Note: This entry strays somewhat from the primary strategic planning and managing thrust of the blog. It is still relevant because of the important role that new technologies have in the shaping of an organization’s competitive strategy. The adoption of particular innovations (e.g., a hard-to imitate surgical procedure, a unique method for developing cancer biomarkers) can give an organization a sustainable advantage A more aggressive approach to innovation in general may be adopted as a major strategic objective.
There is a very large volume of medical evidence generated each year on new FDA-approved drugs, medical devices, surgical procedures, biomedical equipment, and other technologies that health care organizations are asked to consider for adoption and payment.
· In 2003, approximately 105,400 articles were published in professional journals in the areas of clinical medicine, biomedical research, and health sciences.[i]
· The National Guideline Clearinghouse maintained by AHRQ contains 1,887 clinical practice guidelines in its database, with another 136 guidelines currently in its pipeline.[ii]
· The Blue Cross Blue Shield Association-sponsored Technology Evaluation Center conducts an average of 20-25 assessments per year.[iii] The California Technology Assessment Forum, sponsored by Blue Shield of California, reviews approximately 15-20 new and emerging medical technologies each year.[iv]
· The ECRI Health Technology Assessment Information Service issues between 560 and 600 reports per year.[v] The Hayes Medical Technology Directory produces 80-100 reports annually.[vi]
· During the five years from 2000 to 2004, the US Patent and Trademark Office (USPTO) granted a total of 71,320 patents to products in classes related to medical care delivery.[vii]
· During the years 2003-2005, the FDA gave final approval to 271 new medicines, 373 new or expanded uses for already approved drugs, and 987 generic versions of existing drugs[viii]. During those same years, it gave pre-market approval to 2,007 medical devices[ix].
· The Biotechnology Industry Organization reports that its members have more than 400 medicines and vaccines in their clinical development pipelines.[x]
It has been argued that the cost of adopting and offering such new technologies has been responsible for roughly one-third of the annual increases in the national health care budget over the last four decades.[xi] The challenge is to make sure that the health care system and its constituent organizations spend all the money necessary to acquire health-enhancing technology and not one cent more.
Introduction
There are thousands of people in universities, research institutes, government agencies, and for-profit companies, conducting research designed to generate useful new evidence, technologies, and study findings. A group of researchers at the Harvard School of Public Health recently were winding up a multi-year cancer prevention project that studied interventions through individuals’ workplaces and health plans[xii]. They felt that they were coming up with some useful new perspectives on preventing the onset of cancer, and wondered what it would take to persuade a managed care organization (MCO) to adopt their recommendations.
No comprehensive literature could be found on how MCOs learn about, evaluate, and decide to implement new medical research findings on preventive medicine, although there were reports of studies on MCO decision making regarding coverage of new health interventions in general[xiii]. In the absence of solid information, the researchers decided to conduct a survey of MCOs on their policies and practices toward new preventive medicine evidence and technologies. If the MCO procedures were systematic and objective, the investigators believed that they could frame their research output to enhance its chances of being accepted and adopted. If not, they hoped to explore means for making the procedures more transparent and predictable. This article makes recommendations for accomplishing that end.
MCO Survey on Adoption Procedures for New Cancer Prevention Strategies
The survey focused on MCOs rather than provider organizations and systems for two reasons. As the ultimate payers for care, once they receive premium payments from employers, MCOs have a dominant influence over the allocation of resources throughout the health care system. Their reimbursements to providers often determine the providers’ ability and willingness to acquire new technologies.
In the survey, two experienced interviewers conducted 30-45 minute telephone interviews using a 15-item qualitative questionnaire of the medical directors of 24 MCOs.
They were asked how their organizations learn about new cancer prevention evidence, evaluate it, and plan the implementation of the interventions selected.
Decision Process. Roughly half of the MCO’s surveyed employ what might be described as a formal procedure for deciding which prevention services to offer to their members. The procedures include steps like these.
