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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.