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Ezekiel Emanuel Confronts Health Care Costs – and Doesn’t Like What He Sees

Just describing the huge challengeof reforming the health care system of the United States demands drama and superlatives,so Ezekiel J. Emanuel, MD, PhD, was ready. He was the presenter at a recentGrand Rounds sponsored by the department of Psychiatry at the Perelman Schoolof Medicine, called “Health Care Reform and the Future of American Medicine.”Emanuel began by citing a figure: $2.80 trillion. That, he told the large audience,was how much was spent on health care in the United States in 2012. Heencouraged the audience to consider that figure. “Trillions are, like, out ofthis world!” By itself, that total makes U.S. health care “the fifth-largesteconomy in the world,” surpassed by only by the economies of four entirenations. In 2010, Emanuel continued, the United States spent $8,362 per capita.Considering that the country has more than 300 million people, that, Emanuelasserted, “is a huge amount ofmoney.” In comparison, during an equivalent period, the total cost of SocialSecurity was $730 billion and defense spending $660 billion.

An oncologist by training, Emanuelis the Diane v.S. Levy and Robert M. Levy University Professor and chair of thedepartment of Medical Ethics and Health Policy. His CV includes stays at theNational Institutes of Health, where he was founding chair of the department ofbioethics, and the White House, where he helped frame the Affordable Care Act.After earning a doctorate in political philosophy, in other words, he has hadplenty of real-world experience in the political trenches. As he noted laterduring the question-and-answer segment, his support for training doctors totalk to their patients about end-of-life care “got me called Doctor Death” bysome opponents of the ACA.

One of the surprisingcharacteristics of health care, Emanuel said in framing his discussion, is thatit does not perform the way other essentials like food do; instead “it behaveslike a luxury good” – like diamonds or Maseratis. From year to year, the nationadds another $100 billion more to the total. Where does all the money go? Heshowed a list of possibilities, including insurance companies, “nasty drugcompanies,” defensive medicine, and demanding patients. As it turns out,Emanuel continued, defensive medicine accounts for less than 1 percent of thebudget (“almost no effect”); insurance companies and drug companies account forabout 10 percent each. Two sizable portions are hospitals (31-33 percent) anddoctors (20-22 percent). But the main driver, Emanuel emphasized, is technology.

The implications are very serious.Rising health costs jeopardize other aspects of the commonweal, such ascoverage and access to health care. Higher costs mean families may decidecoverage is too expensive. State budgets are strained, leading to higherMedicaid costs and higher premiums for state employees. Ultimately, Emanuelargued, the high costs accelerate the shrinking of the middle class (during atime, he noted, when corporate profits increased 200 percent). The cost ofhealth care “affects our world standing . . . undermines our ability to dothings.”

After painting such a grim picture,Emanuel offered some possible solutions. Regarding the Affordable Care Act, hesaid, “The really important part of the bill” is how we change the delivery ofcare to our patients. Half of the population (the young, on the whole) consumesvery little of the total – about 3 percent; whereas 10 percent uses nearlytwo-thirds of it. “The key to saving money,” Emanuel stated, “is prevention”:keeping the population healthier and keeping people out of the health care system as much as possible. Can we do it? heasked rhetorically. Emanuel did not hesitate: Yes.

Emanuel cited the “Three I’s”: informationbased on comparative effectiveness research, infrastructure, and incentives. These,he argued, will help re-engineer care for higher quality and lower costs.

As an example of success, Emanuel pointedto a local organization, Main Line Oncology Hematology Associates. Thepractice has modified electric medical records; doctors have prompts tocomplete their notes; adherence is tracked and deviations requirecustomization. There are fewer low-level employees and more qualified nurses,who are used to treat common symptoms. In addition, “nurse navigators” provideconcierge care, gathering all pertinent clinical data, coordinating with otherdoctors (complete with “hand-off” agreements to maintain care), and doingtelephone triage. According to Main Line Oncology’s data, 77 percent ofsymptoms were managed at home, and there was a 51 percent decline inhospitalization.

Emanuel’s second example of a betterway to run health care was CareMore, whose headquarters is in California. CareMore,which treats older patients, has mobile medical units; has 24/7 accessibility,which reduces having to send patients to emergency rooms; and makes use ofproactive monitoring of its patients and “advanced predictive modeling.” Ofparticular note, Emanuel said, is the organization’s focus on patients’ psychiatricissues. They are routinely screened even before they go for treatment, because,as Emanuel noted, psychiatric problems exacerbate other health problems. CareMore’sreported data are also impressive: a hospitalization rate 24 percent belowaverage; hospital stays 38 percent shorter; and readmissions 25 percent less.

“I’m an optimist when it comes tohealth care reform,” said Emanuel. He conceded that it will be “bumpy,” becauseof the necessary transitions. But, he concluded, “By 2020, the American healthcare system will be better than it is today.”



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