· One or more committees systematically gather data about new research findings.
· Use predetermined criteria to select new interventions for further development.
· Prepare a formal proposal to implement the intervention, including projections of likely utilization, outcomes, and cost, as well as program goals.
· A higher level executive committee or a single official makes the final decision.
· Implement the program on a pilot basis for six months to several years.
· Evaluate achievement of predetermined goals or, if none have been set, general performance in comparison to external standards.
· The program is continued, revised, or dropped.
Four of the MCO’s in this survey employ all these steps; another three carry out all but one of them. At the other extreme are organizations that wait passively for physicians or committees to make proposals that are then approved or disapproved by a single high level manager. At least four MCO’s fell into this category. The procedure at most MCO’s falls between these two extremes, relying on just two or three of the formal steps.
Sources Consulted. In reaching their decisions about prevention services, MCO’s consult a wide variety of resources to inform themselves about the latest research findings. The greatest number of MCO’s (14) relied on journals and other medical literature, both print and online. The other most popular sources mentioned were internal review committees (8 MCO’s), individual physicians (7), government agencies like AHRQ, CDC, and NIM (6), technical assessment committees (6), media reports and coverage (4), USPSTF guidelines (4), medical specialty societies (4), and commercial update services (3).
Selection Criteria. The next focus of the survey was the specific criteria used in selecting which new prevention strategies to actually implement. The emphasis was on sound scientific justification. Ten of the 24 MCO’s surveyed based their decisions on “clear evidence” or some form of clinical effectiveness, efficacy, or appropriateness. Eleven of the MCO’s referred to third party recommendations that are typically based on such data – such as USPSTF recommendations, HEDIS ratings, NCQA requirements, and specialty society guidelines.
Financial Implications. The survey tried to determine whether and how MCO’s took into account the costs of a planned new prevention service. All but seven of those contacted claimed that they engaged in some a priori financial analysis. From their descriptions, it appeared that nine conducted truly thorough studies.
Program Budgeting. The effectiveness of a prevention initiative may depend on the resources committed to it. The survey asked the target MCO’s how they decided how much money to spend on a new program. Exactly half of the 24 MCO’s said that they did not set a specific dollar amount. At three other MCO’s, if the proposed initiative is recommended by a good or important source (e.g., USPSTF. HEDIS, NCQA) or backed by other solid evidence, it will be offered automatically, without concern for the cost.
Program Evaluation. When modern business organizations implement significant new programs, they frequently set goals for the purposes that the program is intended to achieve. The survey sought to see if this was the case with MCO-initiated prevention initiatives. Only five of the MCO’s questioned claimed to set no program goals at all. Eight defined objectives for the success rates (i.e., smoking quit rates) or health outcomes they wished to achieve. Thirteen MCO’s aim to measure their performance by the program enrollment or participation numbers they reach. Six survey respondents compare their program’s performance to external standards like HEDIS ratings or the numbers achieved by other MCO’s renowned for their prevention commitment.
Shortcomings of Current MCO Practices Toward New Technology Adoption
The survey results were discouraging. The general absence of systematic methods for considering new prevention research findings makes it hard for the researchers to plan their efforts to meet the needs and criteria of MCOs. They wondered if the MCOs took a more rigorous approach to new curative medicine research findings. For one thing, prevention services are more easily treated as optional benefits since they do not address a current health need. For another, it is more difficult to take into account the benefits of prevention that are uncertain and occur so far in the future
A further search of existing literature confirmed the initial conclusions/findings, revealing the following deficiencies in the ways that MCOs address new technologies.[xiv]
· Many are not hearing about and assessing the full range of new procedures, interventions, devices, products, and services available.
· The methods by which new medical evidence is discovered, evaluated, and adopted is often random, ad hoc, and unsystematic.
· They do not seem to take into account the long-term and organization-wide financial implications of capital spending on new tech adoptions.
· They do not seem to tie new tech adoption decisions to strategic objectives of the organization.
