Giacomini M K
J Health Polit Policy Law. 1999 Aug;24(4):715-58. doi: 10.1215/03616878-24-4-715.
To rationalize and restrict health care spending, policy, makers in many jurisdictions have withdrawn insurance or funding for selected health care technologies. Numerous analytic frameworks and applied exercises have emerged to guide decisions about "which" services to cut. But in their focus on choice-making processes, these efforts have paid little attention to the problem of defining and dividing the set of technologies to choose among. If technology assessment refers to methods for weighing services for their relative value, the term technology assembly might be used to refer to methods for framing the technological trade-offs to enroll in such contests. This article examines technology assemblies found in several types of theoretical and applied rationing exercises (including Oregon's Medicaid rationing process, economic evaluation literature, citizen "values" surveys, and Canadian provincial deinsurance policies). Based on this review, some key conceptual conventions and problems in technology assembly can be identified. The boundaries between health technologies are fuzzy, interlocked, layered, and continuously moving. Consequently, the defining features of technological trade-offs are inevitably socially constructed and negotiated. Trade-offs can be arranged along numerous dimensions, and the divisions typically correspond to broader political, administrative, and ethical dilemmas in health policy. Examples include equity among demographic classes, concepts of need, legitimacy of therapeutic goals, and so forth. Insights into the process of constructing technological trade-offs may help policy makers better question what technologies they are looking at and why, before moving on to the task of determining which ones to cover.
为了使医疗保健支出合理化并加以限制，许多辖区的政策制定者已取消了对某些医疗保健技术的保险或资金支持。众多分析框架和实际应用已应运而生，以指导有关削减“哪些”服务的决策。但这些努力在关注决策过程的同时，却很少关注如何界定和划分可供选择的技术范围这一问题。如果技术评估指的是衡量各项服务相对价值的方法，那么“技术组合”这一术语或许可用来指代构建参与此类竞争的技术权衡的方法。本文考察了几种理论和实际配给方案（包括俄勒冈州的医疗补助配给过程、经济评估文献、公民“价值观”调查以及加拿大省级取消保险政策）中所发现的技术组合。基于此项综述，可识别出技术组合中的一些关键概念惯例和问题。医疗技术之间的界限模糊、相互关联、层次分明且不断变化。因此，技术权衡的界定特征不可避免地是社会建构和协商的结果。权衡可沿多个维度进行安排，而划分通常对应于卫生政策中更广泛的政治、行政和伦理困境。例如不同人口群体之间的公平性、需求概念、治疗目标的合理性等等。对构建技术权衡过程的深入理解，或许有助于政策制定者在着手确定涵盖哪些技术之前，更好地审视他们所关注的技术及其原因。
