End the medical arms race

The public's love affair with advanced medical technology shows no signs of abating.

When it comes to deploying advanced technology—the latest imaging machinery, ever more precise radiation beams, tiny cameras that peer into the inner workings of the heart, or implantable devices that repair or replace joints, blood vessels and organs—it's easy to convince the average American, especially when he or she is in the midst of a serious or life-threatening situation, that bringing the most sophisticated and expensive technology to bear is the right thing to do.

That's the demand pull side of the story. But there is also supply push.

In most major cities across the U.S., highly competitive healthcare systems are engaged in a long-standing medical arms race. Hospitals advertise their latest robotic surgery devices on billboards along local freeways. They run ads in print and on television touting their high-tech expertise in high-revenue service lines such as orthopedics, cardiovascular care and oncology. They know their customers. Advanced technology sells.

Like Russia and the U.S. during the Cold War, no system can afford to lag behind in this medical arms race. They risk losing contracts with insurers or major employers—at least those that still want to offer their workers good insurance coverage and access to the best physicians in town. Indeed, physician recruitment, especially at top-ranked academic medical centers and major big-city hospital complexes, can hinge on a system's ability to provide young, ambitious doctors with access to the latest technology.

It requires considerable upfront capital to invest in next generation medical equipment. The cost of the system is only the beginning. New and existing staff must be trained. Operating rooms and labs must be reconfigured. The adoption period where the hospital or practice moves up the learning curve in using the new system can drain revenue from other capital projects.

While the upfront cost for the latest intensity-modulated radiotherapy system, for instance, might be in the range of $2 million, the actual expenditures by the hospital for a full installation can be as high as $10 million, according to one consultant I spoke with last week. And that pales beside the cost of the next generation of radiation therapy. The cost of a new proton beam facility has soared beyond $100 million.

Voices questioning the wisdom of this medical arms race are growing louder—in part because the medical evidence that justifies investing in the latest high-tech equipment often isn't there, at least not yet. Last week, researchers led by a team at the University of Michigan published a study in the Journal of the American Medical Association that showed the rapid growth in the use of IMRT and robotic surgery for men with low-risk prostate cancer—that is, those whose risk of dying from the disease was no different from those who simply choose to do nothing, sometimes known as watchful waiting.

Yet as the study authors pointed out, if you can market the perception that IMRT radiation treatment has fewer side effects—the biggest threat is the incontinence and impotence associated with standard radiation therapy—then older men diagnosed with slow-growing, i.e., low-risk, prostate cancer are much more likely to sign up for the treatment. Definitive evidence that IMRT either works better or has fewer side effects won't be known for at least five to 10 years, when the results of a National Cancer Institute-funded study dubbed START (Surveillance Therapy Against Radical Treatment) are known.

In a fee-for-service environment, pushing people to the pricier technology may have made sense. Competition between systems over who has the best technology at least had an internal marketing logic.

But as payers move toward rewarding high-value care and providers assume more financial risk for their patients, that logic no longer applies. Perhaps the time has come for competing systems to engage in their own START talks to end the medical arms race.

Follow Merrill Goozner on Twitter: @MHgoozner