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THE TECHNOLOGICAL IMPERATIVE VERSUS COST CONTAINMENT

The underlying paradigm of critical care medicine is the technological imperative: "the desire of physicians to do everything that they have been trained to do, regardless of the benefit cost ratio."[229] This approach evolved during the period of fee-for-service reimbursement when there was no reason to contain costs. Since CCU care is disproportionately expensive, reducing its cost is central to all managed care schemes.

The Office of Technology Assessment case study on intensive care units listed the following as factors that led to a treatment imperative in intensive care medicine:

1)
The focus on high technology, which obscures the underlying rational for treatment;

2)
The nature of ICU illnesses, which often require technologically oriented treatment just to keep the patient comfortable. This blurs the distinction between palliative treatment and definitive treatment;

3)
The moral climate which stresses erring on the side of more treatment, rather than less;

4)
Diffusion of decision making responsibility;

5)
The problem that many patients are not able to make their wishes known;

6)
The practice of so called "defensive medicine";

7)
A payment environment which encouraged ICU care in general and procedure oriented care in specific; and

8)
The difficulty of projecting the probability of recovery for specific ICU patients.[230]

[229]Fuchs VR: Who Shall Live? Health, Economics and Social Choice. 1974.

[230]Berenson RA: Intensive care units (ICUs): Clinical outcomes, costs, and decision making. (Health Technology Case Study 28) prepared for the Office of Technology Assessment, U.S. Congress, OTA-HCS-28, Washington, DC, Nov 1984 at 12.


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