Effects of federal policies on extracorporeal shock wave lithotripsy Page: 11
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centers) of treating each patient and, under cur
rent payment arrangements, most likely the ex
penditures of payers. Conversely, localization of
ESWL to a few regional centers may lower per
patient cost but implies more difficult access to
those patients living at great distance from these
centers. As with any expensive and sophisticated
technology, this problem will be especially acute
for rural inhabitants, such as many American In
dians, since small rural hospitals (including IHS
hospitals) will not be able to afford or justify ac
quiring ESWL capabilities,
Hospital managers and physician groups may
urge the purchase of ESWL units despite the prob
lems that may be encountered with oversupply
of the service, particularly if the payment rates
of Medicare and other payers are generous, On
the one hand, if a facility acquires an ESWL unit
in an area that produces a sufficient stone popu
lation to support the unit, that facility will reap
both prestige and profits. Furthermore, by not ac
quiring the device, a facility may lose a signifi
cant proportion of its patients to other facilities
in the area that do provide ESWL. Hospitals may
wish to acquire ESWL because they compete for
patients directly, and because they compete for
physicians as a way of drawing the patients re
ferred by those physicians. These considerations
are strong incentives to purchase the machine, de
spite the fact that if many facilities in one area
provide ESWL, they will all have small caseloads
and consequently high costs and low profits or
losses, Furthermore, these incentives operate to
some extent even if payment rates are low, ex
acerbating the low or absent actual financial gains.
In theory, either payment or planning policies
could prevent overpurchase of ESWL and assure
a distribution of units consistent with population
size and stone incidence. In practice, neither will
probably fully achieve these goals.
Finally, the combination of payment and plan
ning effects may have a significant effect on the
urology specialty. In any community in which notall urologists have access to, or are trained to use,
ESWL, the urologist to which a patient is referred
may have a strong influence on the treatment re
ceived, Urology may develop a "subspecialty" of
those physicians who can perform ESWL and
have access to ESWL units. Such a development
could have positive implications for the quality
of care afforded those patients receiving ESWL,
since their ESWL physicians would be highly ex
perienced. However, it might result in great var
iations in treatment for the same indications, if
urologists who do not have access to ESWL units
are reluctant to refer their patients to urologists
who do. The incentives would be for urologists
without access to ESWL to underprescribe this
treatment for their patients, perhaps by routinely
performing surgery on younger patients with first
stones. Conversely, urologists with access to
ESWL would have an incentive to overuse it, per
haps by recommending the procedure when med
ical treatment might be sufficient.
Universal access of urologists to ESWL is no
panacea, however. In areas where a large num
ber of urologists have access to an ESWL center,
patients have the greatest potential access to
ESWL through their urologists but could receive
lower quality treatment if each urologist does
ESWL only a few times a year and is consequently
less proficient at the procedure.
ESWL exemplifies the service specialization and
regionalization of tertiary care, as "stone treat
ment centers" specializing in urinary stone care
proliferate. The lessons learned from current pay
ment and planning experiences may well be appli
cable again as ESWL technology is turned toward
treatment of gallstones, involving an entirely new
set of physicians and other providers and requir
ing new payment levels and a new assessment of
the appropriate role for ESWL, The fact that
ESWL for gallstones is likely to require a dedi
cated device, at least in the short term, suggests
that its diffusion may parallel that of ESWL for
urinary stones.
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United States. Congress. Office of Technology Assessment. Effects of federal policies on extracorporeal shock wave lithotripsy, report, May 1986; [Washington D.C.]. (https://digital.library.unt.edu/ark:/67531/metadc39606/m1/20/: accessed April 24, 2024), University of North Texas Libraries, UNT Digital Library, https://digital.library.unt.edu; crediting UNT Libraries Government Documents Department.