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Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System (Anglais) Relié – 27 février 2014

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39 internautes sur 41 ont trouvé ce commentaire utile 
Six Megatrends: Agree or disagree? 24 mars 2014
Par Philip Lederer - Publié sur Amazon.com
Format: Format Kindle Achat vérifié
Ezekiel Emanuel just published an important book with a great title, "Reinventing American Health Care: How the Affordable Care Act Will Improve Our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System." In it, he describes the history of health care reform in the US, gives an overview of the Affordable Care Act (ACA), and speculates about future trends in American health care.

The concluding chapter of Emanuel's book is entitled, "Six Megatrends in Health Care: The Long-Term Impact of the ACA." I will devote this review to discussing his six "megatrends."

Megatrend 1) The End of Insurance Companies as We Know Them

Emanuel argues that health insurance companies will "shift their business to focus on offering services they have expertise in, particularly analytics, actuarial modeling, risk management, and other management services...." or "transform themselves into integrated delivery systems," or they will go out of business. This seems quite plausible. However, I think it will depend on how the ACA implementation goes over the next several years. If insurance companies raise their rates, there could be major political fallout.

Megatrend 2) VIP Care for the Chronically and Mentally Ill

Emanuel argues that "tertiary prevention" for chronically ill people with diabetes, heart disease, cancer, etc, and mental health care for people with depression/anxiety, will become an increasing focus of our health care system. I agree. I've taken care of many patients with chronic diseases and mental illness who cycle in and out of the hospital. The question is if our fragmented health system can provide coordinated, community-based care for these vulnerable people. Doctors and nurses must learn to use a biosocial approach when taking care of marginalized patients with chronic disease and mental illness.

Megatrend 3) The Emergence of Digital Medicine and the Closing of Hospitals

Emanuel writes: "Digital medicine will allow physicians to monitor patients remotely anywhere they are, get labs and many imaging tests done, and perform interventions once done exclusively in the hospital." I agree - sort of. We are rapidly headed into a digital era. More health care will be provided in the community, and digital devices will continue to proliferate. But will these digital devices provide value for money? Or will the hype outpace their effectiveness? Unfortunately, so far, the hype is winning.

Megatrend 4) The End of Employer-Sponsored Insurance

This controversial megatrend was analyzed in yesterday's front-page New York Times article. I think this megatrend is very difficult to predict. It depends on a number of political and economic factors. Will America's health insurance system remain constant, or will it move 1) towards a Republican system based on tax credits, or 2) towards a single payer system based on universal health coverage, or 3) a Kaiser-like group model? The latter is the most likely.

Megatrend 5) The End of Health Care Inflation

I'm definitely not an economist, but I'm not sure I agree with Emmanuel that the ACA will succeed at controlling the growth in health care costs. In his book, Emanuel admits that the ACA didn't go far enough on payment reform, and that there remains "a serious misalignment between what we want physicians and hospitals to do in terms of improving value, efficiency, and reducing unnecessary care and how insurance companies, Medicare, Medicaid, and others pay them." As long as our fee-for-service system is around, and Medicare payments and RVUs are biased towards specialists, the growth of health care costs won't be controlled.

Megatrend 6) The Transformation of Medical Schools

I agree with Emanuel. Medical schools must change, and become much more team-oriented, community health oriented, and digital medicine oriented. The problem is that medical school curricula are very difficult to change. Can they begin to change rapidly? I'm not sure. If they can, it will require a major awakening of medical students and faculty.
With the enormous amount of material for physicians to learn, does reducing the length of medical school from 4 years to 3 years really make sense? I don't think so. I think it would be preferable to keep medical school at 4 years and subsidize medical school tuition, or provide 100% debt forgiveness for medical students who enter primary care careers. The National Health Service Corps is a good program, but it doesn't go nearly far enough. If medical school is reduced to 3 years, will the training physicians receive really be sufficient?
30 internautes sur 41 ont trouvé ce commentaire utile 
Excellent Overview of U.S. Health Care 7 mars 2014
Par George Bush - Publié sur Amazon.com
Format: Relié
American health care leads the world in costs - 18% of GDP (while excluding about 15% from insurance coverage), vs. 4% for Singapore (excluding no-one) at the low-end. It also infects 5% of hospitalized patients - of which nearly 100,000 die, and kills another estimated 44,000 - 98,000 from other hospital errors. Surely this complicated mess deserves rethinking. Unfortunately, getting from the mess we have now to something akin to the high-quality, much-lower cost care in Singapore, South Korea, Japan, and Taiwan has proven beyond the capability of America's legislative leaders. Decades of failed prior attempts, followed by compromise after compromise was required to even get the limited improvements afforded by the ACA when it was enacted in 2010.

