Medical Technology and the Health Care System A Study of the Diffusion of Equipment-Embodied Technology (1979) / Chapter Skim
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PROBLEMS IN ADOPTION AND USE
PROBLEMS IN ADOPTION AND USE
Pages 23-45
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From page 23... ...
. • Medical information systems have followed a fitful process of diffusion, encountering significant barriers except in the few research centers currently funded to demonstrate and develop such systems (Appendix E)
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From page 24... ...
Are there definable attributes of hospital behavior that would explain why equipment-embodied technology as a whole, or certain kinds of equipment-embodied technology, would be adopted more or less readily than other productive resources? There are two sets of theories of hospital decision making that bear on the question of equipment adoption.
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From page 25... ...
However, perceived quality may be correlated as much with the level of sophistication of those inputs as with their aggregate amounts.46 If patients themselves identify hospital quality with the availability of capital-intensive equipment and systems, or specialized labor, then hospitals wishing to maximize the quantity of services provided would respond by emphasizing these inputs relative to others in order to increase the demand for the hospital's services. Thus, the willingness of hospitals to adopt new technology may rest on the degree to which patients and hospital decision makers equate hospital quality with the availability of this technology.
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From page 26... ...
The physician dominance theory has been criticized by Greer^ and others.93 According to Greer, the hospital administration and hospital boards may have as much or more power than any individual physician or group of physicians. It may also be true that hospital decisions about hospital technology result more often from the coincidence of goals among various groups than the dominance of particular groups.
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From page 27... ...
However, there is some indirect evidence to suggest that at least some of these characteristics are important determinants. The relative advantages of a new technology, either in improving patient outcomes or reducing patient risks, has been shown to be a strong impetus to diffusion.
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From page 28... ...
Indeed, in a study of equipment adoption decisions in l5 Boston hospitals, Cromwell19 found that criteria such as "improvements in patient care," "life saving capability," and "patient safety" were much more important to hospital administrators than were the financial or costsaving attributes of equipment. Characteristics of Adopters Of course, the potential adopter's perceptions about technology depend upon his own characteristics, and, for this and a variety of other reasons, such characteristics play a role in the diffusion of technology.
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Similarly, Cromwell19 found in an intrastate study of hospital diffusion that the range and number of other complex services (for example, intensive care unit, radium therapy, cardiac catheter lab) offered by a hospital is positively correlated with adoption.
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These laws mandate review and approval of large capital expenditures (generally in excess of $l00,000) by local and state health planning agencies, with various sanctions applied to a hospital that goes ahead with an
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CON was found to be significantly and negatively related to rates of adoption of x-ray, cobalt, and radium therapy services, but it was not a significant explanatory variable for other services, including intensive care, open-heart surgery, and diagnostic nuclear medicine -- three services for which it should have been affected. Other forms of health care regulation have also been posited to affect the diffusion of technology.
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From page 32... ...
Lessons from the Empirical Studies The empirical studies of diffusion, though selective, reveal a pattern to the diffusion process for clinical and ancillary hospital technology. At least for the equipment and equipmentintensive services studied, earlier adopters are large hospitals with decentralized organizations and hospitals affiliated with medical schools.
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From page 33... ...
THE IMPACT OF THE HEALTH CARE FINANCING SYSTEM ON THE ADOPTION AND USE OF EQUIPMENT-EMBODIED TECHNOLOGY Four aspects of the present system for financing health care must be analyzed. These are: • Methods for reimbursing hospitals for routine services • Methods for reimbursing hospitals for ancillary services • Methods for reimbursing physicians • Limits to third-party reimbursement.
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From page 34... ...
If occupancy rates are low, the money will be spent for capital equipment; if occupancy rates are high, pressures for new additions to the hospital will mount and capital funds will be channelled in that direction. Salkever and Bice106 have shown that when capital expenditures for new bed capacity have been limited through regulatory action, capital spending has merely shifted to new equipment; in this case, total capital spending is unaffected.
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From page 35... ...
Most important, however, up to this time few expenditures for capital equipment have been denied by health planning agencies. Methods for Reimbursing Hospitals for Ancillary Services Certain hospital services denoted as ancillary services are billed separately from the routine daily rate in hospitals.
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From page 36... ...
The third-party fee-for-service system of physician reimbursement, which rewards physicians on the basis of the number of patient visits or procedures performed, should have a significant impact on physicians' decisions to use health care services, especially in the absence of significant perceived financial or medical risks to the patient.t To what extent does this tendency to overuse health services in general translate into a special problem for equipment-embodied technology? If the ability to perform a procedure depends upon the availability of equipment, then it is incumbent upon the physician desiring to perform the procedure to see that the equipment is adopted by a hospital in which he has staff privileges.
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From page 37... ...
As teaching hospitals train cardiovascular surgeons and then close their doors to the graduates of their residency programs, these physicians must find a hospital either with an existing capability or with the willingness to establish such a capability in order to make a living in the field for which they were trained. In the view of this committee, this example illustrates the combined impact that feefor-service, interhospital competition for prestige and patients, and the system of graduate medical education has on the rate of diffusion of clinical equipment-embodied technology.
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From page 38... ...
Electronic paging systems are an example. By contrast, establishing on-line medical information systems with the capability of processing patient care information and performing certain hospital functions automatically has encountered more resistance from hospital medical staffs.
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From page 39... ...
Although much is known about the process by which new medical procedures become standards of medical practice, the point in the diffusion process at which the standard becomes an important influence on adoption and use and the impact of that timing on the pattern of diffusion are largely unknown. It is frequently asserted that less than 4 years after its introduction, cranial computed tomographic scanning has become a standard of practice for diagnosing certain brain lesions.
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From page 40... ...
In particular, two kinds of technology are likely to be affected : (i) Technology offering significant economies of scale in relation to the size of providers.
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From page 41... ...
For example, some rehabilitative technology appears to suffer from the problem of an insufficient total market.87 The diverse nature of the problems faced by the handicapped and the relative] ^ small number of individuals who can benefit from any particular device often renders the cost of developing and distributing new devices prohibitive to those who need the assistance.
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From page 42... ...
Coordinative system-wide technology, such as medical information systems and emergency medical services systems technology, is often subject to nonadditive benefits -- that is, the benefits accruing from the collaboration of multiple providers outweigh the benefits from individual adoption. For example, the usefulness of the problemoriented medical information system that records patient data on the basis of medical problems is to a large extent dependent upon the integration of ambulatory care and hospital care data.134 In the words of Lindberg (in Appendix E)
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From page 43... ...
Physician specialization in particular has a profound influence on the adoption and use of equipment-embodied technology, although it is not clear whether increasing specialization has caused or resulted from the increasing complexity of medical technology. More study is needed of the relationship between technological change and physician specialization.
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From page 44... ...
And, because graduate medical education is financed largely through third-party reimbursement,52 the ability of hospitals to provide financial support for residents is also a function of patient demand for the specialty services. Sloan111 has tested a similar hypothesis for ophthalmology residency positions and has found that the number of positions offered is negatively related to the stipends hospitals must pay residents.
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From page 45... ...
On balance, the hospital reimbursement system probably creates incentives to overadopt new technology with significant economies of scale relative to the size of individual providers. However, this kind of technology could also be subject to an underadoption problem in the absence of such a lenient cost-based reimbursement system, due to the disaggregation of providers.
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