Academic journal article Australian Health Review

Breaking Up Is Hard to Do: Why Disinvestment in Medical Technology Is Harder Than Investment

Academic journal article Australian Health Review

Breaking Up Is Hard to Do: Why Disinvestment in Medical Technology Is Harder Than Investment

Article excerpt


Developments in healthcare technology, including drugs, diagnostic and procedural interventions, have had a major impact on the scope of healthcare, by expanding the range of people whocan be offered treatment and the complexity of the treatments available. But health technology is also a major driver of rising healthcare costs. Thus, it not surprising that most attention has been directed towards developing a robust framework to evaluate new technologies proposed for introduction into healthcare practice. The development of formal health technology assessment (HTA) can be traced to the early 1970s and was stimulated in part by a concern to assure the safety and efficacy ofnewinterventions, but also by concern about rising costs, and the need to ensure that new technologies represented good buys.1 Although HTA encompasses many perspectives, including ethical, societal, and legal issues, its core focus is the evaluation of safety, efficacy and cost-effectiveness of alternative treatments or other procedures; and, at least for new and emerging technologies, to ensure they provide 'value for money'.

By focussing health technology assessment (HTA) efforts on new investment, many technologies in general use have never been appropriately evaluated, and their cost-effectiveness is unknown. The early advocates of HTA argued that if new technologies were accepted for funding on the basis of cost- effectiveness, the armamentarium of funded technologies would, over time, become more cost-effective as the new (evaluated) technologies replaced the existing ones, thus improving the efficiency of the health system. However, as long as they remain safe and are not shown to do harm, existing technologies are generally not reviewed; thus their relative value for money is unknown.

In Australia, for example, although new technologies have been subject to formalHTAfor over a decade, only about3%of all technologies currently reimbursed have been subject to formal review.2 In addition, many technologies are approved for reimbursement on a cost-minimisation basis, providing the same health outcome for the same cost as existing technologies. The implicit assumption is that there will be no additional cost from the new technology/procedure. However, in practice, these new treatments often become additional to, rather than alternatives to, the already funded treatments, creating pressure for additional spending.

The aim of this paper is to explore several issues related to disinvestment in light of recent discussion in the literature. Disinvestment refers to processes by which a health system or service removes technologies, without necessarily replacing them. First, we describe current approaches to encourage or facilitate disinvestment by applying existing HTA methods and processes. Second, we briefly discuss potential means of identifying candidate technologies for disinvestment; and some approaches to the implementation of a disinvestment process. Third, we discuss the possible reasons for the lack of progress and the challenges of designing a framework for disinvestment in health technologies.

Disinvestment through health technology assessment

The term disinvestment is used with a range of meanings and there are different ways of examining this concept.

Elshaug et al. defined it as 'the process of withdrawing (partially or completely) health resources from any existing healthcare practices, procedures, technologies and pharmaceuticals that are deemed to deliver no or low health gain for their cost and thus [do] not [represent] efficient health resource allocation'3. Disinvestment has also been described as the cessation or restriction of potentially harmful, clinically ineffective or cost inefficient practices.4 Even though Goodman does not define disinvestment, obsolete/outmoded/abandoned technologies are described as those that have been superseded or demonstrated to be ineffective or harmful. …

Search by... Author
Show... All Results Primary Sources Peer-reviewed


An unknown error has occurred. Please click the button below to reload the page. If the problem persists, please try again in a little while.