined, 37 n.1
and doctor-patient relationship, 46, 203
functions of organizations, 41
growth in private sector, 41-45, 222, 243
objectives of, 203
and outcomes research, 45-46, 49
and pharmaceutical innovation, 201-216
physician practice patterns under, 205
point-of-service products and, 43
and quality management, 45
reimbursement arrangements, 41
and technology development and
dissemination, 45~9, 145-146
utilization management, 46-47
see also Health maintenance
organizations; Macromanagement of
health care; Micromanagement of
health care
Massachusetts
adoption of new technology in, 129
MRI adoption in, 137, 138, 140
teaching hospitals, 126
Massachusetts General Hospital, 59, 156
Matschulat, Natel K., 176
McWhinney, Ian R., 183
Medicaid
certificates of need, 125
cost-containment strategies, 63-64, 71
organ transplant coverage, 64
Medical Device Amendments, 135, 219, 220
Medical devices
1965-1976 policy trends, 219-220
1976-1983 policy trends, 220-221
1983-present policy trends, 221-227
adoption by hospitals, 123-132
Cartesian graph of costs and outcomes,
227, 228
classification of, 123-124
companies registered with FDA, 225
determinants of demand, 107, 219
diffusion of, 220
FDA regulation of, 220, 223, 228
investments in R&D, 227
market for, 222
outcomes studies, 225
in outpatient settings, 222
premarketing approval and notifications,
223, 225-226
profitability, 229
public policy trends, 219-227
OCR for page 277
INDEX
R&D implications of public policy trends,
221, 223-227
regulatory "screens," 225
reimbursement policies, 220
turf battles over, 140-141
user fees, 104, 223, 225-226
utilization, 227
see also Innovations; Medical technology
Medical education
and authoritarianism/paternalism in
physicians, 189-190
Canadian enrollments, 108-109
and health care economy, 115
and physician supply, 108-109
reforms, 16, 253
salaried sabbaticals, 30-31
Medical manpower
and costs of care, 11
growth of, 11
see also Physicians
Medical Outcomes Study, 181-182
Medical technology
defined, 5
"halfway," 6, 103
and health care sector growth, 101
"hidden," 47-48, 124, 131
investments in, 29-30, 251-252
marketing of, 86, 103, 170
Medicare expenditures on utilization,
220-221
micromanagement of care and, 31, 111-
112
minimally invasive procedures, 6
net social benefit of, 6
pricing of, 86
reimbursement for, 187
"supportive," 124
universal policies for, 7
see also Innovation; Medical devices;
Technology assessment
Medicare reimbursement
and adoption of new technology, 125,
126, 175
and cost shifting, 38, 222
diagnosis-related group rates, 38, 125,
126, 140, 223, 234-235
and medical device technology, 219
Prospective Payment System, 38, 138,
139, 191, 219, 221, 234-235, 237
and quality of care, 205
savings on renal transplants, 238-239
277
Memory loss, 209
Merigan, Thomas C., 174
Miami Valley Hospital (Ohio), 176
Micromanagement of health care, 3
and cost containment, 12, 21, 31
criticisms of, 20
delegated decision model, 11-13, 15-17,
18, 21
and depersonalization of care, 162
and doctor-patient relationship, 11, 19-20,
21, 27-28, 161-162
ethical weaknesses of, 20
goals of, 145-146
innovation and, 27-32
and global limits, 73, 145
market share, 145, 146
at patient level, 52
and patient preferences, 20, 28
problems in, 72
rules of practice, 19-20
and utilization, 12, 146
Microsurgery, 156
Monitors, 131, 220, 224
Mount Sinai Medical Center, 176
Mosbacher, Robert, 103
Muller, Ralph, 177, 178
Multiple Risk Intervention Trial, 171
Multiple sclerosis, 166-167, 173
Myelograms, 156
Myocardial infarction, 69, 238
Myocarditis, 70, 72
National Cancer Institute, 158
National Institute of Allergy and Infectious
Diseases, 174
National Institutes of Health
consensus conference on gastric restrictive
procedures, 237
Office of Research on Women's Health,
171
outcomes research role, 214
Nelson, Alan, 101 n.4
Net benefit of treatment, calculation, 67, 69
Neurologists, 141
Neurosurgeons, 25, 141
New England Medical Center, 178-179
