The challenge of providing affordable, high-quality health care for all Americans is the subject of furious debate in the nation’s capital. University of Pennsylvania’s Ezekiel Emanuel, chair of the medical ethics and health policy department and a health care management professor at Wharton, helped craft the Affordable Care Act during the Obama administration. He puts forward some ideas for improving the system in his book, Prescription for the Future: The Twelve Transformational Practices of Highly Effective Medical Organizations.
The book is aimed mainly at practitioners and professionals in the health care system to spark ideas about providing better care at a lower cost. Emanuel recently joined the Knowledge at Wharton show, which airs on SiriusXM channel 111, to talk about the findings in his book.
An edited transcript of the conversation follows.
Knowledge at Wharton: Who is the target audience for this book? Is it the public or the people working in the health care system?
Ezekiel Emanuel: It’s really both, but I would say primarily it is people in the health care system who need to understand that the system is changing. Everyone in the system knows that. They understand that the direction is towards being paid for more value, and the real question is, what do I do? If I’m in the system, if I’m a doctor or a health care executive, or I run a hospital, or I’m a nurse working in an organization, what do I do to move it along to the next level of performance — higher quality, lower cost?
There are also important lessons for the average person who is looking for a doctor. The last chapter in the book is about, how do I choose my doctor given all of these changes in health care? To make sure I actually have one who provides high quality care, and I just don’t go to the magazines that rank the 50 or 100 best doctors in the neighborhood.
Knowledge at Wharton: Most Americans think, ‘I get insurance from my work and don’t have to worry about it.’ But for a lot of people, the 20 or so million on the Affordable Care Act, they have more of a personal investment trying to figure it out.
Emanuel: In some ways this book is for both of those. If you work for a big company, you get the insurance through them. So, that’s the insurance part of it. But how do I navigate the system part, how do I get my services, which doctor do I go to, which health system do I go to? That is still up to me largely, and I have to make those decisions. Some employers are helping with that but, by and large, these are still my decisions.
This book is about what questions you can ask that would indicate that you have a pretty high-performing doctor or health system. And if you’re a doctor or a hospital or some other delivery component in the system, what do I need to do to take myself to the next level?
“I often say that if you put conservative and liberal health policy people together in a room, we could solve the issue.”
Knowledge at Wharton: You bring up the fact that the accountability of doctors, and the health care system in general, needs to be addressed.
Emanuel: One of the 12 transformational practices we identify in the book is performance metrics and performance management. If you’re a doctor or a hospital, you have to begin understanding how well you perform relative to national benchmarks and to other people in your area, and what you can do to improve. For too long, doctors have not had any information on which to base that.
When I was practicing oncology in Boston, it’s like, did I do a good job with my breast cancer patients or not? I had no information. Was I over-treating them? Was I over-testing? I had no data. Well, one of the good things about the current system is we actually have data.
Knowledge at Wharton: Right, but is it fully understood?
Emanuel: First of all, doctors are resistant to some of that data. But a lot of people in the system don’t actually understand it, don’t have access to it. That’s the negative side of it.
The positive side is the government has been creating more performance measurement, at least on the Medicare side of things. You can go and look at the performance of hospitals, at the performance of health plans under the Medicare Advantage Program, which is the managed care part of Medicare. It turns out that when they have that data, they have been migrating to the better performing systems. That measurement, albeit imperfect with all of the caveats we want to surround it with, does shift people to some degree.
Knowledge at Wharton: You talk in the book about how there are doctors in individual practice or medical organizations out there who are making these shifts and trying to improve the system on their own. It’s a little bit like the water dripping out of the faucet, not the gush we need at this point.
Emanuel: Right. One of the purposes behind the book was to say, what is happening out there that is positive and what could we learn from those positive experiences? It does turn out that there is a lot happening out there. It hasn’t coalesced into a gush that everyone can see, and part of the point of the book is to say you can be optimistic because we do have some insights as to what works and what doesn’t work. A lot of the 12 domains I point out are experimental, for lack of a better word. People are trying them out, trying to validate them.
But on things like chronic care management, open access scheduling, performance measurements, standardization of practices, even behavioral health — in all of those we do have important models. If I had to say what is the one most important thing out of the 12 that people have to do, I would say that it is good chronic care coordination and management. In part, because 84 cents of every dollar in health care is spent on patients with chronic illness, so it’s where the money is. It is critical to keep these people healthier — that will also save us money because we will use the system in a much better way.
Lots of people have tried chronic care management. It’s not like it’s a new idea. But they have tried it did quite badly. For example, the insurance company will have a nurse call up people [to follow up]. Well, under no [circumstances] are you really going to listen to the advice of that nurse.