· They do not seem to view proposed new technologies as pieces of an overall technology portfolio for the organization. They generally are assessed on an ad hoc basis using inconsistent standards.
· They do not seem to prepare a formal plan for the implementation of a new technology, including expected benefits, resources required, financial projections, an implementation timetable, and success goals.
· They do not seem to anticipate ever discontinuing the offering of new technologies. A responsible capital project has a viable exit strategy when predetermined performance criteria are not being met.
There is a lot of room for improvement here. In an health care industry where the use of “best practice” treatments and procedures has come to make so much sense, it might be useful to look at the methods used by companies in other industries to make these kinds of decisions.
In the remainder of this article, the general term “technology” is used to include, not only the proposed cancer prevention initiatives, but also the full range of new medical evidence, research findings, approved drugs, new medical devices, innovative new procedures, and other products and services that enter the health care marketplace each year.
Best Practices Approach to New Technology Adoption
The health care industry has been experimenting for some time with established business management principles and practices used by organizations in most other industries. There is a steady movement toward the modern, professional management and operation of health care organizations. The implementation of rational resource allocation procedures would be a major step along that path.
There is a robust collection of tools and methodologies for investing in new capital projects (including technology), incorporating elements of corporate financial management practice, that has been followed and refined over several decades in other industries. They do need to be adapted to the unique features and values of the health care industry.
Allocating Limited Resources to New Medical Technologies
The foundation of a best practices approach is a formal, rational allocation process that takes into account the sound purposes that a new technology project is intended to serve and the various limited resources required to implement the project. These may include people, space, time, focus/attention, political influence, and money. The adoption decision making process must survey the available resources and determine whether they are sufficient for the project at hand.
New technologies should be adopted, not on an individual ad hoc basis, but as components of a carefully crafted portfolio of technologies that are consistent with and supportive of the organization’s mission and strategic objectives. Doing so makes it easier to employ a consistent method for evaluating all investments in a category, prioritize capital expenditures, make decisions that complement each other, and define direct linkages between a project and a related strategy. The portfolio approach allows for negative ROI investments, like many prevention initiatives, as long as they are more than offset by those with positive ROI. Irrational, impromptu technology decisions will result in expensive mistakes and waste of resources.
To simplify the consideration of the several assessment factors, a systematic tool like the following could be employed.
New Technology Adoption Decision Tool for Health Care Organizations
This multi-phase tool enables MCOs to make decisions to adopt new technologies in a rational, systematic, predictable fashion, employing predetermined criteria tailored to the needs and values of each particular organization. It might be described as “evidence-based decision making”.
Phase One: Safety and Efficacy
The first step is to assess the safety and efficacy of the technology. The FDA performs this function for drugs and devices. Currently, clinical assessments of sufficient validity are not regularly performed for other categories of technologies. Somewhat lower quality assessments may be available from individual researchers and technology manufacturers and vendors. Even when reliable assessments become available, it may be several months or years after the provider/payer entity needs to make an adoption/coverage decision.
Each MCO must make its own judgments about the adequacy of the studies or evidence behind the available assessments. One approach is to grade a technology’s safety and efficacy information along these lines[xv].
A - Very strong and valid evidence of clinical efficacy with negligible side effects
B - The evidence is somewhat less robust, the efficacy is somewhat lower, the safety risks are somewhat higher, or the efficacy level does not as substantially outweigh the side effects.
C - The evidence is significantly weaker though still possessing some legitimacy, the efficacy is significantly lower though still offering some positive effects, the safety risks are significantly greater but can be controlled through extraordinary measures, or the balance between efficacy and safety risk is significantly closer.
D - Valid studies have been conducted that show no or insignificant clinical efficacy and/or potential side effects that are substantial and overwhelming.
Hold - Insufficient evidence of safety or efficacy at this time. No pressing reasons for immediate adoption.