New Haven, Connecticut, hospital beds, 21,
23, 24, 27
New Jersey
adoption of new technology in, 129
teaching hospitals, 126
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New York
adoption of new technology in, 125, 129
hospital marketing, 176
regulation of new technology, 137
teaching hospitals, 126
Non-Hodgkin's lymphoma, 70
Nursing, innovations in, 225
Obesity, 190, 237
O'Connor, Flannery, 168
Opportunistic infections in
immunocompromised hosts, 71, 116
n.l4
Organ transplants, 5, 64, 67, 233, 244
cost factors, 231, 234
ranking of indications for, 70
regulation and, 129
women's access to, 171
Oregon Health Decisions, 65
Oregon Health Services Commission, 65, 68,
71, 72
Oregon priority list, 10 n.1
alternatives to, 27
benefit package, 71
and capitation, 73
cost-effectiveness analysis, 72
discussion, 71-74
effect on Medicare population, 251
funding levels, 71
"gaming" by physicians, 73
and malpractice, 73
patient preferences in, 72
problems with, 72, 250
ranking methodology, 65-68, 74
ranking of condition-treatment pairs, 68-
71
rationale and background, 20, 63-65
results, 68-71
Orthopedists, 141
Orthotics, 101
Osteoarthritis, 69, 71, 72
Osteoporosis, 209
Outcomes
management, 100
patient involvement in care and, 160-161
physician focus, 182
Outcomes research, 83
and benefit-utilization curve, 14, 15, 19
on BPH, 15
collaborative studies, 212-214
communication of results, 215-216
deficiencies in, 10
INDEX
economic component of, 206
government role in data collection, 214-215
knowledge base, 12-13, 180
managed care and, 45-46, 49, 59
medical device development and, 225
pharmaceutical innovation and, 212-214
physician reallocation to, 29, 30, 115-116
practice guidelines and, 31
and shared decision making, 20-21, 45
on surgical innovations, 235, 236, 244
and technology assessment, 29
and utilization management, 47
see also Randomized controlled trials
Outpatient facilities
growth of, 222
physician ownership interests in, 143, 147
regulation of, 143, 146
surgical innovations in, 231-232, 235
technology adoption in, 126-127, 128,
129, 137, 143, 222
Pacemakers, 69
Pain control, 177, 188
Pancreas transplants, 64, 70
Patents, 102 n.6, 204
Patients
activism, 170-174, 187, 189 n.2
compliance with treatment regimen, 186,
212
decision-making role, 153, 154-159
discretionary disfunctioning, 186
effects of changing health care economy
on, 153-162
as information source, 187, 190-191
involvement in managed care, 52
out-of-pocket expenditures for care, 202
physician detection of disability in, 181
182
satisfaction, 11, 45, 161, 177
self-assessments as clinical measures, 178
shared decision making with physician, 7,
12, 20-21
surveys, 177-178
views of illness and successful treatment,
166-169, 181
see also Doctor-patient relationship
Patient-administered analgesic units, 177,
188
Patient Outcome Research Teams, 213
Patient preferences
and accountability demands of payers,
175-179, 192
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INDEX
benefit-utilization curve and, 16-18
BPH treatment, 16-18
macromanagement of health care and, 28
micromanagement of health care and, 20
pharmaceutical innovations and, 212
and physician as decision maker, 11, 25,
180-181
and prioritization of health services, 72
shared decision making and, 12, 187
and surgery, 25
and technology development and
acquisition, 147, 169-174, 224
and utilization of services, 17-18
see also Preference research
Percutaneous removal of disc material, 156
Percutaneous transhepatic cholangiography,
240, 242-243
Percutaneous transluminal coronary
angioplasty, 4, 238
Perfusionists, 106
Perineal cystotomy, 232
Peripheral vascular disease, 18
Peritonitis, 69
Pernicious anemia, 71
Pharmaceutical industry
British, 102-103
economic structure of market, 203
Pharmaceutical innovations
adoption by hospitals, 125
alternatives to surgery, 211
beta-blockers, 5
cost-effectiveness analysis, 86, 175, 206-
207
cost vs. patient benefit in adoption of, 202
costs of R&D, 201-202, 215
