There is a tension between health systems and their need for innovative technologies and the absorptive capacity of the health system itself to both adopt an innovation and modify existing clinical practice to release the full benefits of the innovation. From a policy perspective, this presents a variety of problems not the least of which is that it is largely pointless to put more money into unreformed health systems. From a commercial perspective, how is business to decide what are priorities, what are the innovations to back and what markets will adopt them. Governments and payers can do much to signal markets what their priorities are and back that with appropriate reimbursement policies to enable these technologies to earn their way in the world.
But it is not that simple, and there is a clear need for policy makers and ‘the market’ to interact productively, so both win. In the absence of this, we will have the continuing saga of the medico-industrial complex driving technologies forward but with no payers.
Competing interests characterise what people think are healthcare technology priorities. With the often overbearing weight of government, healthcare technologies often reflect preferences that emerge from the policy priorities of governments locked in an iron triangle with industry and (usually) doctors. This medico-industrial complex leads to technologies that are sought by doctors, and when companies seek guidance for their own product development priorities, they consult doctors, and around we go. There is some good reason to do this, as it is widely argued that it is doctors who decide what services, medicines and devices patients will end up using, so it is sensible to ask them what they would like. The problem with this is obvious, as doctors are not consumers of the functions of the medicines or devices they prescribe. That countries are invariably forced into some form of economic evaluation of health technologies and the use of prescribing guidelines offer some evidence that doctors, in this case, cannot in the main be trusted to make appropriate decisions in this respect.
Let’s take e-health as a case in point. Often confusingly called ‘telemedicine’, the priorities range from devices and services that patients may actually use, to technologies to facilitate consultations and information exchange between health professionals. The latter, though, is really just the automation of existing clinical practice. The former is far more interesting, and far more disruptive of existing practices — perhaps that is why we don’t have much of it? Then there are technologies that really have a major impact on disease diagnosis, but which are expensive, but through elaborate clinical protocols are restricted or limited — why not adopt ‘best technology first’ and stop wasting the patient’s time.
Some priorities for further thought:
- Following work by Christensen and others, how can health systems identify technologies that will have the positive benefit of disrupting in the nicest possible way stale clinical practices and yield an order of magnitude improvement in health system productivity (with a corresponding decrease in per-capita costs)?
- What technologies are most effective from a patient/end-user’s perspective and that they will actually value and use?
- What commercial realities are needed to enable sensible reimbursement of e-health services by payors?
- How do we research, invest in and commercialise winning technologies and move them very quickly into use?
That is to say,
- how much do we really want to reform health care delivery using innovative technologies, and what implications will that have on our current approaches and assumptions — this is as much about clinical change as political will;
- what technologies can we have now, today or soon;
- how can we use reimbursement/payment systems to encourage use and uptake, and
- why is healthcare so slow to adopt new technologies?