But there are places that have been doing this for 30 years with very sick patients and are very successful. They identify their high-risk, high-cost patients. Again, most of that is not some fancy algorithm produced by Silicon Valley, it’s by asking the nurses and doctors, it’s the patients they see, the patients they worry about. Then you have these chronic care managers actually co-located and embedded in the practice who work side-by-side with the doctors. They are empowered to reach out to the patients; they don’t wait for the patients to come to them.
One of the most impressive places in southern California is CareMore, and for their diabetics they run a toenail clipping service. Now you ask, why are you doing toenail clipping? Diabetics have a hard time feeling their toes because one of the side effects of diabetes is neuropathy. You can’t feel very well in your extremities. If you cut your own toenails, you might clip your skin and allow infection to develop. The next thing you know, you’ve got gangrene then amputation. That’s a very costly complication. Also, while clipping toes it is possible to talk to someone in a more intimate way and get a lot more useful information about the stressors in their life, how hard it is to follow the diet, things that you can then tweak and make their care better.
Knowledge at Wharton: Conversation also needs to happen to improve scheduling.
Emanuel: I am exhibit No. 1 of that problem with scheduling, where I tried to schedule my doctor here at UPenn and the first appointment I could get was seven weeks down the line. It’s like, this is not the modern era. When I began the project, I had no idea that scheduling was going to be really important. But it turned out scheduling is very important because the right scheduling system allows the health system to actually take care of today’s problems today. It allows them to take care of it in the doctor’s office as opposed to sending them to an emergency room, where it will be more expensive to deal with and you won’t have someone who really knows the patient.
“Eighty-four cents of every dollar in health care is spent on patients with chronic illness.”
What open access scheduling means is when a doctor starts the day, between 20% to 50% of their appointments are empty for people who are going to walk in, people who have a problem that day, or people who find themselves with the free time and need to just finish up some routine care like their mammogram or their pap smear or whatever. That open access scheduling is very important to efficiency. Places that have transformed [health care], almost all of them have open access scheduling.
Knowledge at Wharton: Is it doctors who are resistant to following that model?
Emanuel: Totally. Doctors get nervous. They think, I’ll have open [appointments]. I won’t collect the revenue and make enough money. Then who is going to pay the office debt? It doesn’t work that way.
Knowledge at Wharton: And I’ve got to pay back my loans for medical school.
Emanuel: It turns out that if you do open access scheduling, typically you get fewer no-shows. If I schedule now something for six weeks from now, when six weeks rolls around something else comes up and I don’t show up. Whereas if I called today and can go in two hours, I’m not going to miss that appointment.
Knowledge at Wharton: Part of the problem with health care today is not related to anything around actual care, but it’s the people in Washington, D.C., who are negotiating what is going to happen. You have met with President Trump on a couple of occasions. This has become way too political, in my opinion.
Emanuel: Yeah, it’s definitely become too politicized. I often say that if you put conservative and liberal health policy people together in a room, we could solve the issue. But when it becomes political, we’re doing it for other reasons. We’re doing it to satisfy our base, etc. Then you have a real problem. People who think it doesn’t affect them should think again. If the insurance exchanges collapse because of uncertainty created by the Republicans and President Trump, if Medicare rates don’t keep up, if Medicaid gets cut back and more people become uninsured, that is going to affect all of us.
There is something called cost shifting, which is if hospitals and doctors still have to provide free care to these people because they are sick, but the providers can’t collect money, they are going to increase their rates in other parts of the system for people who have regular insurance. We’re all going to end up seeing higher payments. That’s not a formula for everyone liking the system. A lot of this really does affect the entire country.
Knowledge at Wharton: A lot has been discussed about what works and what doesn’t with the Affordable Care Act. You were in the frontline many years ago. I heard an interview in which you said that if this was a corporation, things would be tweaked as they go along.
Emanuel: I wouldn’t say it’s a long list, but there are probably five pages of things that need to be done, most of them focusing on affordability. Once you’ve got a lot of people in the system, people are content in terms of their options. We’ve got a country of 300 million people; not everyone is always going to be happy. But the big problem has become affordability. We need to get our handle around affordability. There are a lot of things that can be done to try to bring the cost down, but we have paralysis.
“One of the most impressive places in southern California is CareMore, and for their diabetics they run a toenail clipping service.”
The thing that I find so strange is that President Trump did run on the issue of affordability in insurance. He kept talking about how high expenses were, how high drug costs are. This Republican bill has literally zero on affordability, and if anything it’s going to make affordability worse. How does this match up with what the American public wants? Part of the problem is the political problem. We’ve had paralysis in Washington, so you haven’t been able to make the changes to the Affordable Care Act you need to.