defined, 124
diffusion of information on, 207
drug delivery technology, 188, 209, 212
economic risk for, 207-208
FDA approval process, 7, 171-173, 205
gatekeeping and, 201, 202-208
and health care sector growth, 101
information transfer, 215-216
investments in, 29-30, 210
managed care and, 201-216
marketing of, 207
micromanagement and, 31
marketing of, 170, 208
new disease targets, 210-211
and outcomes research, 212-214
patent protection, 102 n.6
279
prazosin, 29-30
and pricing formulas, 7
quality-of-life measurement, 86, 175
reimbursement policies and, 125, 206
research strategies, 201, 208-213
resources for R&D, 205-206
technology base for R&D, 208-210
third-party intervention in health care
decisions and, 202
trends in, 209
U.S. competitiveness, 207-208, 213-215
see also Drugs; and specific compounds
Pharyngitis, 71, 72
Physician's Health Study, 171
Physicians
accountability demands of payers, 175
authoritarianism/paternalism in, 189-190
biomedical model, 182-183
capacity of work force, 25, 26, 46, 105,
107, 113
cognitive role of, 31
communication with patients, 184-186
conflicts of interest, 82
as decision makers, 10, 12-13, 160-161,
169, 180-181
demand determinants, 106, 107
detection of disability in patients, 181
182
gatekeeper role, 80, 82, 176
incomes, 113, 144
joint ventures with hospitals, 141
measures of successful treatment, 181
ownership interests in outpatient facilities,
143
participation in managed care, 144
as patients, 166, 168-169
peer assessment programs, 101
perceptions of role, 24
practice style, 23, 184
preferences and biases of, 180, 183
priority ordering by, 81
problems faced by, 12-13
rate of production of, 116
reallocation to research and quality
management, 29, 31-32
referral of patients, 31, 140-141, 146, 170
reimbursement policies, 30, 104, 105,
143, 191, 192, 222
resource utilization by, 23-24, 144
third-party micromanagement of, 101
utilization of, 9
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views of illness, 166-167, 181
workload, 23
see also Clinical practice; Specialists/
specialties
Picker/Commonwealth Patient-Centered Care
Program, 177, 178
Placebo effect, 186-187
Pneumonia, 22, 24, 69, 70
Poliomyelitis vaccine, 5
Portasystemic shunting, 236
Power, J. D., 192
Practice guidelines, 31
Prazosin, 29-30
Precertification review, 52, 144, 146
Preference research
and benefit-utilization curve, 14, 19
BPH treatment, 16, 17-18
and shared decision making, 20-21
and utilization rates, 17-18
Preferred provider organizations, 144, 222
Prescription medication, patient preferences
in, 65
Preston, Thomas A., 188
Prioritization of medical services
condition-treatment pairs, 74
ethical issues, 82
methodology, 65-68, 74
in a needs-based system, 82-83; see also
British National Health Service
problems in, 72, 89
see also Oregon priority list
Private health care systems
access to care under, 87
in Canada, 104
characteristics of, 92-94
see also Employer-provided health care
benefits
Prolapsed urethral mucosa, 69
Prostate cancer, 165
Prostatectomy, for BPH, 14-16
Prostheses, 101, 225
Public health care systems
access to care under, 87
characteristics of, 92-94
Pulmonary hypertension, 70
Pulse oximeters, 131, 225, 227
Pyle, Thomas O., 192
Quality-adjusted life year, 83, 94
Quality assurance programs, Canadian, 101
Quality management
physician reallocation to, 29
INDEX
technology assessment and, 29, 30
Quality of care
pharmaceutical cost containment and,
204-205
status of, 25
Quality of life
analyses, 4, 86
importance to patients, 181
questionnaires, 183
theory of surgery, 14
women's issues, 158
Quality of Well-Being Scale, 183
Radiologists, 141, 146
RAND Corporation, studies of technology
adoption, 74, 134-141
Randomized clinical trials
adjuvant chemotherapy for breast cancer,
158-159
autologous bone marrow transplants for
breast cancer, 49
biases in, 156
ethical propriety of, 174
on low back pain, 155, 156
pace of progress by, 58
patient demand for innovation and, 188
