He was waiting outside the Doctor Radio studio, reading through his notes, when I got there for the interview. I would be speaking with Dr. Ezekiel Emanuel, former adviser to President Obama and a major architect of the Affordable Care Act, about his new book, "Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations." Though I had debated him several times on Fox News about health reform, this radio interview would not be a debate about ObamaCare or the various attempts to repeal and replace it. Rather, my guest, the world-renowned vice provost for global initiatives and chair of medical ethics and health policy at the University of Pennsylvania, was there to discuss the crisis in health care and what could be done to reorganize health care delivery and change the essential culture.
He maintained that health care in the U.S. is too expensive (27 percent more per capita then the next closest country, Luxembourg) and too fragmented to deliver consistent quality. As he had in his book, he cited the example of “Mrs. Harris,” a patient who received an implanted cardioverter defibrillator (AICD) but didn’t know why. She saw several specialists, none of whom communicated with each other, most of whom duplicated tests that others had already done.
Emanuel’s book presents a “cure” for Mrs. Harris’s problem. While reading it, and again while interviewing him, I was surprised to find myself agreeing with many of the principles he set forth. He wasn’t talking about mandates or exchanges or subsidies, but rather about practical principles for making the practice of medicine smoother and more efficient while hopefully preserving quality. Key focus points included care coordination, standardizing variances, shared decision-making, behavioral health and the de-institutionalization of care. I agreed with the importance of all.
When it comes to the role of physicians, Emanuel and I see things somewhat differently. He acknowledges the importance of physicians as practice leaders, but he believes our performance needs to be measured with “health care effectiveness data” and “information set data sharing.” I am more concerned about the quality of a physician’s life, about the burnout rate, about a new study that found that physicians spend a whopping 86 minutes of “pajama time” documenting in Electronic Health Records every night.
Emanuel believes that “if the physicians do not aspire to and work toward achieving the highest possible quality of care, transformation will not happen,” and he believes quality of care and efficiency should be rewarded. I agree. But should a patient’s lack of compliance affect payments to doctors who are trying as hard as they can? I don’t think it should. What if a patient refuses to stop smoking or improve diet despite my best efforts?
Emanuel’s first transformational practice involves taking scheduling away from physicians to make it more centralized and efficient. He is right that physicians who control the scheduling book “have various ways of manipulating their schedules to their liking,” including padding them with stable patients and patients they like to talk to. But shouldn’t a hardworking physician who is overwhelmed with computer documenting be given some leeway here? I think so.
Emanuel’s book presents a clear model for reducing redundancy, where specialists work within their specialization only. Back pain is his powerful example of where overreaching generalists end up prescribing too many opioids or referring for too much surgery because of inadequate training in the field. We discussed his approach to dying cancer patients and when to call in the palliative care team. In his book, he describes with sensitivity the moment of transition from hope to comfort-care-only, and he points to Caremore, a transformational multiple-site health practice that focuses on community outreach and is particularly effective at approaching and coordinating cancer care.
Emanuel, an oncologist, became emotional at this point in the interview, describing how his views on treating terminal patients had led to accusations of “death panels” when the ACA was in its formative stages. “I went to President Obama and offered to resign,” he said, “but he wouldn’t accept my resignation.”
The hour we spent on the radio changed my views on health care delivery. I still see the insurance companies as too often providing a self-sustaining roadblock, rather being the automatic enabler of care they claim to be. And I am still concerned that using the word “insurance” as a euphemism for “care” is a bait-and-switch that helps politicians and insurers, but ultimately hurts doctors and their patients as much as it helps them.
But Emanuel and I achieved a meeting of minds and hearts on many principles of transformation, including teamwork and care coordination, even if we disagree on physician happiness or the ability to measure effectiveness. As a member of a large and highly successful faculty practice, I can tell you that many of these concepts work, and I am much more appreciative of my practice's success at preserving quality while decreasing duplication and increasing efficiency than I was before the interview.
On the political front, here were two partisan opponents coming together to share ways to treat and heal a broken health care system. Congress could certainly learn from this approach.