This book analyzes policy fights about what counts as good evidence of safety and effectiveness when it comes to new health care technologies in the United States and what political decisions mean ...for patients and doctors. Medical technologies often promise to extend and improve quality of life but come with many questions: Are they safe and effective? Are they worth the cost? When should they be allowed on the market, and when should Medicare, Medicaid, and private insurance companies be required to pay for drugs, devices, and diagnostic tests? Using case studies of disputes about the value of mammography screening; genetic testing for disease risk; brain imaging technologies to detect biomarkers associated with Alzheimer’s disease; cell-based therapies; and new, expensive drugs, Maschke and Gusmano illustrate how scientific disagreements about what counts as good evidence of safety and effectiveness are often swept up in partisan fights over health care reform and battles among insurance and health care companies, physicians, and patient advocates. Debating Modern Medical Technologies: The Politics of Safety, Effectiveness, and Patient Access reveals stakeholders’ differing values and interests regarding patient choice, physician autonomy, risk assessment, government intervention in medicine and technology assessment, and scientific innovation as a driver of national and global economies. It will help readers to understand the nature and complexity of past and current policy disagreements and their effects on patients.
Making Policies about Emerging Technologies Kaebnick, Gregory E.; Gusmano, Michael K.
The Hastings Center report,
January/February 2018, 2018-Jan, 2018-01-00, 20180101, Letnik:
48, Številka:
S1
Journal Article
Recenzirano
Odprti dostop
Can we make wise policy decisions about still‐emerging technologies—decisions that are grounded in facts yet anticipate unknowns and promote the public's preferences and values? There is a widespread ...feeling that we should try. There also seems to be widespread agreement that the central element in wise decisions is the assessment of benefits and costs, understood as a process that consists, at least in part, in measuring, tallying, and comparing how different outcomes would affect the public interest. But how benefits and costs are best weighed when making decisions about whether to move forward with an emerging technology is not clear. Many commentators feel that the weighing is often inadequate or inappropriate. Those who argue for a “precautionary” approach to the weighing do so precisely because they feel the need for a restraint on the dominant decision‐making tools and processes for assessing outcomes.
This Hastings Center special report examines those tools and processes, taking the method known as cost‐benefit analysis as a starting point. In U.S. governance, CBA, sometimes informed by risk assessment, is the most widely used and extensively studied method, and authoritative reports on genetic and reproductive technologies often use language suggestive of cost‐benefit analysis. There is also a long‐running debate about the role of values in CBA and other formal impact assessment mechanisms—and about how those mechanisms compare to the precautionary principle. The guiding idea in the report is to engage in a close examination of the strengths and limits of CBA for ensuring that emerging technologies are used in ways that square with the public's values, drawing on applications of synthetic biology to illustrate and sharpen the analysis and then considering corrections to CBA and some alternative methodologies that handle values differently.
This paper examines changes in infant mortality (IM) in Moscow, Russia’s largest and most affluent city. Along with some remarkable improvements in Moscow’s health system over the period between 2000 ...and 2014, the overall IM rate for Moscow’s residents decreased substantially between 2000 and 2014. There remains, however, substantial intra-city variation across Moscow’s 125 neighborhoods
.
Our regression models suggest that in higher-income neighborhoods measured by percent of population with rental income as a primary source, the IM rate is significantly lower than in lower-income neighborhoods measured by percent of population with transfer income as primary source (housing and utility subsidies and payments to working and low-income mothers, single mothers and foster parents). We also find that the density of physicians in a neighborhood is negatively correlated with the IM rate, but the effect is small. The density of nurses and hospital beds has no effect. We conclude that overall progress on health outcomes and measures of access does not, in itself, solve the challenge of intra-urban inequalities.
Growing executive branch discretion in the U.S. separation-of-powers system has elevated the importance of the administrative presidency. However, research on this topic has paid scant attention to ...federal policies that rely on the states to implement them. We seek to advance knowledge of the administrative presidency under conditions of fractious federalism by examining the nature and efficacy of the Obama administration's efforts to secure state cooperation in implementing the Affordable Care Act (ACA). This law sought to assure that nearly all Americans would have health insurance. Despite strong partisan, ideological pressures on Republican policy makers in the states to refrain from implementing the ACA, the Obama administration has had some initial success in overcoming their resistance. Waivers have been a particularly valuable presidential tool.
In the technology assessment literature, the leading alternative to CBA‐like methods is usually held to be precaution, which is understood in various ways but is always about making decisions under ...conditions of uncertainty. Under such conditions, proponents of precaution commonly hold, a straightforward tallying of potential outcomes does not seem possible. Since CBA aims to tally up outcomes to determine which outcome would produce the greatest public benefit, precaution begins to look like, not just an alternative to CBA, but an incompatible alternative.
Nonetheless, some of the better‐known formulations of a precautionary principle expressly call for combining precaution with assessment of costs and benefits. This essay examines the possible intersection of precaution and CBA. It argues that a moderate kind of CBA is a necessary part of a moderate kind of precaution. The existing proposals for integrating CBA and precaution start with an assumption that the integrative task consists in combining decision tools that generate (contrasting) substantive guidance. An alternative approach, explored here, starts with the idea that precaution is not a decision‐generating tool. Rather, it is a way of organizing the thinking that leads eventually to substantive conclusions. The appropriate policy response is reached not by applying a principle but by studying the situation—the proposed action and the problem it is meant to address—and developing recommendations tailored to it. What makes the thinking precautionary is that it emphasizes certain questions—about risk, uncertainty, and values—that CBA tends to suppress. So understood, precaution may well slow the science but is not intrinsically opposed to science or innovation. It can be understood, in fact, as continuous with the science because the contextual understanding of the science and the problems it is meant to address would emerge—in part—from a close engagement with the science.
French Lessons Gusmano, Michael K.
The Hastings Center report,
November-December 2014, Letnik:
44, Številka:
6
Journal Article
Recenzirano
During the past year, I have worked with colleagues in the United States and France to compare the countries’ rates of hospital readmission for patients sixty‐five years of age and older. The ...comparison with France can help shed light on a debate about one feature of the Patient Protection and Affordable Care Act. Our study highlights the complexity of hospital readmissions and raises the concern that we may be creating a significant problem if we pressure hospitals financially to discharge patients as quickly as possible and penalize them again for the foreseeable consequence of this action.
In 1949, China established a government-run health system with an emphasis on primary care and prevention. The economic reforms of the 1970s led to a dramatic reduction in public expenditures and ...undermined the public health and health care systems of the country. In 2009, the government reversed course yet again and established several social health insurance schemes. The country has expanded social health insurance to the vast majority of its 1.3 billion citizens, but public spending remains low. The continued reliance on private financing generates inequalities in access to health care. The delivery system is “mixed” with a dominant role for public sector institutions, but the reliance on private financing means that public hospitals and clinics are insufficiently attentive to public goods and addressing the needs of vulnerable patients.
PDF
