Book Review

A 12-step Program for American Health Care

Peter Boland

There is no end of commentary on what ails the American health care system and the politics of reforming it. This book is different. It rests on the premise that American health care underperforms and is unaffordable. But Prescription for the Future is true to its title and proposes a five- to 10-year agenda for transforming expensive, wasteful American health care into a system that delivers high-value care.

Underperformance and unaffordability must be addressed by radically changing how physicians, hospitals, and other providers deliver care, argues Ezekiel Emanuel, MD, highly regarded physician, medical ethicist, and policymaker who is now at the University of Pennsylvania. He describes 12 transformational practices in detail by examining how dozens of delivery systems have succeeded. This is a qualitative book based on case studies that identify and systematize how to improve quality, patient experience, and cost.

The shift away from fee for service to alternative payment systems (ACOs, bundled payments, MACRA) is well documented. The important point is that concepts like the triple aim, population health, and patient-centric care are easier espoused than executed. The hard part is translating them into concrete actions. Doing so means creating and then implementing a set of management and financial policies for physicians and hospitals.

Emanuel lays out in clear terms how health care leaders have changed the culture of their organizations through specific performance benchmarks, data analytics, and governance practices, all of it infused with healthy doses of emotional intelligence.

The 12 practices of transformation start with physician office infrastructure: scheduling patient appointments, registering and rooming patients, measuring physician performance, and standardizing patient care and chronic care coordination. He delivers a nuts-and-bolts guide to innovation and improvement.

The book likewise prescribes how to change provider interactions through shared decision making, citing care with high-value clinicians and facilities, and deinstitutionalizing care away from traditional hospital-based services. Emanuel explains the necessity of expanding typical American health care so it embraces behavioral health, collaborative care models, home and palliative care programs, and community-based interventions such as community health workers.

The book does not shy away from skewering sacred cows of the health care industry, such as the promise of telemedicine. Emanuel develops the context for assessing the value and impact of telemedicine on clinician–patient interactions. He sees health care as being fundamentally social, with change arising from collaborative strategies that keep the patient involved. Attending to the nitty-gritty of implementing those strategies is the way to transform health care, not overinvesting in telemedicine, which Emanuel sees as a bit player, helpful but not terribly consequential.

Emanuel ends with a practical chapter titled “How to Pick Your Doctor.” Everyone struggles with this question. Emanuel, an oncologist who specializes in breast cancer, says open-access scheduling is probably the clearest, most concrete way a physician group can convey that patient time and discomfort are taken seriously. A second key indicator is participating in performance-measurement and care-improvement efforts.

To further clarify physician selection, Emanuel presents a detailed table of what people should consider based on their particular medical condition. He puts the characteristics into three buckets: absolutely necessary; important for select types of patients; and nice to have. Organizing the advice this way is refreshingly practical.

Emanuel has seeded his book with dozens of compelling patient stories that illustrate the many shortcomings of the health care system in this country. But the picture he paints is far from bleak. Emanuel shares stories about how some providers are improving clinical care and reducing costs through specific transformation practices. And he makes an optimistic prediction: By 2030, health care in the United States will be much better than it is today by adopting transformation practices.

Peter Boland of Boland Healthcare is a health care consultant in Berkeley, Calif., and a member of Managed Care’s editorial advisory board.

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