A medical devices manufacturer might spend millions of dollars over several years improving an old hospital standby–a bedside monitor, say, which measures blood pressure, heart rate, or blood-oxygen levels, and which sounds an alarm when a patient’s vitals go awry. The manufacturer might program the gadget to distinguish between real alarms, triggered when a patient’s blood pressure plummets, and false alarms, prompted by something as innocuous as a patient rolling over onto his arm. One company created just such a device, according to Eric Freitag, director of engineering services at Smart Design, who didn’t want to name the manufacturer because the product is still under wraps. The new monitor was geeked out in dampening algorithms and complex alert software that would’ve make Rube Goldberg’s head spin. And, sure enough, it did a wonderful job distinguishing between alarms. There was just one problem: No one could figure out how to use the damn thing.
When an alarm buzzes, real or not, nurses’ first priority is to shut it off, so they can then determine what’s wrong with their patient. They don’t want to waste time tinkering with elaborately programmed menus. Those technical gewgaws were beside the point. What the gadget needed, above all, was a snooze button. It was bad design, innovation for innovation’s sake. The price tag on this sort of thing, as Freitag tells it: $50 to $100 million.
It’s a meager sampling of what has become the single largest contributor to rising health-care costs in the United States: Technology. Having entered the mid-20th century a triumphant antidote to the guesswork of medicine, technology has emerged, 50 years hence, a malignant cancer on affordable health care. We can credit half to two-thirds of growth in medical spending to technology, which includes drugs, devices, and tests. The public has trained most its wrath on the $200 billion a year pharmaceutical industry, but medical equipment rates a close second, with annual expenditures clocking in at about $70 billion. Technological advancement in any sector relies on heavy investment. Gutenberg didn’t invent the printing press for free. The difference in medicine is that while new technology can help, it doesn’t always produce healthier people, and, in some instances, it can actually make us sicker. Bad design, like the snoozeless bedside monitor, isn’t just an unfortunate feature of the system; it’s practically built into it.
Some context: The 1980s saw the proliferation of a managed care system that gave insurance companies a dictatorial hold over what procedures doctors could perform and on whom, all in the name of lowering premiums. Hospitals didn’t buy new medical technology unless they absolutely needed it. Costs fell, but doctors and patients rose up, furious at ceding control over health care and eventually forced insurers to retreat. Free from the cost constraints of the insurance cartel, doctors could order–and get reimbursed for–as much treatment as they pleased. Drug and medical equipment companies saw a business opportunity in innovation for innovation’s sake. Why not? As Dean Baker, codirector of the Center for Economic and Policy Research, tells it, the American government incentivizes bad behavior. “People do their research, they spend a lot on their research, they get a patent for it, they want to recover those costs, and the only way to do that is charge a lot of money,” Baker says. “The expectation is that [the equipment] is better than what it’s replacing. Whether or not that’s true varies.” This has occasioned a mad dash for new, but not necessarily better, toys. “Today,” writes the journalist Shannon Brownlee in Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer, “hospitals in cities and towns across the country are engaged in a medical-technology arms race.”
Nowhere is this arms race more evident than in computed tomography (CT) imaging. Commercialized in the 1970s, CT scans capture intensely sharp images of human organs, ostensibly refining doctors’ ability to detect disease. New scanners tout “unprecedented coverage speed” and “ultimate performance,” to quote GE’s literature on its popular LightSpeed VCT range, which sounds more like a new model of sports car. At $2 million apiece, with a monthly maintenance bill running around $20,000, scanners are bought in bunches by hospitals eager to lure patients and blue-chip doctors. In contravention of basic macroeconomics, the supply is actually driving demand. The more scanners hospitals snatch up, the more scans doctors order–76 million in 2005 versus 40 million in 2000–in part because they’re paid per test (that’s another story), but also to recoup hospitals’ losses on the equipment. It’d be one thing if that translated to healthier patients, but as Brownlee notes, it doesn’t, at least not always. CT imaging carries significant risks, among them radiation and false positives that lead to additional testing and, in some cases, unnecessary, invasive surgery. Thank lax Food and Drug Administration regulations. Whereas the FDA requires drug makers to conduct studies that prove their products benefit patients, medical equipment manufacturers only need show their scanners are accurate and safe. The arms race shows no sign of letting up.
Designers are often enablers, sheathing a CT scanner in shiny white plastic or sexing up a $1,200 brand-name arthritis drug, whose generic (and generic-looking) equivalent could be bought for a fraction of the price. Superficial packaging reigns in our health-care system; a product that’s practical, long-lasting and reusable is the last thing a manufacturer would want to produce. Great design is the exception.
Consider Smart Design’s proposed fix for that confusing bedside monitor. Among other improvements, the 130-person product development firm suggested adding an alarm-silencing button to the gadget’s top center, a spot nurses would intuitively click. The design would’ve turned a technological labyrinth into something Steve Jobs might admire, and for a pittance–about one-tenth a percent of the R&D outlay that likely went into developing its alarm-management software. Nevertheless, the company balked, convinced its intricate technology could transcend trifling matters of how people actually make a product work. “We see a lot of low-hanging fruit in the medical industry,” Freitag says. “Clearly a lot of work goes into R&D of new stuff, and most of that is being driven by scientists and engineers. God love ’em, but they’re so focused on the technology piece. If you focus on the optimization of an idea at hand and put the money there, as opposed to developing a new technology from scratch to replace the old one, there’s probably a lot of savings and a better ability to serve your customer base.”
Good design occasionally triumphs, but even then, it ends in some act of surrender. Washington’s Carbon Design Group took one company’s proof of concept for a system to remove plaque from peripheral arteries–a confusing welter of tubes, pumps, and burrs–and turned it into an error-proof console that could prevent hundreds of thousands of people from losing their limbs each year. Pathway Medical Technologies’s PV Atherectomy System works by running a catheter into the body, then a drill bores plaque out of arteries no wider than a Bic. One pump mainlines saline to the catheter tip in the blood vessel, another dispatches the discarded plaque (and other goop) into a collection bag. Affix the goop tube to the saline pump, and your patient’s in serious trouble. So Carbon engineered the tubes to click into cartridges that work like one-way streets; even the most inept doctor can’t mis-attach them.
The designers, though, failed to sell Pathway on another aspect of good design–the sort Mother Nature can get behind. They wanted to engineer a non-disposable motor for the burr; Pathway, citing mechanical challenges, wanted otherwise. Balancing technical, financial, and environmental imperatives in a life-or-death field like medicine is tricky, and if you ask five health-care workers their opinion on reusing medical equipment, they’ll give you five different answers. But when you add to the equation a medical culture that sees only dollar signs in waste, the balance skews inevitably toward bottom lines. “The medical companies are for profit,” Peter Bristol, a lead designer at Carbon, says, speaking generally. “Disposables provide continuing revenue. Convincing companies to reduce is a bit of an effort because of that.”
Understandably. The health-care system doesn’t exactly encourage economy. Short of overhauling patent law, Dean Baker agitates for the United States to follow the lead of other countries, such as Canada and Germany, who negotiate down the cost of medical technology on the public’s behalf. Good product design will flow from a well-designed system. “You take away some of the money,” he says, “you give people less incentive to act in ways that are to some extent antisocial.” There’s a thought: innovation for the public’s sake.