A predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking — free “checkups” for everyone — is one of the few provisions they aren’t attacking. Why should they attack them? Simple — checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?
How worthless are checkups? Dr. Ezekiel Emanuel — one of the architects of the ACA and its “free” checkup centerpiece — recently recommended not getting them. As if “free” is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups — or fine them if they don’t. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize.Continue reading…
In the October issue of The Atlantic, physician and medical ethicist Ezekiel (Zeke) Emanuel, brother of Rahm Emanuel (former official in the Clinton White House, then Congressman, then Chief of Staff for President Barack Obama, now Mayor of Chicago) published an article why he thinks we should all forgo advanced age and die at 75. As a 69-year-old moving toward 75, my response to that article is this blog post requesting a stay of execution from our newly appointed Czar of American longevity.
An Open Letter to Ezekiel Emmanuel.
Dear Ezekiel Emmanuel:
Please forgive me for taking so long to comment on your article in The Atlantic arguing that we should declare our lives to have reached their productive limit at age 75 and therefore gracefully exit this world before we move into an inexorable decline. Your article – “Why I Hope to Die at 75″ –– appeared in The Atlantic in October and here it is December and I have not joined the 3000 plus people who commented on it earlier. First, I confess, I did not read it until almost a month ago, and then, I had to stew in some juices before figuring out how to reply. You make many good points in your article. Americans do indeed consider themselves to be “immortals,” do prolong death rather than extend life when they push for futile treatments or agree when their physicians who too often recommend them (if they were not so enthusiastically recommended, would so many American patients so heartily sacrifice themselves on the altar of science?) But does the solution to the out of control medicine lie in declaring that 75 should be the age of exit? See, for example, Shannon Brownlee’s Overtreated.
In your article, you carefully explain why you have picked 75 as the human sell by date.Continue reading…
On Wednesday June 4, the Kellogg School of Management hosted its annual MacEachern Symposium. A packed auditorium listened to an impassioned discussion about The Future of the Physician. Presidential adviser Ezekiel Emanuel and AMA President Ardis Hoven were among the speakers. While Emanuel was optimistic about the impact of the Affordable Care Act on hospital-physician integration and the resulting potential for cost savings and quality improvements, Hoven was concerned about the impact of the business of healthcare on the medical profession. In this blog, we offer our perspective on the evolving role of the physician.
The hit television series Marcus Welby, MD last aired in 1976. Dr. Welby was the physician of every baby boomer’s dreams, whose patients always felt cared for and always got better. By the end of the century, Dr. Welby had been replaced by Dr. House, an MD cum Sherlock Holmes with Narcissistic Personality Disorder and an opiate addiction. While his bedside manner is decidedly not Welbyesque, Dr. House still embodied the basic premise of the all-knowing and dedicated provider that solves problems with little concerns for costs or standard practice.
But in the real world, physicians are evolving along a different—and we argue—better path. The 20th century physician was self-employed, championed the interests of patients, and had complete control over the medical system. But this system had at least two primary problems: (1) ever escalating costs and (2) dramatic variations in physician practice patterns with little connection to outcomes. We shudder to think how much Dr. House spent on his patients. This system is no longer sustainable.
Enter the 21st century physician, who is increasingly an employee of a large provider organization that scrutinizes every medical decision based on both cost and quality. We may all be better off for this transformation – the question is will we accept it? If past is prologue, we fear that American public is still not ready.
Previously, I wrote about some wondrous developments that are taking place in medical science. Implantable or attachable devices already exist — or soon will exist — that can monitor the conditions of diabetics, asthmatics, heart patients and patients with numerous other chronic conditions. These devices will allow patients and doctors to modify therapeutic regimes and tailor treatments to individual needs and responses. Genetic testing is reaching the point where patients can be directed to take certain drugs or avoid other drugs, based solely on the patient’s own genes.
Almost all HIV treatment these days involves therapy cocktails tailored for each individual patient. The FDA has approved a breast cancer drug only for women with a particular genetic makeup. Patients are being advised to steer clear of an ADHD drug and certain blood thinners if they have particular genetic variations.
We are entering the age of personalized medicine, where the therapy that’s best for you will be based on your physiology and genetic makeup — and may not be right for any other patient.
Yet standing in the way of this boundless potential is an Obama administration whose entire approach to health reform revolves around the idea that patients are not unique and that bureaucrats can develop standardized treatments that will apply to almost everybody with a given condition. When former White House health adviser Ezekiel Emanuel told CNN recently that “personalized medicine is a myth,” he was fully reflecting the worldview of the authors of health reform.
Personalized medicine is the future. It is where the science is going. It is where the technology is going. It is where doctors and patients will want to go. Yet unfortunately for many of us, this is not where the Obama administration wants to go.
First, the good news. Biosensors that can be worn on clothing or jewelry, or held against the skin by a Band-Aid-like patch, or inserted beneath the skin are capable of monitoring a whole host of chronic diseases. Among the technologies that have been, or soon will be, developed are devices that can continuously monitor the blood glucose levels in diabetics; the rate of breathing, blood oxygen saturation, etc., of asthmatics; and the heart rate and other parameters of patients with heart disease. There are even heart attack and stroke attack detectors. In some cases, personalized devices can activate therapies. A wearable, automatic insulin pump can be coupled with a blood glucose measuring device to create a virtual artificial pancreas. (See this fascinating summary.)
The science of genetics is also about to explode. There are as many as 1,300 genetic tests currently available that relate to about 2,500 medical conditions. Gene tests can predict your probability of getting particular types of cancer, whether you will respond to routine chemotherapy or whether there is a special therapy that only works on people with your particular physiology. The days when experts argued over whether men should get a prostate cancer test could be long gone. A simple test can tell if you have a high probability of contracting the disease, or a low one.
“I think the vote will be 6:3 in favor with Kennedy and Roberts voting for.” There is “No doubt it is constitutional,” he declared. “Legally, this is an open and shut case.”
Emanuel, now chair of the Department of Medical Ethics and Vice Provost for Global Initiatives at the University of Pennsylvania, also revealed that he recently had dinner with Supreme Court Justice Antonin Scalia. Emanuel says Scalia will not vote for the reform bill. (No surprise there.)
For reasons I have explained in earlier posts here and here, I tend to share Emanuel’s optimism. Nevertheless, I could easily be wrong.
As health reform evolves, I’ve been watching multihospital systems grow in size and power and speculating what their gigantic size means.
Here, as of 2008, were the 10 largest systems in revenue size
1. Veterans Administration Hospitals, $40.7 billion
2. Hospital Corporation of America, $28.4 billion
3. Ascension Health, $12.7 billion
4. Community Health, $10.8 billion
5. New York Presbyterian, $8.4 billion
6. Tenet Health, $8.3 billion
7. Catholic Health Initiatives, $7.8 billon
8. Catholic Health West, $7.6 billion
9. Sutter Health, $6.9 billion
10. Mayo, $6.1 billion
What strikes me about this list are that such giant systems like Kaiser, the Cleveland Clinic, Johns Hopkins, Duke, and Health Partners in Boston don’t even appear, and the large number of Catholic multisystem chains. The revenues of multihospital systems has undoubtedly grown since 2008. In 2011, hospital mergers and acquisitions hit an all time high.