Really with Zeke and Amy

Readers of the New York Times were recently treated to Ezekiel Emanuel’s four-part series on how to rein in the cost of health care. I’m not an expert on health care; this post is not about his proposals. That said, the coming paragraphs are a crash course in Ezekielcare. If you read the series, feel free to skip ahead to the jump, or consider this a refresher.

In the first of four parts, Emanuel lays out the problem:

In 2010, the United States spent $2.6 trillion on health care, over $8,000 per American… our health care spending is the fifth largest economy in the world.

But he also recognizes that the issue is not the absolute dollar value spent on health care – it is the results those dollars buy. If we chose to spend exorbitant sums on health care, life expectancy skyrocketed, and disease disappeared, that cost would reflect a funding priority, a policy or market decision to exchange resources for a specific form of quality of life.

Instead, there is almost no correlation between the amount spent and health outcomes, relative to other developed countries. Simply put, Americans waste a lot of money at a time when they don’t have much to waste:

Almost no matter how we measure it — whether by life expectancy or by survival for specific diseases like asthma, heart disease or some cancers; by the rate of medical errors; or simply by satisfaction with health services — the United States is actually doing worse than a number of countries, like France and Germany, that spend considerably less.

In Part 2 of his series, Emanuel describes certain solutions – from tort reform to transforming health insurance companies into nonprofits – he says would do too little to solve the problem. