Ezekiel Emanuel: Health Care Reform and the Future of American Medicine



I want to talk to you about health care health care reform and also what you can do to promote your own personal health care reform I like to begin with this number by the end of this year December 31st the United States will spend 2.8 trillion dollars on health care now you're very smart audience you came out Sunday morning to learn something about health care I've gone around the world spoken at the great universities great hospitals of the world whether it's Oxford or Harvard or Stanford and one thing I can be sure is no matter how smart you are no matter how financially savvy you are you have no idea how big this number is so I like to put it in context in a variety of ways but one way is this if you look at the gdp s– of the world the united states has far and away the largest GDP in the world at fifteen trillion dollars i didn't even put it on this list china's number two at about seven point three trillion dollars little difficult to measure because of the currency exchange issues japan's third germany's fourth I draw your attention to France their fifth their GDP that's all the spending on everything they do for 66 million Frenchmen is 2.8 trillion dollars that's for all that great French food that great French wine those lovely vacations in the Riviera those crappy Puzo cars 2.8 trillion dollars in other words the American healthcare system is the fifth largest economy in the world that's a pretty astounding fact it means lots of different things we're spending a lot of money it's very hard to change it won't happen overnight I tell my students at the University of Pennsylvania we go to the next slide this is the most important slide in health policy so let me walk you through it usually I spend 40 minutes with this slide alone on the x-axis it's how rich a country is that's the GDP the gross domestic product everything produced per person and on the y-axis up and down is how much you spend per person on health care and what you can see is an upward sloping line and every country in the developed world Switzerland Germany Denmark Iceland is on that line except one we're on another planet we are not on planet Earth that line is planet Earth we are somewhere else we're 40% off that line and again there are many many things we can conclude from this that shape of that line if you studied economics in school you'll recognize the shape of that line as not being about basic necessities of life actually in basic necessities like the richer you get the less you spend on them this is more characteristic of luxury goods diamonds and Rolls Royces where the more you earn the more you spend on them you might think about how that relates to health care which we normally think of as a basic necessity but for me the most important conclusion from this graph is we could get down to that line without the need to ration care no one no credible health policy person says Oh Switzerland Germany they ration care we could reduce our spending we could save money have high quality care without the need to ration and that's a very important point it's not just how much we're spending in every year it's also how much it increases year to year it's about a hundred well this is the breakdown of course sorry this is where all the money goes and you can see the top place it goes hospitals about eight hundred and fourteen billion dollars last year getting close to nine hundred billion dollars now that's more than we spend on Social Security more than we spend on all of Medicare more than our defense budget hospitals are the single biggest industry we have second is doctor services at about twenty one twenty two percent of total spend everything else is in the weeds many of you will say well what about all those drugs drug companies spending turns out that's roughly ten percent of the total and it's been ten percent for a long time as I say it's not just how much we're spending but how much it's increasing year to year every year the amount we're spending on health care goes up by a hundred billion dollars just think about what we could do for a hundred billion dollars in this country improve education improve the infrastructure our bridges reduce the debt just an astounding number now it wouldn't be so bad all that money wouldn't be such a waste if we had fantastic care 10 20 30 % better care than the rest of the world there is no doubt we have peaks of greatness in this country that are the envy of the entire rest of the world but we also have valleys and you heard some of them hospital infections a hundred thousand a year that kill people in mistaken operations it's this problem of uneven care and the fact that it's even our best care is not 30 50 percent better than other countries that is a real problem here are just a couple of statistics if you look at life expectancy in the United States when people reach 65 I'm not talking about from birth because a lot of people say that's not an accurate assessment of the health system this is when people reach 65 and where the health care system is key to they're living a long time the United States for men ranks 12th and for women 16th in the world I would note and draw your attention to the fact that France is number 2 here's another example Rann which is a big company that does a lot of research and health care look at people discharge from hospital at 65 years of age and investigated whether they got proven treatments this is like was their blood pressure measured and where they put on blood pressure medications to lower it to normal if they had high blood pressure was their cholesterol measured and was that treated if it was high if they came in for pneumonia did they get a vaccine so that it wouldn't recur and what they found was basically it's a flip of a coin fifty-five percent of the time people discharged from great hospitals got that treatment and when they redid the study for children it was even worse only 46 percent of the time so it was mentioned it's a big system complicated system and people aren't always getting proven treatments so we're spending a lot of money not getting the best care we have been trying to reform our health care system for a century going all the way back to Teddy Roosevelt right before World War two there's a big effort to get universal coverage in the United States and get everyone access to health care it died for two reasons one was the entry of World War two and anything German and universal health care coverage started out in Bismarck Germany became forbidden and the second is that the American labor movement actually opposed it they thought they could get a better deal from their employers Franklin Roosevelt thought about trying to pass a bill for universal health care in 1930s but he took it out of Social Security because he thought it would sink Social Security when Harry Truman became president one of his most fervent domestic policy agendas was to get universal coverage he really believed in it and he campaigned for three years and the AMA created a very nasty campaign at calling it socialist medicine and defeated it might surprise you in the 1960 election Kennedy versus Nixon there was a big debate about universal health care coverage which candidate supported health care reform this is a trick question assessing your American history knowledge turned out it was both candidates both Richard Nixon and John Kennedy supported universal coverage and comprehensive reform like surprised you that but it still couldn't pass 1965 Lyndon Johnson came in with the landslide victory against Barry Goldwater he got Medicare and Medicaid great advances but no not universal health care coverage how do we know we have fifty million people uninsured today 1973 we had a very unusual collection of people Richard Nixon in the White House Ted Kennedy in the Senate and a guy named Wilbur Mills in the house controlling health care they all agreed we'd have universal coverage and then a couple of Washington scandals including Watergate and someone called Fannie Fox an exotic dancer who fell out of a car Wilbur Mills his car it turned out killed health care reform wasn't taken up again for 20 years until Bill Clinton tried it in 1993 right after he got elected never even made it to the floor then this March 23rd 2010 enactment of the Affordable Care Act it really is a world historical event and I won't try to get your knowledge of current events by asking you who that person sitting with the red and blue tie is there what is Joe Biden saying to that little