on shared decision making, 59
of surgical innovations, 235, 236
unsuitability of, 174
Rational agency theory, 169
Rationing of care
age-based, 10
alternatives to, 27
basis for, 12
benefit-utilization curve and, 9-10, 12
by cost-effectiveness, 10
equality and, 89
ethics of, 87-95
freedom and, 88-89
hospital bed supply and, 23
personal responsibility and, 88
through rules of practice, 27-28
social concern and, 88
Reconstructive breast surgery, 66
Regulation
and innovation, 7, 172, 220-221
of outpatient facilities, 143
and technology adoption by hospitals,
125, 126-127, 129-130
Reimbursement policies
and adoption of technology, 125- 126,
144-145
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Canadian physicians, 30, 104, 105
capitation, 73, 80, 144, 145, 146
capping models, 105
and cost-effectiveness analyses, 175
and cost shifting, 38
and costs of care, 11, 10S
fee for service, 80, 104
for investigative or experimental
technologies, 48-49
of managed care organizations, 41, 48-49
for MRI, 13, 138-140
number of patient visits linked to, 192
"reasonable, customary, and usual"
method, 144, 236
regulation and, 125
resource-based relative value scales, 104,
144, 222, 234, 236
and surgical innovation, 234, 236, 237
technology assessment and, 11, 48
universal decision rules, 7
and utilization rates, 30, 41, 191
Research and development
cost-effectiveness considerations in, 4
economic constraints on, 4
patient activism and, 171 -174
physician role in, 107
recommendations, 49
see also Medical devices; Pharmaceutical
innovations; Surgical innovations
Resources, see Health care resources; Supply
of resources
Retinal artery occlusion, 69
Robertson, Jerry E., 225
Rosenbaum, Edward E., 166
Rothman, David J., 173
Rules of practice, 19-20, 21
on hospitalization, 22
rationing of care through, 27-28
Sacks, Oliver, 168
St. Luke' s-Roosevelt Hospital Center, 176
Screening, risk-based approach to, 56-57
Second opinion programs, 100, 237
Seldin, Donald W., 166
Seizer, Richard, 189
Serotonin re-uptake blockers, 209
SF-36 Health Status Questionnaire, 183
Shared decision-making model, 20
and art of care, 183
and cost containment, 7, 21, 45
ethical issues, 7, 12, 184
and innovation, 28, 46
281
interactive computer videodisc
technology, 46, 59, 188
managed care model contrasted with, 45
strengths of, 185-186
in surgery, 237
and utilization management, 47
weaknesses of, 21
Sickness Impact Profile, 183
Single-payer model, 30, 251
Social insurance-based health care, see
Canadian health care system
Sorbinil Retinopathy Trial, 214
Specialists/specialties, 244
and costs of care, 11
income, 104 n.7, 109
supply of, 11, 23, 25, 109
reimbursement policies and, 191
technology and, 107
Spinal stenosis, 181
Stanford University Center for AIDS
Research' 174
Stark, Fortney "Pete," 238-239
Storage and Recall Obstetrical Management
Systems, 224
Streptococcal sore throat, 69, 72
Strokes, 22, 167
Strong Memorial Hospital (Rochester), 130,
131
Subarachnoid and intercerebral hemorrhage,
71
Substance abuse treatment, 65
Supply of resources
and benefit-utilization curves, 27
and theories of efficacy, 21-25, 27
Surgical innovations, 31, 232-233
assessment of new procedures, 235-236
back, 25, 156
carotid artery, 25
common conditions with options for, 18-
19
cost-benefit analysis, 234, 236-237
cost-effectiveness of, 226, 234, 238-239
current status of, 233-235
dynamics of, 242-243
economics of health care and, 231-244
and hospital lengths of stay, 235
novel therapies, 232-233, 234
outpatient setting, 231-232, 235
preventive theory of, 14-15
quality-of-life theory of, 14-15
rates for BPH, 18
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regulation of, 233
reimbursement and utilization rates, 30,
233, 234-235, 237
synergisms of, 241-242
Swedish mammography trial, 56
Symptoms, weighting of, 66
Tarlov, Alvin, 178
Taxes/taxation, Canadian, 104
Technology, see Medical technology
Technology adoption/diffusion
assessment of technology and, 130, 145
