The Technology Conundrum

During my 34 years in ophthalmology practice I have witnessed a truly amazing contribution by technology to alleviate visual problems.  Young myopes can now throw away their glasses thanks to Lasik.  Cataract surgery is now done as an outpatient, under topical anesthesia with implanted lenses which obviate the need for strong glasses.  Thanks to scanning lasers we can diagnose damage to the retinal nerve fiber layer long before the typical ravages of glaucoma are apparent.  Wet macular degeneration meant certain blindness, yet today anti-VEGF injections are saving eye sight.  The list of miracles goes on.  (see my notes)
I just returned from the national meeting of my specialty society.  A new device was being sold for the treatment of an irritating problem—dry eye.  Many of these patients are not bone dry but suffer inflammation of the sebaceous glands in their lids.  The product of the inflammation is a soap like substance which produces chronic irritation.  Currently antibiotics and warm compresses are the mainstay of management.  Regrettably the glands lie deep in the lid.  It takes a lot of time to get the full affect from warm compresses.  A new device was being offered which both warms the under side of the lid and then gently expresses the sebum.  Sounds like a nice thing to offer.  The device was being offered for $90,000!  The economics of purchasing such a device would require the patient to pay a very high fee for what amounts to a high tech hot compress and squeeze.  Should our struggling Medicare program be hit with an enormous bill for treating oil glands?  This is a very common problem in the elderly.  This device can be of some benefit but is it worth it?  Eye irritation is not life threatening although a quality of life issue.  Further it is a recurring problem.  If insurance is not going to pay, is it right to charge our patients over a thousand dollars for a fancy warm compress?  If it would relieve their symptoms better than the hot towel I have some patients who would readily pay such a fee.  Reality though is that most of our patients would be better off with the free hot towel.
An even bigger conundrum is presented by the LenSx laser machine.  For years we have patiently explained to our patients that we use lasers for all sorts of things but cataracts are removed with ultrasound.  Now the same technology which assists us with lasik can be used to create the tiny incisions we make to introduce the ultrasonic needle.  The machine is being offered for nearly $500,000 plus per case use fees.  Well are the results superior?  The laser makes a very precise incision but so far no data proves it is superior.  In fact after you use the laser you then introduce the ultrasonic needle and remove the cataract the same way.  Does it make the surgery faster?  Actually it creates another step so no it does not.  So what is the scientifically proven benefit—none so far.  Does Medicare pay the patient or facility extra for this technology—no.  The patient is going to have to pay out of pocket.  Most of my colleagues have come to the same conclusion I have.  Not ready for prime time but an evolving technology which will be important in years to come.  Right now this machine is perfect to get the attention of reporters who love stories about new technology in health care.  For the first doctor willing to spend the money, this machine will likely earn back much of its cost in media attention.  Further patients have come to accept technology like a religion.  If it is new technology, it must be superior whether medical studies support that or not.  Some will be willing to pony up the cash to be among the first to have this “benefit”.
We have reached a point where technology has created a great conundrum.  The office of technology assessment decides what is cost effective for our society.  The ability to pay makes the rest of the calls.  Is technology at any price our religion or should science and cost benefit guide the advice we give our patients.  This is a strange time to be a patient centered physician like me.  When I went into practice years ago, publicity seeking doctors were shunned and advertising was prohibited.  The FTC in its wisdom determined this prohibition was anti-competitve.  Advertising should increase competition, bring down prices and thus over all costs.  Yet, I rarely see a medical ad with a competing price.  (One ad I do recognize is a blatant bate and switch from a corporate center.  It takes advantage of a public which still mostly trusts physicians.)  Most of the ads and articles are meant to drive demand by hyping technology and never mention price.  Theses ads have been successful and demand has soared.  With demand costs have soared as well.   Now we have to face this conundrum as a society or see our standard of living erode. 
Notes: Wet macular degeneration is the bad type which produces blindness.  Dry macular degeneration is more common.  It usually produces impairment but is not as severe.
VEGF is a hormone discovered by a researcher.  It signals blood vessels.  By blocking this hormone with injections, the “fire” feeding macular degeneration is put out.

Posted in: Uncategorized