Progress and economy in medicine

Reduced health care budgets are expected to inhibit the progress in medicin e and to lower the quality of medical care. We postulate that these expecta tions are not justified if decisions in medicine will be based on scientifi c criteria. Using a clinical scenario we try to describe the difference bet ween true medical progress and application of new techniques. We also try t o give reasons for the advantage of differentiation between effectiveness a nd benefit of medical care. This differentiation leads to a hierarchy of cl inical-economic decisions, first on effectiveness and subsequently on effic iency. Effectiveness of medical care is assessed in the dimensions of effic acy, effectiveness, and benefit. Efficiency is assessed in the dimensions o f patient's preference, patient's compliance, and the relation of costs and consequences. Finally we use three examples to discuss the advantages of t hese assessments and the possibility of their realization. A necessary cond ition for this realization is the conceptual change from an effectiveness-o riented medicine to a benefit-oriented one. If we are ready to support futu re decisions on health care services by solid scientific evidence, we will sooner or later realize the huge gap in and the resulting need for relevant data on health care decisions. This need of investments will bind free res ources and will, if adequately directed, lead to a new and large area of se rvices provided by physicians the setup of a comprehensive health care data base. From these changes in medicine we can expect a reduction in the numb er of provided services which are characterized either by low effectiveness or by low efficiency (low eff services). This reduction step will be pract icable only if its economic component is compensated by other - more effect ive or more efficient - services. The rewarded setup of a comprehensive hea lth care data base is one of these meaningful and urgently needed possibili ties. Following this way it is rather unlikely that progress in medicine wi ll be inhibited; it is rather likely that the necessary resources for finan cing the progress in medicine will be not bound by low eff services but wil l really be available to pay for urgently needed information.