SAN DIEGO—Eight years after the passage of the Affordable Care Act, one of the key architects of the law is “wildly optimistic” about the direction of the American healthcare system.
He doesn’t share the same optimism about technology’s ability to influence that direction, however.
“Virtual medicine can’t change behavior by itself and our big problem is patient behavior change and physician behavior change,” Ezekiel Emanual said at the AHIP Institute and Expo in San Diego.
The former special advisor for the Office of Management and Budget under President Barack Obama was one of the key architects of the ACA. Now the vice provost for global initiatives and chair of the department of medical ethics and health policy at the University of Pennsylvania, Emanuel said he and his former colleagues are “always amazed at how well [the ACA] has done.”
During a keynote address, he highlighted lower uninsured rates among adults and children and slower growth of healthcare costs as critical metrics since ACA's implementation.
But he also acknowledged that the U.S. still lags behind every other developed country when it comes to costs and life expectancy, trends he attributed to inefficiencies across the system. Patients still get as many as 10 radiation treatments for a cancerous bone marrow lesion despite evidence that one is just as effective. For breast cancer patients, three weeks of intense radiation is just as effective as seven weeks, yet only one-third get the shorter duration.
Perverse financial incentives, he argued, can be eliminated with a greater reliance in bundled payments and capitated—or risk-based—payments for primary care providers.
Providers that have successfully lowered costs and improved quality have done so using low-tech solutions, including care coordinators embedded alongside providers to help manage chronic care and an increased focus on behavioral health.
“They are not having a care coordinator call telephonically from an insurance company—that does not work,” Emanuel said. “And they don’t use fancy algorithms with AI and blockchain or any of that crap.”
Virtual care, he said, can carve out space to augment care coordination in some situations. Using tele-ICUs to identify certain patient measures, connecting patients with behavioral health providers when its an emergency or using telehealth to connect doctors with specialists.
But time and again, he said, studies show gadgets like wireless pill bottles or blood pressure cuffs don’t have the kind of impact that lives up to the hype.
“You have to be reasonable,” he said. “It’s not taking over the world. It can augment, but it has to be built on the basis of good physician-patient relationships. Too much of it is trying to supplant rather than supplement.”