Revisit - There are significant open questions about the safety or efficacy (probably due to insufficient evidence), and there are compelling reasons for immediate adoption (i.e., strategic value, media pressure, competitive pressure).
Phase Two: Cost-Effectiveness
An MCO will carry out this phase if it sees value in considering the society-wide benefits of a new technology. For instance, it may wish to promote the fact that its technology adoption decisions take into account societal benefits as well as entity-specific benefits like cost savings and return on investment. This phase may be skipped if a valid cost-effectiveness analysis (CEA) has not already been performed on the technology.
Over at least two decades, the CEA methodology has been well refined. Properly conducted, there should be no questions about a CEA’s validity. There is a good chance that the necessary CEAs can be found in the CEA Registry at the Tufts-New England Medical Center[xvi].
Phase Three: Subjective Factors Assessment
Phase Three attempts to take into account the subjective factors that legitimately bear on technology adoption decisions and which currently are either acknowledged implicitly or not at all. By determining in an objective, methodical fashion how well a proposed technology satisfies these factors, the tool assures that undue influence is not allowed to any one factor.
This phase of the tool begins with the preparation of a list of the subjective factors that are important to the particular MCO. Among the many possibilities are enhancing patient satisfaction, engendering medical staff support, and satisfying accreditation criteria. The next step is to assign a weight to each of the factors. The sum of the weights for all the factors on the list should be 100.
When a technology is assessed, it is given a rating on a scale of 1 to 5 for how well it satisfies each of the factors.
5 - Completely satisfies this criterion.
4 - Does a very good, but not complete job of satisfying this criterion.
3 - Does a mediocre job of satisfying this criterion.
2 - Satisfies this criterion in very minor ways.
1 - Does not in any way satisfy this criterion.
The rating for each subjective factor is multiplied by its weight. The resulting scores for all the factors are totaled to produce an overall Subjective Factor Score for the technology. That score is compared with the scores for other technologies for treating the same condition, with the average scores for all technologies over the last three years, or with a minimum Subjective Factor Score that is required of all new technologies.
Phase Four: Financial Assessment – Return on Investment (ROI)
This is the assessment that, until now, has rarely been performed in the course of deciding whether or not to adopt a new technology. While all resources are essential to the success of a technology project, financial resources are the lifeblood of a thriving organization. It is particularly important that their spending on technology initiatives be carefully managed. Lessons can be learned from the best practices of other industries[xvii].
The three most popular measures of investment attractiveness are net present value (NPV), internal rate of return (IRR), and payback period. The decision rules for this phase are that, unless a technology proposal demonstrates a positive NPV, an IRR that exceeds cost of capital, or a payback period within a predetermined number of years, it will not receive further consideration. Technology proposals can be ranked by the level of positive NPV, by how much they exceed the cost of capital, or by the length of the payback period. Those projects that meet the financial assessment criteria are moved on to the fifth and final phase.
Phase Five: Feasibility Assessment
Just because a technology proposal is safe and efficacious, is cost-effective, satisfies several subjective factors, and can produce an attractive return on investment does not mean that there are sufficient resources to implement it. In this phase, the type and amount of various resources required to put the technology into practice are determined. In most cases, a virtual business plan will be created for each technology proposal.
By using these objective data and a modest amount of intuition and good judgment, the entity can confidently make its technology adoption decisions.
Impediments to Evidence-Based Technology Adoption Decisions
If there are best practices for allocating scarce resources, proven through decades of use in other industries, their application to the health care industry should be obvious, natural and immediate. These are a few of the barriers that keep this from happening.
Availability, timeliness, and expense of clinical trials
Valid studies of clinical efficacy and safety, preferably randomized controlled trials (RCTs), are not available in a timely fashion. The Institute of Medicine reported in 1985 on an estimate by the federal Office of Technology Assessment that randomized clinical trials had been applied to only 10-20% of medical practices.[xviii]
Skepticism about cost-effectiveness analyses
While the methodology has been around for over 20 years, cost-effectiveness analysis (CEA) has never been fully accepted into the mainstream of health care resource allocation in the US. One of the reasons[xix] is that the societal perspective of CEAs, while persuasive for national policymakers, is not much help to decision makers in individual private organizations.
