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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

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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

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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

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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

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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

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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

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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

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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

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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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278 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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280 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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INDEX 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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282 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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INDEX 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