Speaking Notes

PADM 5791

April 14, 2010

Dr. Neubauer

WHERE WE ARE

• I would like for each of you to take the final examination next week -- April 21st at the regular class meeting time.
• Study suggestions for the final are available on the web site. The final is likely to be about five essay questions, each of which may have multiple parts. I will be looking for one solid paragraph PER PART of each question. The final will be closed-book, without notes or other resources.
• This evening's material (below) reflects the final chapter of our textbook.

CHAPTER 11

Piecemeal legislation regarding managed care, such as required minimum hospital stays for newborn infants and their mothers does not scale-up well. If Congress designed a car one piece at a time it would be a "super Hummer." Perhaps there is need for a comprehensive foundation of services that all insurance policies must include. But even that is probably too "explosive" to create in our present political climate.

• The consequences of the continued pollution of our planet as it affects the health of citizens.
• Rising rates of autism, dementia and mental illnesses, the causes of which we do not understand.
• The increase in the number of costly halfway technologies that create chronic illnesses of conditions that in the past caused premature death.
• The prospect of new generations of customized drugs designed for specific individuals at very high costs.
• A mindset (and reality) in which INCREASED ACCESS and COST CONTROL are not both possible together -- a zero-sum mentality
• Demographics
• Technologies that bring us nearer to being able to create life and perform genetic engineering
• Immigration (it is a medical policy issue whether we want it to be or not)
• Demosclerosis
• Absolutist/dualistic thinking
• Political polarization fueled by "toxic" advertising, half truths and irresponsible advocacy
• Increasing threats of violence against public officials
• "Ethics wars" that will continue to be created as the bounds of scientific/medical abilities continue to evolve.
• The possible effects of radical life extension on world populations.
• The fact that there are limits to the capacities of planet earth.

Rationing is necessary and choices are hard when there are specific pairs of eyes holding our gaze. Do government agencies want to sit in the seat that Dr. Linda Peeno once sat in? Who can make those decisions? Can we always pretend that "we" did everything possible? Do we want to go further down the road of making judgments regarding medical treatments based on economic criteria (potential earnings) such that we judge others by their abilities and their professions? What is the value of a life and the proper criteria for making trade-offs between one very expensive procedure for this person and alternative uses for the same dollars?

Does competition lead to more efficient managed care organizations or does it cause them to engage in potentially "evil" marketing practices by hiding exclusions in the fine print and "engineering" ways to avoid large payouts to patients with very costly needs?

Long-term care is costly, whether in nursing homes or when provided by home health services.

There is tremendous administrative overhead in our present system related to figuring out who owes whom how much for what -- and with it great potentials for fraudulent claims. Any way to SIMPLIFY the system could help. This is the attractive feature of SINGLE PAYER approaches.

We have not yet mastered automated information systems. These applications are often poorly designed and because of their complexity are still often, "buggy." I continue to be concerned about the AUTHORATATIVE NATURE of such systems and their "stupidity" in light of the fact that artificial intelligence has yet to master COMMON SENSE. I fear we are offloading the management of knowledge onto computer systems that are not yet fully, "up to speed.") At another level, many cashiers are no longer able to count change.)

In times past, issues related to conception, birth, and death were largely "in the hands of God" and socially addressed through religious organizations. There was little that humans could do but let, "nature run its course." Our abilities will rapidly become more "god-like" and ultimately the responsibilities that we once could only defer to God will wind up as the burdens of government. It is not possible to hold God accountable (Job tried). Government is more accessible and cannot justify its actions (or inactions) to the satisfaction of every citizen or every major "kind of citizen." It is not "fair" to blame government for these ethical dilemmas. We forget that we are the government, or at least our claim that our nation is self governed.

I believe that our union is fragile and that some of these issues threaten to break the staining bonds of pluralism that hold us together as one nation. Much of the political dialog today is toxic and, in my opinion, threatens the nation as we know it.

The conviction that "the Washington bureaucracy" can't get anything right serves to counter moving in the direction of a command system rather than a market system. So far, we have not yet devised a market system that does not create PERVERSE INCENTIVES for someone, and it is unlikely that we will, given the power of interest groups.

The textbook ends on a gloomy note -- we are not going to solve this, now or even in fifty years.

There will be a future and we will continue to rock along. We need to go forward with a clear understanding of the challenges we face and the realities that apparently lock us into an evolutionary path. Something may happen that will jar the system (however defined) into a radically new "attractor." But if it does, it is not likely to be some good thing that causes the shock, nor will a new attractor (pattern) necessarily be good. Perhaps the best we can hope for in the near term is to continue to rock along, to somehow manage the level of conflict, and to at least understand the nature of the challenges we face regarding health care policy and politics.