Overriding clinical decisions for economic reasons
In the traditional clash between the MD and the MBA, many clinicians, along with policymakers and patients, view controlled allocation of resources to clinical technologies as direct interference in the diagnosis and treatment of disease by non-practitioners.
Apprehension that non-coverage decisions will be overruled by courts
There is a steady stream of well-publicized cases in which patients have challenged in the courts the attempts of health plans to deny coverage for a procedure or technology on the grounds that it is in the “experimental stage” and not encompassed by the language of the member-patient’s policy[xx].
Specific legal and regulatory barriers
States continue to pass laws mandating that specific services or providers be covered in order to prevent insurers from limiting access to certain technologies and services, and requiring independent appeals mechanisms. There currently are over 1,800 state-mandated benefits and provider categories.[xxi]
Political and public opposition to “rationing”
When HCFA attempted to introduce cost-effectiveness as a factor in Medicare technology coverage decisions in 1989 and again in the mid-1990s, it provoked vigorous opposition from consumer groups, technology vendors, and influential politicians[xxii]. The proposals were characterized as attempts at cost-containment and rationing.
Unwillingness to accept that health care resources are limited
Perhaps conditioned by decades of virtually “free” health care coverage through their employers, many consumers are reluctant to accept that there may be resource limits to that coverage, particularly of technologies.
For providers, all the costs and few of the benefits
Clinical technologies are usually implemented at the provider level, at the providers’ expense. Most of the benefits accrue to the payers, who do not readily make corresponding adjustments to provider capitation rates or fee schedules.
The imperative of Medicare/Medicaid coverage
The Medicare and Medicaid programs are a major source of revenue for nearly every health plan and provider organization. When the federal Centers for Medicare & Medicaid Services (CMS) decides to cover a particular technology, sophisticated assessment methodologies are moot. The MCO must make it available.
Strategies for Moving Toward a Formal and Explicit Technology Adoption Process
Some incremental steps can be taken to more speedily overcome these barriers.
1. An MCO can begin by instituting a bare bones systematic procedure or tool for making technology adoption decisions. This may initially contain relatively few assessment methodologies/steps or criteria, but it will establish a precedent of transparency, predictability, and uniformity in the process.
2. The tool might be initiated with those components that are palatable to the MCO’s stakeholders and in which it is proficient. Starting with the Safety and Efficacy and Feasibility Assessment phases would provoke the least controversy. The Cost-Effectiveness phase could be added when good studies become available, Subjective Factors might come next, and the more contentious Financial Assessment phase would be implemented last.
3. The next step could be simply to publish the results without using them. Knowledge of these metrics would alert patients, payers, policymakers, and the general public to the financial and other practical implications of the passion for medical technology
4. An MCO could seize opportunities to put its decision making tool into practice. For instance, if an employer-payer shows an interest in customizing its benefit plans for several premium levels, the MCO could suggest different technology intensity levels as a distinguishing feature.
5. The continuing roll-out of consumer-driven health plans may offer unique opportunities to implement more systematic management of technology adoption. If market research and experience show that consumers are receptive to choosing among health plans on the basis of varying levels of technology intensity, the MCO can use its decision making tool to define the levels, being sure to share the underlying calculations with consumers .
6. Many MCOs can build on substantial prior experience with guiding consumers’ utilization of services. In the past, rather than unilaterally withhold a benefit from members, MCOs have allowed them full and free choice but used payment differentials to steer their choices in the desired direction. All these practices set precedents for using similar cost-sharing devices to steer patients away from more expensive, less efficacious and cost-effective medical technologies.
Movement toward more rigorous, business-like technology adoption procedures would permit researchers and vendors to focus their efforts on new products and services most likely to meet the needs of health care organizations and enhance the health of their patients.