kid that we can't say on public air I would also notice that you see the guy in the purple shirt and the white tie right close to the president no one knows who he is it's not a congressman he's not a senator what's he doing there in any case this is a world historical event I'm an optimist there are certainly going to be bumps along the road in enacting the Affordable Care Act but by 2020 all of us are going to benefit from the Affordable Care Act we are going to have a better health care system because of it let me give you an example all of us will have access to care we'll have either if we're poor Medicaid or better off we'll be able to buy individual coverage in the exchange with subsidies for those people who can't afford it and the quality side hospitals are focusing on reducing their infections reducing medication errors reducing surgical errors we're all going to have an interoperable electronic health record right now they're not so great but over the next decade they're going to improve substantially remember when Apple computers couldn't send emails to pcs and vice versa that disappeared same thing here the electronic health records going to get a lot better we're gonna have real measurement of the quality of hospitals and the quality of doctors and we're going to know whether the Mayo Clinic is really the Mayo Clinic and similarly on costs we're going to have effective cost control and reduction of unnecessary care I want to talk to you about how the bill is going to change the system and last I'm going to conclude about how you can improve healthcare – this is an important slide 50% of the American population essentially is out of the healthcare system uses about 3% of costs healthy kids young adults they don't get sick they may break their arm get stitches they need a little but they don't get sick turns out that 10% of the population consumes nearly two-thirds of all the dollars these are people with chronic illness these are the people we need to focus on if we want to improve the system and the reason is or the key is prevention now when I say prevention you're probably thinking vaccines cancer screening tests but I'm talking about what's called tertiary prevention that is taking people as sicknesses like high blood pressure or heart disease or diabetes or emphysema and preventing them from getting sicker that is the key to improving the quality of the healthcare system and reducing its costs because by keeping them healthy we keep them out of the emergency room and out of hospitals well we know how to do this it turns out we have to transform the system better so a colleague of mine from Stanford named Arnie Milstein went around the country asked insurance companies get me practices that are high in quality and low in cost and then he studied some of them in depth and here's a group of four I want to focus on care more they have twenty six centers mainly in LA little in Arizona and Nevada they take care of 50,000 Medicare Advantage patients that are seniors mostly people with chronic illness they have a lot of disease management programs so they focus on diseases crime and chronic illness and things that can happen to patients with those chronic illnesses like Falls and they try to keep these people healthy they have a whole lot of health management services to help those patients engage in their health exercise and strength training to prevent Falls home care mental health programs social services podiatry look at the last one transportation for a lot of people with chronic illness getting to the hospital's trouble so they actually provide a car service because the next stop if they don't get to the office might be the emergency room and a hospitalization what are their results hospitalization rate 24 percent below average hospital stays 38 percent shorter because they can take care of patients at home pretty intensively diabetics have sixty percent fewer amputations than the competition and their prices how much do they cost eighteen percent lower than average what's the elements of success they don't care for patients just doctor the patient they have a whole team doctor nurse practitioners assistants pharmacists they have expanded hours so there's someone who actually knows the patient available 24/7 sees their medications knows their illnesses knows the care plan their specialized clinics so the reason they have low numbers of amputations they have one expert in caring for foot sores diabetics you often get foot sores gets infected produces gangrene needs an amputation they care for those foot sores impeccably so that they don't need amputation they monitor early signs of problems whether it's the glucose for a diabetic or the weight for patients with heart failure or breathing for patients with emphysema they work with selected of specialists they collect data a lot of data and follow it to make sure that they're not missing something and that they incentivize physicians to actually practice well you might think about this care more last year was bought by a big for-profit insurers why our insurance company is looking at people who provide care and can do it efficiently just think about that and they're trying to launch care more now in new places like New York and Richmond Virginia to see if they can reproduce this let's talk about giving power to the patient when you think about a treatment you should evaluate it in one of four ways does it improve your survival improve your quality of life reduce side effects or reduce costs doctors should stop recommending and ordering medical interventions that do those four that don't do those four things and you should stop taking them I know that might sound controversial but there are a lot of things out there that are not proven to do one of these four things that we're still pushing and that costs a lot of money proton beam therapy for prostate surgery the facilities to give proton beam they cost about a hundred million dollars because they're in a football size field they're really important proton beam therapy for kids with brain tumors because they reduce the problems they have of brain development hearing loss but for prostate cancer never been shown to be better than regular radiation therapy at least twice as expensive any men in the audience who've had prostate cancer will know about the da Vinci robot advertise very heavily for arms really sleek million-dollar machine by the way no evidence it's better costs more five six thousand dollars per surgery more and there is some evidence that it's worse for impotence and incontinence why are we doing this why are we advertising it doesn't improve survival doesn't reduce side effects and it costs more one of the things you need to know is that prices for various services whether a cat scan or a colonoscopy or a surgery vary widely as much as four fold in different areas you're almost never given price information one thing we have to do with the system is change that you have to get price information so you know where to get your care you also need quality information so one of the things we've called for is full price transparency release information by 2014 so you can know and you can choose the hospital or the doctor that is reasonable but the last thing I want to emphasize is what you can do day to day it's not only about the healthcare system it's also about your choices more than 75 percent of healthcare costs are due to chronic illness in this country they're costly and preventable and there are four things we need to focus on that can actually chronic illness like diabetes heart disease emphysema first tobacco use 43 million Americans about 19 percent still smoke we just have to get rid of that insufficient physical activity one-third of all US adults failed to meet minimum recommendations for physical activity based upon our guidelines gotta get out there and exercise not a lot twenty minutes a day three times a week poor eating habits sixty percent of US children and adolescents eat more than recommended daily amount of saturated fats calories sugar and all the rest of it changing our eating habits more fruits and vegetables proteins key and excessive alcohol use about one in six Americans age 18 and older engage in been drinking five or more drinks in an occasion in the past 30 days change those three things stopping smoking exercise eat better and reduce binge drinking and the fact is we can actually prevent chronic illness ourselves we can be healthier and we can actually save the whole system a whole lot of money thank you very much

