David E. Rogers

Medical Technology — A Different View of the Contentious Debate over Costs

There is a growing conviction that medical technologies are major contributors to escalating costs, and regulating them is generally viewed as the least contentious way to control expenses in the 1980s. Five forms of technology control are being discussed or developed. All aim to reduce costs by controlling big, expensive technologies in the class of computed tomographic (CT) scanning. We present evidence that technologies such as the CT scanner account for far less of the growth in medical expenditures than do the collective expenses of thousands of small tests and procedures. Furthermore, we suggest that each strategy for controlling large technology involves substantial practical and conceptual problems that would severely limit its effectiveness. We thus suggest a shift away from attempts to harness the big technologies, and toward incentives to encourage the more discerning use of all technologies. To this end, we propose changes in physician reimbursement and education and expanded insurance incentives to encourage physicians and hospitals to be more selective in the use of technology.

Treatment of disseminated mycotic infections: A new approach to amphotericin B therapy

Abstract Because dose-related toxicity is a regular accompaniment of amphotericin B therapy, a therapeutic approach has been utilized which allows individualization of dosage. Amphotericin was administered daily in amounts sufficient to provide peak serum levels at least twice those necessary for inhibition of the infecting fungus for a ten week period. Total doses much smaller than those generally recommended were frequently sufficient to control systemic mycotic infections. Fifteen patients with cryptococcosis, disseminated histoplasmosis and blastomycosis have been treated in this manner. Therapeutic results have been excellent. Eleven patients are alive and free of disease an average of twenty-four months after a single course of therapy. Two patients have died of myocardial infarction, one during therapy and the other three months after therapy. In neither case was there evidence of active fungal infection at the time of death. One patient was killed twenty-six months after the completion of amphotericin therapy for pulmonary cryptococcosis. Only one (questionable) relapse occurred in a patient with underlying malignant disease. This therapeutic approach provides a more rational basis for administration of amphotericin B to patients with severe mycotic infections and provides guidelines for adjusting dosage in the face of impaired renal function and other underlying medical problems.

Who needs Medicaid

Faced by a worsening economy and a powerful public mandate to decrease taxes and non-defense government expenditures, many are calling for additional cuts in spending for Medicaid-a large, not very popular program that pays for the medical care of many of the nations poor. Available evidence suggests that Medicaid has been far more valuable than is commonly realized: It serves a broad cross-section of the American people, its adoption coincides with major improvements in the health of Americans, and its costs per recipient are about the same as the costs of care per person for all Americans of similar age. Not widely recognized is the programs importance to the financial well-being (if not the very survival) of any major teaching hospitals and the majority of nursing homes in this country. Public and professional awareness of the accomplishments of this program may be a crucial factor in determining whether the cuts will spare many of the gains in access to medical care that have been made during the past two decades. If we do not wish to reduce needed medical services to the poor, health-care institutions and health professionals will have to cooperate with each other and with the government in developing less costly ways of delivering high-quality care.

The academic medical center: a stressed American institution.

In recent years, relations between academic medical centers and the government have become increasingly adversarial. Although the centers and the government were formerly partners in a number of health ventures, to the mutual benefit of both, the climate is now too often confrontational. It is a confrontation in which there will be no winners, but the larger society may be the loser. A number of pressures on academic centers have helped to contribute to this situation. The federal sector and academic medical institutions must understand one another better and rediscover effective ways to preserve the special strengths of academic medicine in this country.

THE CURRENT PROBLEM OF STAPHYLOCOCCAL INFECTIONS

Excerpt During the last decade staphylococcal infections have become a problem of increasing concern. Most of the acute bacterial infections of man respond promptly and predictably to the antimicro...

Recommendations for Control and Prevention of Human Immunodeficiency Virus (HIV) Infection in Intravenous Drug Users

Abstract Considerable evidence indicates that intravenous drug users are emerging as the group at greatest risk for both acquiring and spreading human immunodeficiency virus (HIV) infection. Thus, ...

The Shortage of Hospital Nurses: A New Perspective

Abstract There appears to be a critical shortage of hospital nurses in the United States, despite a 15-year national effort to bring the supply of nurses into balance with increased demand. Careful...

The Academic Medical Center Today

Some recent circumstances, including the nations economic difficulties, a probable physician surplus, a declining need for acute-care medical beds, and an overwhelming public perception that medical care is too expensive, are creating serious problems for academic medical centers today. To survive, many academic medical centers probably will make certain short-term adaptations that will be viewed as undesirable by many. We suggest four initiatives that may help academic centers maintain their vital national role. These initiatives include becoming major public advocates for the medical care needs of the least fortunate; a sharp reduction in the training of subspecialists; the commitment of more of their faculty practice income to academic research, teaching, and support of low-income students; and refocusing attention on the training of young persons to be the physicians of tomorrow.

Who should give primary care? The continuing debate.

Elsewhere in this issue of the Journal, Drs. Fishbane and Starfield offer us some new data comparing the care of children given by general practitioners and by pediatricians in a number of ways.1 T...

Evaluating a private foundation's health program

Abstract Public policy decisions in health are increasingly difficult and expensive. Although there will never be enough information available, private foundations can help to bridge the most important gaps in knowledge. Larger foundations may also wish to respond to those who doubt the value of foundation activities. This article reviews the experiences over the past eight years of The Robert Wood Johnson Foundation in employing evaluation and related social research procedures in the planning and implementation of a major philanthropic effort to improve the health and medical care of Americans. Discussed are the still evolving Foundation evaluation framework, the unanticipated problems in undertaking specific evaluations, and the substantive findings of some of the studies.