[i] Regional and Country Portfolio of S&E Articles, By Field: 2003. Appendix Table 5-45. Science and Engineering Indicators – 2006, National Science Foundation. Accessed on 9.26.07. at http://www.nsf.gov/statistics/seind06/pdf_v2.htm.
[ii] Accessed on 9.26.07. at www.guideline.gov/browse/guideline_index.aspx.
[iii] Accessed on 9.26.07. at http://www.bcbs.com/tec/tecassessments.html.
[iv] Accessed on 9.26.07. at http://www.ctaf.org/section/assessment/.
[v] Email message received on 5.5.06. from Vivian Coates, Vice President, Information Services and Technology Assessment, ECRI.
[vi] Email message received on 5.2.06. from Suzanne Stoll, Manager, Clinical Support Services, Hayes Inc.
[vii] Patents Counts By Class By Year, January 1977 – December 2004, US Patient and Trademark Office. Accessed on 9.26.07. at http://www.uspto.gov/web/offices/ac/ido/oeip/taf/cbcby.pdf. The classes considered to be health care delivery-related were 128, 424, 433, 514, 600, 601, 602, 604, 606, 607, and 623.
[viii] FDA Center for Drug Evaluation and Research, accessed at http://www.fda.gov/cder/reports/rtn/2005/rtn2005.htm on 9.26.07.
[ix] FDA Center for Devices and Radiological Health, accessed at http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfPMA/pma.cfm on 9.26.07.
[x] Accessed on 9.26.07. at http://bio.org/speeches/pubs/er/statistics.asp.
[xi] P.E. Mohr et al., "The Impact of Medical Technology on Future Health Care Costs," Final Report (Bethesda: Center for Health Affairs, Project HOPE, 28 February 2001).
[xii] Healthy Directions – Health Centers intervention study conducted as part of the Harvard Cancer Prevention Program Project under a grant from the National Cancer Institute (PO1 CA 75308).
[xiii] One looked at the sources of information used in evaluating clinical and cost effectives. L. Bergthold et al, “Using Evidence and Cost in Managed Care Decision-Making”, Center for Health Policy, Stanford University, August 23, 2002. Another examined the role of “technology assessment” in a variety of provider and payer organizations, four of which were HMOs. BR Luce, RE Brown, “The Use of Technology Assessment by Hospitals, Health Maintenance Organizations, and Third-Party Payers in the United States”, International Journal of Technology Assessment in Health Care, 11:1 (1995) 79-92. In a third study, interviews on their methods for setting prices for new medical technologies were conducted with key officials at large purchasers of health care services, three of which were “insurers”. PE Mohr, PJ Neumann, and S Bausch, “Paying for New Medical Technologies: Lessons for the Medicare Program from Other Large Health Care Purchasers”, Final Report, October 2002, Project HOPE Center for Health Affairs, (submitted to Medicare Payment Advisory Committee). Accessed on 9.26.07. at http://www.medpac.gov/publications/contractor_reports/Jun03_MedTechPay_PurchSrv(cont)Rpt2.pdf.
[xiv] M.J. Coye and J. Kell, “How Hospitals Confront New Technology”, Health Affairs 25, n. 1 (2006), 163-173; M.V. Pauly, “Competition and New Technology”, Health Affairs 24, no. 6 (2005), 1523-1535; D.M. Eddy, “Evidence-Based Medicine: A Unified Approach”, Health Affairs 24, no. 1 (2005), 9-17; T. Bodenheimer, “High and Rising Health Care Costs, Part 2: Technologic Innovation”, Annals of Internal Medicine 142, no. 11 (2005), 932-937; A.M. Garber, “Cost Effectiveness and Evidence Evaluation As Criteria for Coverage Policy”, Health Affairs, Web Exclusive, 19 May 2004; S.R. Tunis, “Economic Analysis in Healthcare Decisions”, The American Journal of Managed Care 10, no. 5 (2004), 301-304; B.S. Bloom, “Use of Formal Benefit/Cost Evaluations in Health System Decision Making”, The American Journal of Managed Care 10, no. 5 (2004), 329-335; P.J. Neumann, “Why Don’t Americans Use Cost-Effectiveness Analysis?”, The American Journal of Managed Care 10, no. 5 (2004), 308-312; and D.M. Eddy, “Technology Assessment, Deployment, and Implementation in Prepaid Group Practice”, Ch. 5, from Toward a Twenty-first Century Health System, by A.C. Enthoven and L.A. Tollen, Editors, Jossey-Bass, 2004.
