Speaking Notes

PADM 5791

Dr. Neubauer

March 17, 2009

WHERE WE ARE

• We are in Chapter 8 of our textbook which is on Health Care Technology
• My present plan is that you may take your final examination (in class) on either the 21st or the 28th.
• We will cover three more chapters during the final four weeks of regular classes this semester, prior to the 21st.

CHAPTER 8

As I read it, this chapter includes information about the impacts of technology on medical care (and the costs of medical care) in the U.S. followed by a lengthy section on several particular aspects of the situation that are especially controversial. That aspect is only going to become a lot harder as we move forward into genetic engineering and so forth. Almost anything is possible and what is possible will be done, somewhere by someone.

There is a lot of (private sector) research and development in new drugs and new medical devices because patent protection makes this a potentially very lucrative situation. Public offerings have become the single largest source of support for biotech firms. (our textbook, page 320)

The prospect of individually customized pharmacotherapy is amazing and is likely to be VERY costly (and produce huge additional ethical issues).

REMOTE PATIENT MONITORING has prospects to actually save money while improving the quality of people's lives.

Typologies of medical technologies offered on pp. 322-323 of our textbook.

• Nontechnology (?) -- lost cost, low efficacy
• Halfway technology -- reactive, relatively high cost
• High technology -- proactive, relatively low cost

The phrase, "halfway technology" appears frequently in this chapter. As opposed to "high technology" halfway technologies are REACTIVE and relatively EXPENSIVE.

Pricing mechanisms

• capitation/managed care
• retrospective reimbursement

	NON-TECHNOLOGIES	HALF-WAY TECHNOLOGIES	HIGH TECHNOLOGIES
MANAGED CARE		avoidance of high costs likely to lead to rationing	useful to prevent conditions that otherwise would be costly
RETROSPECTIVE REIMBRUSEMENT		"highly combustible mixture"	may be crowded out by high costs of half-way technologies

In the presence of insurance, neither providers nor patients are likely to let costs influence of demand.

Those without insurance may suffer or die, but many will receive at lease some medical care which will be paid for indirectly by higher prices charged to insured patents.

Believing that "science" can "fix" almost anything, Americans are not highly motivated to adjust lifestyles or go out of their way to use "high technologies."

Technologies are greatly expanding the range of what is possible, such as saving the lives of very low birth-weight infants. Such infants are likely to have large medical needs throughout life.

Many Americans expect providers to "do everything possible" to lengthen the lives of very elderly people "at all costs."

Practical and other economic realities cause our sense of SOCIAL EQUITY to run up against the fact that needs/wants exceed available resources -- for example in the instance of waiting lists for organs to be transplanted.

Hospitals BUY COSTLY TECHNICAL DEVICES as a way to market themselves to physicians, which is important because most (insured) admissions are through physician-referral.

Patients often value "half-way" technologies more than "non-technologies" such as convenience and "bedside manner."

Physicians are likely to be "geeks" -- meaning that they are likely to be fascinated by the newest technological "gadgets." Better tools can mean - - -

• better diagnoses
• better medical outcomes
• higher earnings
• higher reputations
• more personal satisfaction
• fewer malpractice suits

Patients are likely to view high technologies in a positive way and not realize the possible risks involved with repeated exposures to radiation, and so forth.

SOCIAL/POLITICAL/CULTURAL IMPLICATIONS

• Access to quality medical care largely seen as a RIGHT in the U.S.
• We are socialized to expect INSTANT GRATIFICATION.
• We are a highly litigious society. (I fight, I win, One call, That's All)
• Our faith in science sometimes produces unrealistic expectations.
• We assume that any pain or discomfort is unnatural and must be masked.
• We have been taught that we can have it all -- preferable right now.
• We interpret SOCIAL EQUITY as "bottom moving up" rather than as "top moving down"
• We tend to minimize INDIVIDUAL RESPONSIBILITY for one's own choices and behaviors
• We tend to discourage people from getting early help for mental/emotional problems until there has been some kind of a crisis.
• Advertising usually places premium value on youth and beauty that can have negative consequences in people's self-perceptions.

WHO SHOULD ASSESS NEW MEDICAL DEVICES AND ASSESS THEM FOR WHAT?

• They are assessed for safety and effectiveness -- not for cost/benefit.
• Providers (venders) have a bias in the assessment of the worth of new technologies.
• The authors of our textbook write that the government needs to be more involved.
• Patent protection may in fact be part of the problem.

MANAGED CARE AND THE COST OF HEALTH CARE TECHNOLOGIES

• Few studies have been completed
• Maybe what we need is the "William Shattner/Priceline" approach to "shopping" for medical services and technology.
• Albany Diagnostic Center -- what is their business model? Under what circumstances do patients go there rather than to a hospital?

BIOETHICS AND AREAS OF PARTICULAR ETHICAL PROBLEMS

Reproductive health services including alternatives to the traditional/natural means of conception.

Organ transplantation -- shortage of available organs and high costs of operations

Life support for persons in a "vegetative state."

End of life care and medical interventions.

SUMMARY

• This is a VERY EXCITING time -- bio-computer linkages, nanotechnology, life engineering and all the rest.
• The SOCIAL IMPLICATIONS go far beyond the costs of medical care.
• What can be done will be done by someone, somewhere.
• AS MORE BECOMES POSSIBLE it is unclear that humanity is ready and able to step up to the consequences of being able to manage what has always been only within the providence of the Devine.