I don’t know about you, but I’m fed up with hearing and seeing Ezekiel Emanuel in the news. “Zeke,” as he’s known, is Rahm’s little brother and the current media darling in charge of making pronouncements about health care policy, the bright status of the Affordable Care Act ( ACA) also known as Obamacare, and who should live and who should die. He was one of the White House’s principal advisors on the construction of the ACA and hailed as the ultimate guru on health care policy.
The recent publication of his new book, Reinventing American Health Care. How the Affordable Care Act Will Improve our Terribly Complex, Blatantly Unjust, Outrageously Expensive, Grossly Inefficient, Error Prone System, has resulted in a media orgy –book reviews, news articles, TV show appearances, NPR interview, New York Times pieces – by both conservative and liberal press outlets. And throughout it all, Zeke is there grinning and delivering his happy doctor-bashing patter with nary a tough question to answer. The media interviews I have seen and read – with the exception of one Wall Street Journal (“ WSJ”) book review and the few letters to the editor published by the WSJ in response to the massive WSJ Review piece ( March 8-9, 2014, page C3) by Emanuel they published have all been very docile. Even the outspoken conservative Bill O’Reilly was fumbling and inarticulate when trying to challenge Emanuel about his book. That’s easy to explain: the media have been bashing doctors for as long as I’ve been tracking and documenting the process and are rooting for and hoping that those rich arrogant doctors (smilin’ Zeke excluded) will get their comeuppance. Never mind that the journalists and their families might well get done in by those narrow networks of specialists –er now called “high value networks” – that somehow failed to include places like national cancer centers with the latest cutting edge cancer treatments. That’s just a bump on the road to lowering health care costs and improving American’s global competitiveness and freeing up dollars so people can buy a new GM car – subject to recall – once a year or so to keep the car dealers advertising and the media outlets profitable. But I digress.
Back to Zeke. He ran into some trouble back in 2009 when the details of the proposed ACA were being divulged. You recall the big flap about “Death Panels.” That flap was supposed to be about the end of life counseling proposed by the bill. It prompted a Facebook post by Sarah Palin which cited a Lancet article authored by Zeke and two other colleagues at National Institutes of Health, where he was head of the Department of Bioethics. That article was published in the British medical journal The Lancet on January 31, 2009 and titled “Principles for allocation of scarce medical interventions.” The authors proposed principles for allocating scarce resources such as organs for transplants, vaccines in epidemics, and ICU beds when demand exceeds supply. The one “figure” used in the Lancet article says it all:
The Reaper Curve: Ezekiel Emanuel used the above chart in a Lancet article to illustrate the ages on which health spending should be focused. “Principles for Allocation of Scarce Medical Interventions” The Lancet, January 31, 2009 . Figure from The Lancet. Caption of graphic from op ed piece by Betsy McCaughey published in the Wall Street Journal, August 27, 2009.
As you can see, your worth to society — according to Zeke — drops off precipitously after age 40. As he puts it, “ When implemented, the complete lives system produces a priority curve on which individuals aged between roughly 15 and 40 years get the most substantial chance, whereas the youngest and oldest people get chances that are attenuated(figure).”
“Attenuated” as in “See you on the other side.”
Now Zeke got all bent out of shape in 2009 when he was attacked for being a “deadly doctor” and promoting euthanasia. But what are people to think when they read such a plan to axe seniors – before they even get to be seniors? Zeke complained that he didn’t want to hurt the infirm as he had a sister with cerebral palsy. I have no doubt that Zeke – and Rahm- would do everything within their considerable political power to help their sister and get her the very best medical care.
But what would they do for your sister? Or your mother? Or anyone who isn’t a big political contributor or an influential lobbyist or a powerful politician?
We all know the answer to that one: Find out where your loved one falls on the complete lives allocation curve above and apply the rule to determine who has a life unworthy of life.
Yes, I deliberately used the term “life unworthy of life” and will deliberately use the “N” word – Nazis – because this is how the Nazis operated. They adopted that term, first used in the 1920s to decide who was too weak or too infirm or too mentally ill or too Jewish or too Gypsy or too homosexual and then killed those they decided didn’t fit into their criteria for a purer, stronger race.
