Science has a habit of making the excesses of the past look like fundamental needs today.
Take, for example, laparoscopic surgery. As it was being pioneered, laparoscopic surgery was seen as an expensive and needless gamble.
It required that hospitals purchase specialised equipment, that surgeons learned entirely new techniques, all while patients bore the costs and risks of a novel approach. To any payor, comparing it against established open surgery, the case for paying more was far from obvious.
Back to the present, and laparoscopic surgery is routine across a wide range of procedures. It affords patients smaller incisions, smaller hospital stays, and faster recoveries.
As a matter of fact, it is now considered so routine – and open surgeries so unusual – that the conversion of a laparoscopic surgery into an open one is often used as a measure of surgical outcomes.
It is, of course, tempting to turn this tale into a parable about the inevitable triumph of innovation. It would enable one to easily draw a parallel to the next frontier of modern surgery, namely, robotic surgery. Expensive and questioned today, but indispensable tomorrow. The defence rests its case.
This might be a convenient conclusion. But it would also be an intellectually dishonest one.
Robotic surgery’s future may see it transform some procedures, or prove its value only for selected indications, or perhaps deliver merely incremental benefits that never rise to justify its considerable cost.
Just as the history of medicine has seen many novelties permanently alter clinical practice, so has it watched as the industry wastefully adopt many that ultimately disappointed.
The difficulty is that we cannot always tell which is which. At least not in the beginning.
This leaves the health care system with a devilishly difficult question: how do we decide, given limited information, what is worth paying for without knowing if today’s excesses will become tomorrow’s needs?
Private hospitals do not generally invent new medicines, devices, or surgical techniques. That is work undertaken by research institutions, universities, and manufacturers.
Private health care instead adopts these technologies, even while they are still expensive, and builds clinical services around them – translating inventions into deliverable care.
This is a far more involved process than the simple purchase of a machine. It requires trained surgeons, nurses, and technicians.
It requires adequate infrastructure, maintenance, and after-sales support from vendors. It requires judicious case selection balanced against economically viable case volumes.
Above all, it requires time. Time for the team to train. Time for processes to be implemented and bedded into everyday practices.
Time to identify appropriate patients and develop the referral pathways through which they may reach these services. Time during which the bills continue to accumulate.
But it is only with time that, should the technology prove useful, experience can grow. Competitors then enter. The equipment improves while prices fall. And soon, what was once available only to patients who were able to pay a premium, diffuses more widely.
There is, however, a serious counter-argument to this worldview: why should Malaysia go first?
As with any technology-driven endeavour, it is the early adopters who pay the highest prices, only to receive the least mature versions of the technology, all while assuming the greatest risk of clinical and commercial uncertainty.
Hospitals may invest millions, only to later discover that patient volumes are insufficient, that insurers are unwilling to reimburse them, and that the promised outcome improvements remain unrealised.
In fact, even when a technology succeeds, later adopters can still learn from the mistakes of its pioneers. This is the much-vaunted second-mover advantage.
Let larger and wealthier health care systems pay these tuition fees. Malaysia can wait for better evidence and learn from its peers, all while the equipment improves and prices fall.
It can then adopt, from a position of great confidence, these technologies that have survive scrutiny and are supported by a better-developed body of knowledge.
This worldview is a sound one.
In the aptly subtitled study Standing On The Shoulders Of Pioneers, Halls and team found that later adopters achieved comparable outcomes after fewer cases than the original pioneers. Knowledge generated elsewhere travels far and quickly.
Waiting does not always equal stagnation: it often means learning at lower costs and lower risks.
Indeed, countries with limited health care resources should not aspire to own every shiny new machine simply because it exists. Newness and novelty, in and of themselves, are not value.
In my previous article for CodeBlue, When Every Hospital Becomes The Same Hospital, I argued that not every difference in health care is waste – some differences reflect meaningful investments in improved systems, equipment, and capabilities.
Emerging technology, however, is perhaps the hardest test of this distinction: its costs are immediately visible, while its value takes time to establish.
And yet, the second-mover advantage rests on an important assumption: once a technology is proven, the capability to deliver it will be acquired as easily as the equipment itself. But this is not always true.
Machines may cross borders easily, but mature clinical teams do not. Expertise accumulates through patient volume. Referral pathways form around established centres. Manufacturers develop support networks where demand already exists.
Clinicians seeking to establish their practice at the frontier of medicine gravitate towards institutions where they are provided with the tools to do so.
And all this builds reputation. A reputation that, once established, attracts still more patients to create still more experience – a virtuous cycle the establishment of which is easier said than done.
Being late by design is, therefore, different from ending up unable to move. The former is strategic patience. The latter is systemic dependence.
The choice presented to us, then, is not between recklessly adopting everything and cautiously adopting nothing. Malaysia does not need to be a pioneer in every emerging technology.
A more sensible position is to become a selective fast follower, allowing others to resolve the earliest uncertainties while retaining enough expertise, capital, and institutional flexibility to avoid falling into an entrenched capability gap.
This does not mean we need a blank cheque. It means we need a pathway for adoption.
Not every hospital needs to acquire every new technology. Selective adoption will allow these designated centres to generate the volumes needed to develop competencies and properly measure outcomes.
With properly considered definitions for intended patients, outcome measures, and cost drivers, these centres will be well-positioned to review whether or not the promised value of these new technologies is actually realised.
This, in turn, means payors do not need to offer unrestricted reimbursement. Indications can instead be carefully defined, with conditional coverage offered in cases that fulfil these criteria rather than pricing out every emerging technology by putting it into an untenable position between price caps and complete exclusion.
Perhaps even manufacturers, via pay-per-use schemes and consignments, can bear some of these early commercial risks instead of transferring them in their entirety to hospitals and payors.
But even with these measures, some technologies will fail to demonstrate sufficient value and be withdrawn. This should not be seen as evidence of the system’s wasted effort. On the contrary, it is evidence that the system is capable of learning.
Early adoption should not begin from an assumption that a technology has already proven its value. Its purpose should be to discover, as quickly and honestly as possible, whether or not it works well enough to deserve a place in the Malaysian health care system.
Nobody should be required to pay for a treatment simply because it is new. But a system in which nobody will pay until a technology is already cheap, familiar, and universally accepted will have no mechanism for developing new capabilities of its own.
Malaysia may not need to be first, but it cannot afford to always be last. Prudence lies in knowing when to wait. Strategy lies in ensuring that, when the time to move comes, we still can.
Dr Ng Kuo Chern is a medical doctor with an MBA and works in hospital operations, where he is involved in service delivery, organisational improvement, and value-driven outcomes. He writes on health care systems, economics, and policy in his personal capacity. The views expressed in this article are the author’s own and do not represent those of his employer or any affiliated organisation.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
