Dr Ezekiel Emanuel's "Prescription for Success" to Improve US Healthcare

At the America’s Health Insurance Plans (AHIP) Institute and Expo, held in San Diego, California, June 20-22, Ezekiel J. Emanuel, MD, of the University of Pennsylvania’s Wharton School and School of Medicine, presented his “prescription for success” for improving healthcare in United States.

To begin, Emanuel showed several sobering slides demonstrating how healthcare in America is becoming increasingly unaffordable each year. The $3.4 trillion we spent on healthcare in 2016 makes American healthcare the world’s fifth largest economy, behind Germany. This growth in spending, however, hasn’t led to proportionate increases in life expectancy, as it has in other developed countries in recent decades.

What’s driving these disparities between American health outcomes and the rest of the world, Emanuel wondered. It’s not that France, for instance, has discovered a magic new gene or has access to innovative drugs we don’t have. Instead, “the difference is how we’re delivering care, and that is on our shoulders,” he said.

He cited several examples of unnecessary or inefficient care leading to wasteful spending. For instance, proton beam therapy centers have sprung up across the nation, even though there isn’t clear evidence of the therapy’s effectiveness for some cancers it’s being used to treat, like prostate cancer.

With these challenges in mind, Emanuel offered some solutions. He sees the shift toward bundled payments, alternative payment models, and population-based reimbursement as especially promising, although the transformation has not been as rapid as he had pushed for while he had served as a special advisor on health policy in the Office of Management and Budget during the Obama administration.

In an interview with The American Journal of Managed Care^® (AJMC^®), Roger Francoline, a senior executive at Remedy Partners and bundled payment expert, agreed that "the progress is slower than everyone would have liked at this point in time. I think that there has been resistance in the marketplace, but the resistance has been on the side of the administrative capabilities." As providers are being offered various opportunities to join bundled payment programs, “There needs to be a certain level of standardization so that we help ease the administrative burden and cost for the provider organizations.”

During his presentation, Emanuel cited some positive early evidence from bundled payments showing that they produce greater average savings than a fee-for-service system without differences in mortality, readmissions, or satisfaction. Practices implementing orthopedic bundles have seen increased efficiency due to shorter procedure durations, reduced prices for implants, and a shift toward lower-cost facilities like ambulatory surgical centers or physician offices.

A study co-authored by Emanuel and published in the June issue of AJMC^® examined how physicians’ practice variation has changed under bundled payment. They found that variation decreased the most for implant costs, but changes in institutional postacute care provider utilization or total episode payments were not significant, indicating that “variation reduction is not an absolute requisite for success under bundled payment.”

While there may not be absolute requisites for success under any payment model, Emanuel identified a few best practices he had identified after observing successful providers across the country. First, chronic care management has been proven to lower costs significantly by embedding care managers into primary care teams and empowering them to proactively reach out to and educate high-risk patients about their illness and how to navigate the health system. This approach, which he saw replicated over and over again in accountable care organizations, can reduce costs by 20%.

Second, Emanuel discussed the need for the American health system to better address behavioral health, which is the fourth largest spending area but often garners less attention. (He confessed to the audience that he got the lowest passing grade in his medical school psychiatry rotation because he didn’t take it seriously at the time.) Some promising avenues include co-locating behavioral health specialists in primary care practices and utilizing virtual medicine to conduct remote consults.

Overall, his nationwide tour of practices left him “wildly impressed” and “very optimistic” about the future of healthcare in America.

“We are the most innovative and entrepreneurial people on the planet,” Emanuel concluded, “and when we put our minds to something”­—whether that something is craft beer, wine, chocolate, or even healthcare—“we succeed.”