And don’t think that kind of thinking wasn’t operative in the U.S. long before Zeke came along.
In the early 1900’s eugenics was an accepted “scientific” program in the U.S. – touted by the leading scientists and medical journals – to sterilize those with mental illness, abnormal sexual behaviors, and even seizure disorders. Some say that the Nazis based their actions in part on the U.S programs and entered into a kind of medical /eugenics arms race to improve the human species. First, the Nazis started with forced sterilizations, I will write more about eugenics in later posts and how it continued in North Carolina and even shamefully at my medical school alma mater, Duke, into the 1970s.
Zeke falls into that group of arrogant doctors who think they know the right way to practice medicine and the right way to decide who lives and who dies. It’s all a matter of being the “smartest” guy in the room and having the right Ivy League credentials.
But back to Zeke. On page 429 of the Lancet article, he gives us a glimpse of how he feels about doctors who take care of sick patients but don’t apply his allocation rule:
Prognosis allocation encourages physicians to improve patients’ health, unlike the perverse incentives to sicken patients or misrepresent health that the sickest-first allocation creates ”
Please read that again. That is an astounding charge.
Zeke is saying that those of us who have taken an oath to do no harm and work hard to keep every patient alive and free of disease are deliberately and/or intentionally sickening patients or letting them be sicker than necessary or sick longer than necessary all for the purpose of making money.
To understand where Zeke is coming from, you also have to know that he has tirelessly worked to change the way doctors are paid from a fee-for-service system to a capitated or bundled system, in which the HMO executives or the hospital administrator in an Accountable Care Organization controls the doctors and probably, under Zeke’s most hopeful scenario, applies the complete lives rationing er allocation curve.
Sarah Palin did the country a real favor by posting the citation to Zeke’s Lancet article. She was right for the wrong reason, in that the real Death Panel in the ACA is in the form of the Independent Payment Advisory Board that will decide who lives and who dies in the Medicare population. But I’ll save that analysis for later posts. The best news about the IPAB is that its members have still not been appointed, because our so-called political “leaders” are too scared to activate the board before any major election, especially the way voters are reacting to the rollout of the ACA.
You would think that with Zeke Emanuel’s various criticisms of practicing physicians and his proposal to allocate scarce medical resources on the basis of age, major medical organizations like the American Medical Association would take issue with him. Would it surprise you to learn that Zeke has been put on the editorial board of the Journal of the American Medical Association? Imagine that: a big time practicing doctor-basher on the board of the very medical journal that hard-working doctors are paying dues to enable. That’s typical of the AMA. And I promise to write more about the AMA and so-called “organized” medicine in later posts. It’s editorial board reads like a Who’s Who of doctor-bashers.
If you don’t think Zeke is a doctor-basher, look at the Viewpoint article he wrote in JAMA on January 25, 2012, “Physician Autonomy and Health Care Reform.” I love the sentence that begins, “Furthermore, solo practitioners will be able to decide whether to join an ACO, with which other physicians they want to collaborate with on a bundled payment, and how to work together to define the care the group of physicians should deliver.” HUH? Where is the “or,” as in “or not join an ACO and not subject themselves and their patients to the abusive practices of hospital administrators with a managed care mentality who want to save dollars as opposed to saving lives?”
Today, there is a report that 60% of doctors don’t want to join an ACO. Zeke would probably say that’s because they want to “sicken” their patients to make more money.
Zeke went on in the JAMA article to assert, “Indeed, greater physician autonomy in the future is linked to accepting more financial risk.”
Memo to Zeke: We tried that in the 1990s. Doctor groups took on risk and rationed care. There were news articles about medical disasters befalling patients. Most of the doctor groups went broke. Lawyers made a lot of money picking up the pieces. Health care costs kept climbing.
The reality is that the ACA has unleashed a wave change to induce frightened doctors sell their practices to hospitals (and some to the likes of Humana) who are consolidating power and patients. Most hospital run ACOs don’t have a clue as to how to manage the bundled payments or doctors under their control. The administrators want the money. That’s the first principle. Get the money. Pay ourselves first, and then we’ll figure out the rest while guys like Zeke keep the media happy and off our backs.
