It has been repeated ad nauseam in recent years that health care is changing rapidly. Today even the pattern of change itself is in flux: modifications seem to be accelerating and shifts are of a more profound nature. Moreover, the prevailing changes are highly interactive and send ripples through a health care arena which presents all the symptoms of turmoil.

In the United States, there is growing determination among health care institutions to slow down cost increases, particularly in acute hospital situations.

One major strategy is to finance and deliver more health care in the home, which is seen as less expensive than institutional alternatives, of equal quality, often more humane, and preferred by many patients. As a result, this practice will most likely become more prevalent as long as quality of care is sustained, even if the costs are comparable to hospital care.

As in many industrialized countries, the national health insurance system of Belgium is concerned about endemic financial losses. In response, the government has probably resorted to the final revenue-producing remedy, an increase in social security contributions, and several reductions in reimbursement rates have been instituted. This classic remedy cannot be repeated again, because some professionals either will not survive or will react with a consumption increase. Other ways must be found rapidly to provide enough savings. This is the essential issue that concerns the policy maker in Belgium, and probably in most developed countries as well.

Throughout the industrialized world—from the United States to Japan, from Scandinavia to Australia—the theme of cost containment dominates the discourse on health care. This issue is the offspring of successful past efforts to ensure all patients effective medical care. While many countries have groups with special health disadvantages, the great majority of people in the industrialized nations have access to modern medical care and make ready use of it. The problem now is its cost, as aging populations, increasing in number as the result of advanced techniques that are more effective in prolonging life, place considerable strains on health care budgets.

For patients who have had the misfortune to develop terminal renal failure, three basic modes of treatment can be offered. One is renal transplantation, with a graft taken from either a living or a cadaveric donor. When successful, it offers the best quality of life and treatment for patients with end-stage kidney disease. However, the elderly and those with severe cardiovascular or systemic complications are not always suitable candidates for renal transplantation (1).

Economic appraisals of health care come in various forms and tackle different questions. A treatment is worth providing, in economic terms, if the benefits it produces outweigh the costs of provision. New treatments and methods of delivery should be substituted for old ones if they allow more patients to be treated for the same cost, or the same patients at less cost. These are the basic issues which cost benefit and cost-effectiveness analyses address.

This essay traces the evolution in France of a clinical research program to perfect an artifical parenteral nutrition device which would be well tolerated by the patient, an ambulatory system which could eventually be used at home. It began in 1970, when we were struck by the number of patients being treated in hospitals for denutrition and the length of time required to reestablish nutritional equilibrium. Moreover, the denutrition of these patients retarded their oncological therapy. Our main goal was home nutrition. Adequate nutrition should be viewed as an adjunct therapy and since people generally eat at home, why not artifical nutrition at home?

As in all European countries, Germany's public health service expenditures have climbed significantly over the last few years, outstripping increases in GNP and cost of living increases. A detailed analysis of this development shows hospitals to be the sector where costs are escalating the most rapidly.

In the last decade, the incidence of mortality caused by malignant disease has risen. Cancer related deaths are more frequent than those caused by infections or accidents, exceeded only by heart and vascular diseases. In most cases, it is not the primary tumor that kills patients, but its metastatic spread: metastases have a fatal outcome more than 90% of cases (1). By the time metastases have occurred, cure is rarely obtained through surgical procedures. Local radiotherapy to distant metastases is also rarely successful in the treatment of disseminated malignancies. Most patients with metastatic disease need a palliative systemic treatment, which means cytotoxic cancer chemotherapy. Its objective is to destroy cancer cells. Systemic chemotherapy has become standard in the last decades for most disseminated malignancies (1).

In 1971, Victor Papanek published Design for the Real World (1), a book which attacked the lack of problem-oriented and population-based reasoning in industrial design. The lack of congruence between need and production, from Papanek's perspective, had resulted in exotic, costly, and idiosyncratic responses to a gadget-oriented market (2).

It has long been assumed that the service sector—that part of the economy devoted to producing intangible commodities—will continue to grow and become the major employer and generator of wealth in developed societies. Such writers as the American sociologist Daniel Bell assume that countries of the first world will advance naturally to become “postindustrial” (i.e., postmanufacturing) societies.

“Service workers” already constitute over half the work force in most developed countries, and take comfort from a view which seems to guarantee their future livelihoods. But, their comfort may be unfounded. I shall outline a contrary, less cozy, alternative view, and suggest its implications for the medical sector.

Curtiss, F. R. (1984). Reimbursement dilemma regarding home health-care products and services. Am. J. Hosp. Pharm., August, 41(8), 1548–57.

Reimbursement mechanisms for home health-care products and services are discussed in detail. The two major categories of the home health care industry—(1) skilled nursing, homemaker, and other services, and (2) equipment, supplies, and other products (including drugs)—are reimbursed by third-party payers differently. While prospective pricing of inpatient care encourages the growth of home-care services, government administrators are concerned about potential spending growth at time of ballooning deficits, and private health insurers are uncertain about coverage criteria. Nuances of Medicare coverage criteria and private insurance reimbursement for home health care services are described. Medicaid coverage of drugs and biologicals for home patients is also described. The Health Care Financing Administration (HCFA) is expected to clarify and restrict Medicare coverage and payment of home-care products, equipment, and supplies. Medical justification will probably become more specific with greater attention to patient diagnoses and prognosis of patient therapies. Per-case payment methods will be refined to encompass home care. The government and private insurance programs will move toward capitation payment methods under which institutions will have even greater incentives to develop sophisticated home-care programs to substitute for institutional care. L.A.M.

This paper recounts the origins of consensus development as a means of technology assessment and traces the evolution of the process from its rather amorphous and variable beginnings to the codified and consistent model of today. Where appropriate, evaluative findings and anecdotal observations will be recounted.