Much of the progress in medicine during the past half-century has involved expensive, high-tech diagnostic tests and therapies. The trend in this direction worries health economists and politicians because it has the potential to send already high health care costs into the stratosphere. Health care spending in 2017 reached $3.5 trillion, or a whopping 17.9% of the nation’s gross domestic product, according to government statistics.
However, there is an important role as well for ingenious, low-tech, less-expensive approaches to improved health and increased longevity. The question is, how do we make them financially attractive?
A drug called nusinersen (brand name, Spinraza), approved in 2016, is a high-tech, hugely expensive treatment for a rare childhood genetic disease, spinal muscular atrophy. It costs $750,000 in the first year and $375,000 annually thereafter, making it probably the most expensive drug in history. There are several new personalized therapies for various cancers that are in the six-figure range, and even one that’s more than $2 million for a one-time treatment.
The cost of facilities can also be exorbitant: A new proton therapy center to treat several types of cancers costs upward of $200 million.
Although the miracles of high-tech may capture the imagination and the headlines, there are many simpler and cheaper yet tremendously important innovations for the diagnosis and prevention of illness. Some are easy to monetize via conventional mechanisms, such as patents, periods of exclusivity enforced by regulators, or even good, old-fashioned advertising (as makers of walk-in bathtubs advertise directly to seniors).
One example is the handheld direct ophthalmoscope, which allows a medical practitioner to look into the back of the eye to ascertain the health of the retina, optic nerve, vasculature, and vitreous humor. Invented in 1851, it costs less than $200.
Another example, described in a 2017 article in the American Journal of Medicine, is a single blood test which can ascertain that a patient in the emergency room is not having a heart attack and so can forgo the inconvenience and expense of additional invasive tests or unnecessary hospitalization. The highly sensitive test measures levels of cardiac troponin, a protein involved in muscle contraction; if the level is undetectable – that is, below the limit of detection of the test – there is greater than 99% likelihood that the patient was not experiencing a heart attack and was at very low risk of other cardiac adverse events for at least 30 days.
But other approaches are not so easy to monetize. Consider an ingenious way to reduce the threat of injury from falls, for example.
Falls are both a cause and effect of declining health in the elderly. They are the leading cause of injury-related visits to emergency rooms and the primary cause of accidental deaths in Americans over the age of 65. Therefore, preventing them or reducing their impact would moderate health care costs significantly. To measure the potential benefits of a low-tech approach to preventing injuries from falls, a 2017 study by a research group in New Zealand compared rates of falling and injuries from falls on low-impact flooring (LIF) compared with standard vinyl flooring on an “older persons health ward.” The frequency of falls and injuries on LIF and those occurring on standard vinyl flooring (controls) were compared.
The investigators found that over the 31 months of the study, there were 278 falls (among 178 persons who fell). The rate of falls was indistinguishable in the two groups, but “fall-related injuries were significantly less frequent when they occurred on LIFs (22% of falls versus 34% of falls on control flooring).” And many of those averted injuries were serious: “Fractures occurred in 0.7% of falls in the LIF cohort versus 2.3% in the control cohort,” more than a three-fold difference.
Thus, the New Zealand study provides a compelling rationale for adding low-impact flooring to housing for seniors, along with other modifications.
Another low-tech innovation that can reduce morbidity and mortality is operating room checklists. A meta-analysis by Norwegian university researchers found that this low-cost innovation is effective “for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity.”
Finally, fluoride prevents the bacteria that cause cavities from entering the tooth, reducing dental decay. The Centers for Disease Control and Prevention estimate a quarter of Americans on public water systems are without access to fluoridated water. Introducing this proven measure more widely or encouraging people to use fluoride-containing mouthwashes would decrease the need for many aggressive and costly dental procedures.
Despite their clear benefits, flaws in the current payment model create disincentives to many low-tech, low-cost innovations. Part of the problem is that the current primary-care model fails to take a “whole-person” approach, “a disruptive primary-care model that uses relatively inexpensive, nonphysician health coaches to identify patients’ unhealthy habits and lifestyles and guide them toward better choices, before health problems arise or become serious.”
Thus, reforms to the current payment model, such as capitation payment arrangements, could reduce those disincentives. Under a capitation arrangement, health care service providers are paid a set amount for each patient under their care, regardless if they seek care or not. The incentives of the primary-care providers under capitation arrangements are then aligned with investing in cost-effective, low-tech innovations, and those payers who do not invest in low-tech innovations will bear the financial consequences of not doing so.
Whatever payment reforms are implemented, alternative structures should be empowered to compete with one another, with the ultimate goal better alignment of the financial interests of the payer with providing the best care for patients.
There is a role as well for federal agencies that fund health care research. They should specifically solicit projects focused on health care interventions that could be relatively inexpensive and cost effective, and that the private sector is unlikely to undertake, such as the New Zealand study of low-impact flooring, the Norwegian research on checklists, and the whole-person approach to care.
The high-tech miracles will continue to garner headlines, but to control health care costs we will also need simpler and relatively inexpensive innovations. That has policy implications. Marine Corps Commandant Gen. David Berger wrote (in a different context): “We must continue to seek the affordable and plentiful at the expense of the exquisite and few.” That applies to health care as well.
Henry I. Miller, a physician and molecular biologist, is a senior fellow in health care at the Pacific Research Institute. He was the founding director of the Office of Biotechnology at the FDA. Economist Wayne Winegarden is a senior fellow in business and economics at the Pacific Research Institute and director of its Center for Medical Economics and Innovation.
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