Dr. Emanuel clearly likes the ACA - understandable given his role in its development. However, he minimizes trying to sell the ACA, doesn't mince words excoriating the initial ACA rollout efforts, and focuses on explaining our current complicated, dysfunctional system. I'm very hopeful that one of ACA's mandates (electronic medical records) will prove far more valuable than imagined, helping to identify important interactions, improve treatment protocols, and save lives. Improving access to care will also save lives. Similarly, encouraging the growth of accountable care organizations with bundled payments should also save lives and reduce costs by incentivizing quality improvement and removing incentives to over-treat. Finally, taxing 'Cadillac' plans will also hopefully make a dent in cost control.

An excellent and objective overview of complicated subjects
3 internautes sur 3 ont trouvé ce commentaire utile 
Lifted the clock of complexity into today's US healthcare system 17 juillet 2014
Par Neil Benson - Publié sur Amazon.com
Format: Format Kindle Achat vérifié
I'm a Brit living in the US. I'm used to the UK National Heath Service which offers great healthcare outcomes and reasonable value for taxpayers' money. Arriving in the US I find myself completely confused by a complex, bureaucratic, expensive private healthcare insurance system. Emanuel's book offered a comprehensive and insightful history of the US healthcare system and explained all the complexities of co-insurance and co-pays. The main topic, of course, was the Affordable Care Act and how it came to pass, what it set out of delivered and the compromises along the way. Emanuel was an architect of the ACA and is principles and pride shine through his writing, but that doesn't stop him pulling his punches when criticizing the Act's failings. An enlightening read.
12 internautes sur 16 ont trouvé ce commentaire utile 
Somewhat optimistic 17 mai 2014
Par Deborah Sue St Clair - Publié sur Amazon.com
Format: Format Kindle Achat vérifié
This book, like the affordable care act, was born from a combination of idealistic beliefs that the dysfunctional health care system was somehow separate from the dysfunctional class divided society that it supports and that the health care systems fails because of inefficiency within itself. In reality the system re-aligns itself periodically according to the payments system, and in this sense delivers what society asks of it to do. The book supports the myth that better technology and electronic health records will allow advanced data mining to discover new medical truths and improve efficiency, in spite of the fact that every advance in technology beyond immunization has raised costs.. It celebrates the highly efficient veteran's administration hospital system as the best we have.
All this has some validity, but it was written before the Snowden revelations and before we discovered that the veterans hospitals cook the scheduling books before reporting their outcomes, bringing into disbelief all that these hospital system claims.
But I was happy to read this book, and it is a smooth fast read giving insights into what the health care planners of the federal government read before they wrote the bill that congress voted after a year of heated debate, but never actually read themselves.
9 internautes sur 12 ont trouvé ce commentaire utile 
ACA Explained Beyond Partisan Headlines 2 avril 2014
Par G. Stockman - Publié sur Amazon.com
Format: Format Kindle Achat vérifié
This is a good primer on the Affordable Care Act. It goes into sufficient detail to leave the reader with a basic understanding of the law. The book emphasizes the ACA goes well beyond its headline attracting features like the individual and employer mandate and includes many provisions that will fundamentally change the health care industry. One of the Act's main objectives the author notes is to tame rising health care costs for all Americans, which, since the 1970's, has outpaced the growth of the economy. The author also points out that the Act is structured to provide incentives and penalties, particularly for hospitals, intended not only to lower costs, but to improve the quality of health care as well. As one of those intimately involved in passage of the ACA, the author is sometimes defensive about the events surrounding passage, but overall does a very good job of explaining - in neutral terms - the details of the law and how they are intended to effect health care in the United States. For those wishing to learn about the specifics of the law beyond partisan interpretation, this book will fill the bill.
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