Summary:
The
future of healthcare in the US has long been a subject of debate, with how to
pay for it overshadowing other aspects of the topic. In publishing
this work, the author, Dr. Ezekiel Emanuel, makes clear: “This book is about
[the] transformation in the delivery of care in the United States” needed to
ensure that “all Americans receive consistently higher-quality and lower-cost
care.” (p. 15)
Paying for health care is not
ignored, and indeed how health care payment methods figure in
health care delivery is taken into account.
Emanuel
builds the book around 12 particular transformational practices as developed
and applied in the several different health care organizations he studied. They
included “small physician offices and large multispecialty group practices,
accountable care organizations, large managed-care organizations, and even
for-profit companies.” He admits to finding these organizations in “a careful,
if somewhat haphazard, way” through a combination of serendipitous visits to
some of these organizations, attendance at presentations showcasing some of
them, and personal recommendations received. (p. 15) Emanuel identifies these
12 transformational practices through “carefully observing and ascribing
significance when various groups and organizations in many different geographic
locations, are independently reporting similar things.” (p. 16)
The
12 transformational practices are covered across three chapters in the middle
of the book. The first describes the practices that involve the way physician
offices are structured and operate (e.g., scheduling patients, measuring
physician performance, standardizing care, coordinating care), the second describes
the practices that affect provider interactions with patients (e.g., shared
decision making, site of service considerations), and the third, the practices
that expand the scope of care beyond traditional boundaries (e.g., behavioral
health, palliative care). Emanuel provides considerable detail on what these
transformational practices entail and on the results they produce. These
chapters are preceded by a separate chapter on recent changes in health care
stimulating transformations, and a chapter on essential elements required for
transformation: catalyzing crisis; leadership; culture, governance, and
physician engagement; data; physician management alignment; and financial risk.
Emanuel recognizes that: “No organization can
institute all 12 transformational practices all at once. No organization has
the management capacity to do that.” (p. 197) Thus, he devotes a chapter on how
organizations can adopt the transformational practices that are best suited to
them. He aggregates the practices into three tiers and ranks them by
prioritization. He carves out a separate chapter on “virtual medicine”—a
collection of technologies and methods that enable a range of patient care activities
(e.g., diagnosing, treating, monitoring) between different locations. Emanuel
covers virtual medicine separately because his view is counter to the
conventional wisdom espoused by “the medical techno-utopians,” as he calls them
(p. 166) He allows that it can augment health care organization performance but
itself is not a transformational practice because “healthcare is fundamentally
social.” (p. 175) So as not to leave patients wondering how they could benefit
from these practices, he devotes another chapter for them on how to find a
doctor.
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