The NACA Position on Health Care Technology and Aging no. 18

Managing The Utilization of Technologies in Clinical Practice

Canada's publicly-insured health care system has encouraged the proliferation of technologies in the system because neither the patient nor the health service provider is accountable for the costs of technological services. Although the need to control costs and to provide the best value for each health care dollar spent has now made it more difficult to introduce new technologies into the health care system without prior assessment, many technologies already accepted into the health care system are used inappropriately or excessively. Health professionals are criticized for being unaware of the costs and real effectiveness of the tests and treatments they prescribe.²⁶

Regulation to remove certain existing technologies from the health care system does not appear to be the approach of choice to manage the utilization of health care technology. A more promising strategy to promote the appropriate and cost-effective use of health technologies is to provide incentives to institutions and practitioners to use technology assessment information to guide their decisions.²⁷

Changes to the financing of health care, as well as to the management of services, have been proposed to promote the use of information from technology assessment. The fee-for-service method of reimbursement of physician services is thought to encourage the provision of excess services, including for instance, an overuse of technological services.²⁸ As pointed out in the NACA Position on Determining Priorities in the Health Care: The Seniors' Perspective (1995), reimbursement by salary or capitation (that is, paying a physician a fixed amount for each patient enrolled in his/her practice) reduces service excess. To encourage physicians to provide extra technological services where more than a minimum is needed, salary or capitation could be combined with financial incentives for special services.

Therefore, NACA repeats its earlier recommendation that:

Provincial/territorial governments adopt methods of reimbursing physician services that combine salary or capitation with incentives for the appropriate use of health care technologies.

Another suggestion is to introduce a system of prospective payment, by which health insurance payments would be made not on the basis of an itemized bill for services already rendered but on an a priori amount that depends on the patient's diagnosis at the time of admission and other characteristics that affect treatment (such as age, sex, prior health status).²⁹ A third proposal is to use technology assessment information to develop clinical protocols to guide practice so that each technology would be matched to its appropriate use; for instance, surgeons might be informed that certain procedures are to be performed only on patients with certain specific diagnoses and/or characteristics.³⁰ Although these methods may appear attractive in theory, they have not been adequately evaluated in practice. Widespread implementation of these and similar measures may be discriminatory, perhaps even directly harmful, if they do not take into account diverse health care needs. For example, if prospective payment schemes motivate hospitals to treat patients at the lowest possible cost, persons with multiple pathologies or who present complications may be ill-served; situations such as these would frequently apply to seniors.

NACA recommends that:

Provincial/territorial departments of health assess different methods of promoting the use of technology assessment information in clinical practice and adopt the methods that are both most effective and responsive to the needs of persons with complex health care needs.

In addition to modifying the structure of the incentives within the health care system, consideration should be given to educating physicians and other health practitioners to remain abreast of assessments of health technologies to guide their use of these technologies.³¹ Certainly, the acquisition of a critical approach to health technology and skills in the evaluation of research evidence pertaining to new (and existing) technologies is imperative in basic health professional training programs, both in coursework and in clinical practicums and internships. Teaching hospitals and clinics are called upon to be leaders in this respect.

NACA recommends that:

Health education programs in universities and colleges, including teaching hospitals and clinics, teach students the importance of keeping abreast of health technology assessments and of modifying their use of technologies accordingly.

As was pointed out in the NACA Position on Determining Priorities in Health Care: The Seniors' Perspective (1995), changing established modes of practice among professionals requires more than the provision of new information in journals or continuing education programs. Methods that may promote greater utilization of health technology assessment information by professionals in practice include external practice audits and opportunities for case discussion, rehearsal of new practice behaviours and the example of local opinion leaders.³² As health economist David Feeny observes, "To be effective, technology assessment information must be deliberately and energetically marketed."³³ To promote the use of technology assessment information in clinical practice.

NACA thus reiterates its recommendation that:

Professional associations and health care institutions establish continuing education programs, peer review committees, external practice audits and other effective methods to guide health care practitioners in the appropriate use of health care technologies.

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