Everyone like me, people who worked on it, say we’ve got to make changes. No company would put in place a policy and not revise it over seven years. That is an insane system. But we have 535 people on the board of directors of the Affordable Care Act. They’re called senators and congressmen, and they don’t want to agree and actually do something. That is no way to run a system. When Hillary Clinton ran, she had a list of things she wanted to do to fix on the Affordable Care Act. No responsible person says we shouldn’t fix it. It just doesn’t make sense. Most people say we should repair it. Even conservatives say we should repair it and not throw it out.
Knowledge at Wharton: One of the other things you talk about in the book are these mega trends you would like to see occur, specifically about specialties in the health care sector.
Emanuel: One of the problems we have in the United States — and this has been long recognized — is that we have too many specialists compared to primary care doctors. We need more primary care doctors, and it is a challenge to both. When you have too many specialists, you end up with a lot of specialists doing a lot of primary care. When I was an oncologist, I would be managing the diabetes or the congestive heart failure for my patient as we’re treating them for their cancer. That is not a good system.
You should have primary care doctors doing most of the management and then bringing in the specialists as consultants for patients who are really sick or have complex problems. I think that we’ve lost that. Again, places that have transformed have had this different relationship between primary care doctors and specialists, mostly using specialists as consultants to confirm diagnoses, to confirm a course of treatment. Not using them to take over the management of bread-and-butter health problems.
Knowledge at Wharton: Why do you think there has been this run towards specialists in the last 70 years?
Emanuel: A large part of it comes after the war. Specialists get paid more, so more people go into specialties. In the VA system, specialists had higher rank. Specialists who had procedures, like cardiologists with catheterization and stuff, got paid for those procedures and could make a lot more money. It really incentivized people to go into specialties. We have to reverse that. In England, primary care doctors are the highest-paid doctors on average in their system. The specialist has prestige of the specialty, but the primary care doctor needs something else to keep them in and keep them attractive.
Knowledge at Wharton: But what does focusing on more primary care physicians do to the industry?
Emanuel: That is a really good question. I spent time writing an essay about the changes we need in American medical education, and one of the big changes we need is to move a lot of the training out of the hospitals. If you go to medical school, roughly the first two years is book-learning about anatomy and biology. But the last two, two-and-a-half years is about training on your clinical studies, so clinical rotations. Typically, they are in the hospital.
“There are a lot of things that can be done to try to bring the cost down, but we have paralysis.”
It turns out that hospital care has really gone down in this country and outpatient care has gone up. Yet we train our doctors in the hospital as if that is where they are going to see most of their patients, but that is just not true. One of the big changes we need is to train our doctors differently, train them more in the outpatient setting and less in the hospital. That is a hard thing to do.
Knowledge at Wharton: Is it hard because of the hospitals themselves?
Emanuel: No, it’s hard because how do you supervise them? How do you standardize the training when they are all in 120 different physician practices? How do you incentivize those physicians to make time to teach students?
Knowledge at Wharton: Are we getting any closer to having a system that will be relatively simple for people to get coverage basically a la carte?
Emanuel: You don’t want that, and the reason we don’t want that is you don’t know what is going to happen to you. You say, for this year I want coverage for X, Y and Z. Say you start that in January, but it turns out in March you have an accident or get pregnant. Lots of things can happen. I think a la carte is a very bad idea.
For example, probably a lot of people say they don’t need mental health. Turns out that mental health problems are very, very common and badly managed. In outpatient, about 30% of people with chronic illnesses have depression or overlying anxiety. They raise substantially the amount we spend on the system. One of the things the best organizations are doing is addressing those mental and behavioral health problems upfront and not sweeping them under the rug, which is what we’ve done for the last 100 years.
So you don’t want people saying they don’t want mental health because they might need that mental health, especially if they get diagnosed with a chronic condition. Cancer is one problem, but the depression that comes along with that diagnosis is another problem that needs to be addressed.
Knowledge at Wharton: There is a growing concern around opioids right now and getting a system in place that better manages that problem.
Emanuel: This is one problem that we have more or less ignored. We’ve known since Richard Nixon was president that we need good substance abuse treatment in the system, that it’s the cost-effective way to deal with opioid abuse. We also know that we really have to stop the pill mills and the doctors who have abused the system. And the drug companies frankly that have abused the system.
Until we get serious about getting the doctors and drug companies that have abused the system and getting in place these opioid treatment centers, it’s going to be hard to get our arms around this. It is seriously addictive stuff, and it’s not [about just harnessing] willpower. No, for 99.9% of us, we do not have that kind of willpower.
