The full content of Annals is available to subscribers

Subscribe/Learn More  >
Medicine and Public Policy |

High and Rising Health Care Costs. Part 2: Technologic Innovation

Thomas Bodenheimer, MD
[+] Article, Author, and Disclosure Information

From University of California, San Francisco, San Francisco, California.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Thomas Bodenheimer, MD, Department of Family and Community Medicine, University of California at San Francisco, Building 80-83, San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110; e-mail, tbodenheimer@medsch.ucsf.edu.

Ann Intern Med. 2005;142(11):932-937. doi:10.7326/0003-4819-142-11-200506070-00012
Text Size: A A A

Technologic innovation, in combination with weak cost-containment measures, is a major factor in high and rising health care costs. Evidence suggests that improved health care technologies generally increase rather than reduce health care expenditures. Greater availability of such technologies as magnetic resonance imaging, computed tomography, coronary artery bypass graft, angioplasty, cardiac and neonatal intensive care units, positron emission tomography, and radiation oncology facilities is associated with greater per capita use and higher spending on these services. Because the spread of new technologies is relatively unrestrained in the United States, many of these technologies are used to a greater extent than in other nations, and the United States thereby incurs higher health care costs. Nations with a greater degree of health system integration have relied on expenditure controls and global budgets to control costs. Although diffusion of technology takes place more slowly in more tightly budgeted systems, the use of innovative technologies in those systems tends to catch up over time.


Grahic Jump Location
Cumulative growth in per enrollee payments for personal health care, Medicare, and private insurers, 1970 to 2000.
Grahic Jump Location




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
For whos good?
Posted on June 7, 2005
Ashish Goel
Conflict of Interest: None Declared

The article on rising costs of health care made excellent reading and Dr Thomas Bodenheimer, needs to be congratulated for the thought proving comments. Another interesting thought that often comes to mind is that whom does techology benefit? It might be acceptable for developed nations, but when you practice medicine in a developing nation where a huge majority of your patients cannot afford two square meals a day, such escalating costs of techonology are certainly not going to benefit the patient. The doctor never gets anything out of technology. It is like the artificial brain which dulls the clinical skills of a physician. It is probably helpful to fill the coffers of large corporate hospitals and the pharmaceutical firms.

It is the doctor who is the loser in this technology rat race. One who loses more is the patient. One who loses most is the doctor-patient relationship.

Conflict of Interest:

None declared

Technological Innovations and Benefit
Posted on June 16, 2005
Cynthia X. Pan
Mount Sinai School of Medicine
Conflict of Interest: None Declared

Dr. Bodenheimer's series on High and Rising Health Care Costs has been informative and digestible, addressing a critical issue in today's health care. From my clinical observations, I would agree that technological innovation contributes most significantly to rising costs, and we are only at the beginning. Because technology is there, physicians will use it. At the end of Perspective 4, Dr. Bodenheimer mentions the question of "benefit," which merits exploration. One, for many patients, benefit or the ultimate outcome may be difficult to predict before a technological intervention. For example, a patient with several comorbidities may undergo cardiac bypass and valve replacement with the hope of recovering uneventfully, but instead remains septic, ventilator dependent, receives a tracheotomy and feeding tube, and ultimately dies in the hospital. Second, how is benefit defined? Is the above outcome a benefit because the patient lived for another few months? There needs to be clarification between quantity of life and quality of life. Third, technological advances are being offered without upfront discussions with patients about the limitations of the interventions or what could be done with them once the patient reaches the end stages of a disease when such an intervention may become more of a burden than a benefit. An example is the implantable defibrillator that shocks the patient with endstage heart failure as the patient is dying, because it is difficult emotionally to turn the defibrillator off. Some physicians may even oppose turning off the defibrillator for ethical reasons. More medical education needs to emphasize communication skills and ethical principles that guide these discussions. There are also systems problems with rapidly developing technological innovations. As a result of technological interventions, there is a growing population of patients who are considered "chronically critically ill," defined as those who have received elective tracheotomy, have other medical comorbidities, and may or may not be able to wean from mechanical ventilation. Because of the high level of skill required to care for these patients, there is a dearth of settings or facilities that are equipped to competently care for them. These patients typically have a long hospital stay and are difficult to discharge because it is hard to find facilities that can take care of ventilators, dialysis needs, and infectious disease isolation requirements all at once. As the technological imperative progresses, the medical community needs to also develop palliative care services across all settings to address patients' goals of care, symptom assessment and management, negotiate a complex health care system, and help patients and families determine the burdens and benefits of interventions at each stage of their illness.

Conflict of Interest:

None declared

Response to William L. Berger's letter to the editor
Posted on August 21, 2005
Thomas Bodenheimer
Conflict of Interest: None Declared

To the Editor Annals of Internal Medicine

I like Dr. Berger's letter. Thank you, Dr. Berger, for writing it.

Thomas Bodenheimer MD University of California at San Francisco

Conflict of Interest:

None declared

Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Related Point of Care
Topic Collections
PubMed Articles
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.