barriers to, 142, 143, 144
competition for patients and, 127-130,
140-141, 144
cost-containment pressures and, 187-188
cost-effectiveness analyses and, 86
decision-making locus and, 130, 131
financing method and, 110, 124-125
hospital/medical staff organizational
relationships, 130, 131
by hospitals, 123-132, 137, 143
incentives for, 135-136
innovation following, 226-227
joint ventures for acquisition, 130
managed care and, 45-49, 145-146
nature of technology and, 143
operating cost recovery and, 125-126, 131
in outpatient settings, 126-127, 146-147,
222
patient demand and, 188
predictions, 132
promoting factors, 142
regulation and, 126-127, 131, 135-138,
143, 221
reimbursement policies and, 125-126,
134, 138-140, 143, 144-145
turf battles over, 141, 146-147
Technology assessment
accounting data bases used for, 7
and adoption of technology, 130, 145
collaborative studies, 213
deficiencies in, 5-6
enforcement of, 85
goals and processes of, 28-29
by HMOs, 53-54
infrastructure for, 29, 30
macromanagement of care and, 112-113
by managed care organizations, 48-49
micromanagement and, 111-112
and outcomes research, 29, 213
process evaluation, 28
INDEX
public-private solution to, 48
and quality management, 29, 30
and reimbursement, 11, 48
resource allocation for, 30
team approach, 29
theory evaluation, 28
uniform research protocols, 49
Technology development
investments in, 29
managed care and, 45-49
see also Innovation; Research and
development
Testicular cancer, 167
Theories of efficacy, resource supply and,
21-25
Thigh fracture, 66
Third-party payers
accountability demands of, 175-179
constraints on health care services, 203
micromanagement of care by, 20, 21, 101
Thomas, Lewis, 6
Tissue plasminogen activator, 130
Toombs, Kay, 167, 168
Trade associations, 48
Transluminal angioplasty, 4, 238
Transurethral resection, 69
Trauma, 22
Treatment of Mild Hypertension Study, 214
Tuberculosis, 69
UCLA Medical School, 181
Ulcers, 181, 186, 190, 210, 235
Ultrasound, 223, 226, 240
Uninsured Americans, 9, 26, 27, 97, 99
United Kingdom, see British National Health
System
United States health care system
British views of, 91
Canadian health care compared with, 97,
98-103
cost containment, 102-103, 115
employer-provided benefits in, 37-41
environmental context of operation, 101
102
macromanagement in, 4; see also Health
maintenance organizations
micromanagement of care in, 19-20, 97
physician reimbursement rates, 105
reforms, 100-101
regulation of, 116 n.15
supply of physicians, 105, 107
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technology development and diffusion,
101-102, 103, 113
utilization rates, 105, 109
University of California at Davis, 188
University of Chicago Hospitals, 177
University of Texas Health Science Center,
103
University of Washington Medical School,
188-189
Upper respiratory infections, 69
U.S. Healthcare, 49
User fees, 104, 223, 225-226
Uterus, noncancerous conditions, 18, 21
Utilization of services
benefit-utilization curve, shape of, 12-17
cascade effect, 190
controls/constraints, 105, 203
diagnostic techniques, 9
funding of' 11
managed care and, 46-47
management of, 41, 46-47
micromanagement of care and, 12, 146
monitoring of, 105
outcomes research and, 47
physicians, 9, 105
283
preferences of patients and, 17-18
rates of, 9, 17-19
and reimbursement, 30, 41, 105, 191
review, 237
shared decision making and, 47
surgery, 30
and technology adoption, 48, 146
Variceal scleral therapy, 236
Volume performance standards, 100, 191
Voluntary Hospitals of America, 213
Ware, John E., Jr., 168, 178, 181, 183
Wenuberg, John, 59
Western Washington Cancer Surveillance
System, 55
Women
access to care, 171
breast cancer screening, 54-58
quality-of-life issues, 158
research initiatives on, 170- 171
Women' s Health Initiative, 171
World Health Organization
criteria for screening, 55
International Classification of Disease
codes, 68-69
Representative terms from entire chapter:
shared decision
