Only doctors can save America


Dr. Ezekiel J. Emanuel, one of the brains behind Obamacare, has a blunt message for his fellow physicians:

Only you can save America.

He's not just talking about medicine. As might befit someone who holds a faculty title at the business-oriented Wharton School at the University of Pennsylvania, Dr. Emanuel spent much of his keynote address here at the American College of Physicians' annual meeting in San Francisco talking about the U.S. economy. The enormous impact of runaway spending on U.S. health care threatens "everything we care about," including access to health care, state funds available for education, corporate wages for the middle class, and the fiscal health of the nation, he said.

"More than any other group in America, doctors have the power to solve our long-term economic challenges to ensure a prosperous future," Dr. Emanuel said.

Dr. Ezekiel J. Emanuel

If the U.S. health care system were a country, its nearly $3 trillion economy in 2012 would be the fifth largest in the world, behind only the U.S. as a whole, China, Japan, and Germany. "We spend more on health care in this country than the 66 million French spend on everything in their society," he said. "It is an astounding number how much we spend on health care."

Take just the federal portions of Medicare and Medicaid, excluding state spending, and you've still got the 16th largest economy in the world, bigger than the economies of Switzerland, Turkey, or the Netherlands, for example. The impact of any other fiscal variable on the U.S. economy, including Social Security, is swamped by the impact of health care costs, said Dr. Emanuel, who is also chair of medical ethics and health policy at the University of Pennsylvania, Philadelphia.

Per person, the United States far outspends other countries when it comes to health care, and the proportion of the gross domestic product consumed by health care keeps getting larger and larger.

Dr. Emanuel served as a special adviser for health policy to the director of the federal Office of Management and Budget in 2009-2011 - during the design, passage, and first steps to implementation of the Patient Protection and Affordable Care Act (commonly known as Obamacare) - and he seemed to address some critics in absentia who have claimed that health care reform will lead to unwanted rationing of care. There's no need to ration, Dr. Emanuel said. Switzerland doesn't ration care, and it spends far less per capita for what is considered quality health care. "We can do a better job in this country of controlling costs without the need to ration care," he said.

The only way to really control costs is to transform the way U.S. health care is delivered, he said. Ten percent of U.S. patients account for 63% of dollars spent on health care. "You know who they are - people with congestive heart failure, COPD, diabetes, adult asthma, coronary artery disease, cancer. People with chronic multiple chronic illnesses. That's where the money's going. That's where the uneven quality is," and that's where health care delivery needs to improve, he said.

Dr. Emanuel proposed six essential components to transforming the health care system. Among them: The focus needs to be on cost according to value, and getting rid of services with no value. The system must focus on patients' needs, not on physicians' schedules or other concerns. And the system must evolve toward clinicians working as teams including allied health professionals, not as individuals. "We are not going to be, going forward, one-sies and two-sies in practice" anymore, he said.

Greater emphasis on delivering health care via organizations and systems, standardization of processes, and transparency around price and quality will be essential, he added.

Transparency in pricing and quality isn't just something consumers will want. Physicians will want it in order to refer patients to quality care and set prices appropriately, Dr. Emanuel argued. "I think this is inevitable, and I think it's going to happen faster than you think," he said.

Most U.S. physicians are stuck in fee-for-service payment systems, which don't provide the incentives needed for change, he said. Doctors "as a group" should push for changes to the payment system, which will increase physician autonomy but also will assign more financial risk to physicians. "I see no way of getting out of that," Dr. Emanuel said.

In his eyes, if doctors don't push for changes in how health care is delivered, we basically can kiss the U.S. economy and future prosperity good-bye. "Doctors are the only people who can re-engineer the delivery system," he said. "If you don't do it, it ain't gonna happen. It's that simple," he said. All previous reform efforts that did not have physician leadership have failed.


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