[xv] Separate quantitative ratings of health benefits and cost effectiveness were assigned to the leading clinical preventive services in, MV Maciosek et al, “Priorities Among Effective Clinical Preventive Services, Results of a Systematic Review and Analysis”, American Journal of Preventive Medicine, 20:10, 1-10 (2006), also available at www.prevent.org/content/view/43/71/. The Executive Committee of the Medicare Coverage Advisory Committee (MCAC) in 1999 developed “interim recommendations for evaluating effectiveness” that defined seven levels of health outcomes. M Christian and M Martinson, “Getting Paid for All Your Hard Work: The Basics of Reimbursement for Healthcare Products and Services”, Regulatory Affairs Focus, July 2002, 5-10, and Letter to HCFA on the Medicare Program; Criteria for making coverage decisions, notice of intent to publish a proposed ruler in the May 16, 20900 Federal Register (from the American College of Physicians), accessed on 9.26.07. at http://www.acponline.org/hpp/letter_medicarecriteria.htm.
[xvi] Accessed at http://www.tufts-nemc.org/cearegistry/ on 9.26.07. There is a similar listing in the Office of Health Economics (OHE) Health Economic Evaluations Database http://www3.interscience.wiley.com/cgi-bin/mrwhome/114130635/HOME?CRETRY=1&SRETRY=0 (Accessed on 9.26.07.)
[xvii] The application of these practices to health care organizations is described well in JH Sussman, “Capital Allocation The Right Way: Consistent, Concurrent, Connected and Communicated”, White Paper, Kaufman Hall & Associates, accessed on 9.26.07. at http://www.kaufmanhall.com/knowledge/CaptialAllocationTheRightWayConsistentConcurrentConnectedAndCommunicated.cfm.
[xviii] “Assessing Medical Technologies”, Committee for Evaluating Medical Technologies in Clinical Use, Institute of Medicine, National Academies Press, p. 5 (1985)
[xix] These reasons are well summarized in Peter Neumann’s article, “Why Don’t Americans Use Cost-Effectiveness Analysis?”, in The American Journal of Managed Care, May 2004, Vol. 10 No. 5.
[xx] MM Mello and TA Brennan, “The Controversy Over High-Dose Chemotherapy With Autologous Bone Marrow Transplant For Breast Cancer”, Health Affairs 20, no. 5 (2001): 101-117; JC Collins, “Experimental Medical Treatments: Who Should Decide Coverage?”, 20 Seattle University Law Review 20 (Winter 1997) 451; and “Kentucky Jury Delivers Blow to HMO, Awards Cancer Patient $13 Million”, Mealey's Managed Care Liability Reporter, Oct. 28, 1998, at 5
[xxi] “A State-by-State Breakdown of Health Insurance Mandates and Their Costs”, Council for Affordable Health Insurance, March 2006, accessed on 3.30.06. at http://www.cahi.org/cahi_contents/resources/pdf/MandatePub2006.pdf
[xxii] “Using Cost-Effectiveness Analysis to Improve Health Care”, Peter J. Neumann, Oxford University Press, 2005, pp. 20-23; and SB Foote, “Why Medicare Cannot Promulgate a National Coverage Rule: A Case of Regula Mortis”, Journal of Health Politics, Policy and Law, Vol. 27 No. 5, October 2002, pp. 707-730.