The most interesting thing about the JAMA Viewpoint article by Zeke is that JAMA didn’t see fit to publish one comment or letter in response to the article. Wow! In this connected day and age: not one doctor wrote to JAMA to protest Zeke’s views. I know I didn’t. Why write to JAMA, as I’ve done in the past, only to have the letter rejected?
Just like JAMA didn’t allow challenges to Zeke, so the media have stopped asking him about the Lancet article and whether he believes that harsh rationing of “scarce” medical resources ought to come in at age 40 and really be applied stringently at age 55 as his complete lives curve suggests. Most of the network TV producers who are booking him have fancy Ivy League degrees. They should be able to understand that rationing curve.
Zeke Emanuel is a dangerous man. He was a principle architect of the ACA, and he has the ear of the media – and you don’t — unless some loved one gets done in by the ACA and then you’ll get 2.5 minutes on some news channel to shed tears and tell your edited story and your loved one will be six feet under and Zeke will still be going strong.
You can be sure of this: Zeke Emanuel is the face of current health care reform promoting rationing schemes that are tantamount to genocide for senior citizens and anyone over age 40 who is not politically connected.
Now after stints at Harvard and the National Institutes of Health, he’s teaching health policy at the University of Pennsylvania.
The nation needs a strong antidote to his lethal brand of policy snake oil.
For the record, here’s the letter to the editor I sent to the WSJ that they didn’t publish:
To the Editor:
Re: The Making of Obamacare, Review, page C3, March 8-9, 2014
It is fitting that the illustration you chose to accompany this piece by Dr. Emanuel features a caduceus rather than the rod of Aesculapius. The Caduceus, with two serpents surrounding a staff, was the symbol of the Greek god Hermes, who was associated for deception and thievery. The rod of Aesculapius which has one snake surrounding a staff is the image most often associated with healing and is the image used by the American Medical Association.
Dr. Emanuel deserves the caduceus illustration for deceptively promoting bundled payments as superior to fee-for-service medicine. We have already tried lump sum payments in the form of capitated payments in the 1990s. That led to all sorts of abusive practices by HMOs and large doctor groups who cut corners to save a buck, with the media having a field day with stories of patient harm. Fee-for-service became plea for service.
Dr. Emanuel makes it sound like all the ivory tower theorists and politicians want to do is fix the price of procedures like hip replacement and pacemaker insertions. But he fails to disclose that real cost savings come from decreasing the volume of services to the aging Baby Boomers not by cutting prices. He deceives people into thinking that their political leaders are giving them a price break – something for nothing – when in fact what is actually happening is that doctors and patients are being herded into organizations facilitated by Obamacare that will in fact usher them out of this world sooner than necessary in the name of corporate greed.
If you think that the only procedures that will be cut are the “unnecessary” ones, think again. Ask Dr. Emanuel why his friends in HMOs and the insurance industry won’t make public their criteria for medically necessary care. After all, if they’ve all figured out the right way to practice medicine, publish the guidelines so everyone can benefit.
And if he were honest, Dr. Emanuel would tell the readers how many restaurants in the U.S. have fixed price menus rather than a la carte menus. The answer is very few. But he wants patients to have not only fixed prices, but narrow networks of doctors and hospitals, as in you can’t keep the doctor you like.
Deceptively, Dr. Emanuel says that the ACA ushered in only 10 demonstration projects of fixed prices. That is a lie. The ACA promoted accountable care organizations of which there are hundreds. These are de facto HMOs run mostly by large hospital systems where highly paid administrators tell salaried physicians how to practice medicine.
Whether in hospital run accountable care organizations, or in insurance company owned HMOs, the managing entity has the legal authority to tell doctors what is medically necessary and that is almost never disclosed to the patient.
Zeke Emanuel arrogantly thinks he knows the right way to practice medicine and is not bashful about imposing his will on our hapless population who think they’re getting something for nothing in Obamacare.
Unlike Greek mythology, when you’re dead from Dr. Zeke’s political machinations, no amount of touching you with a caduceus will bring you back to life. Dr. Emanuel’s painful prescription presages the death of American medicine and many innocent victims of his vast social experiment.