9 comments

  1. and this is the scumbag that wrote Obama care.  WTF.  dude wants to KILL ELDERLY people!  what's next killing disabled babies?  Eugenicist piece of shit.  This clown would have loved to be on hitlers payroll.

  2. Ezekiel Emanuel, YOU don't define health care. You are crazy and dangerous to Patients. Your thing IS medical murder. Scram you dirtbag.

  3. What is driving up prices in medicine is — doctors over prescribe meds, experiment on patients and run a boatload of unnecessary tests and then if something is found wrong, they refuse to treat it. That Emanuel guy is a freak, a heinous freak. Why doesn't he go live in another country if he can't get along in the USA???? We sure won't miss that savage.

  4. That savage wants to reinstall the CIA MKULTRA type experiments. Why is he running around in public rather than being put where he belongs — in a cage?

  5. A heinous savage WHO MURDERS PATIENTS and never had a successful medical practice is going to "reform" the future of American medicine?? Really? What does he think America is? A nazi death camp?? "F" YOU, EMANUEL. By the way you heinous savage, why not tell everyone your real name?????????????

    You people in Chicago need to clean the trash out of your heinous political systems.

    He and his sorry ilk better never, not ever, wheedle into the medical care anyone in my family receives.

  6. You can call him insane, but not ignore the fact that it's something behind his words. I don't like the Walgreen commercial in the back tough.

  7. This guy is a certifiable kook. Over the past couple of years I've personally read stories on what other "reputable" doctors think of Emanuel, plus I've asked some doctors who have excellent credentials. The words used to describe Emanuel were "strange" "radical" "weird" and "bizarre" – and those were some of the nicer comments. He is clearly a "radical" progressive who believes elites should make decisions for "us peasants." All his supposed "facts" have been proven incorrect. Dangerous!

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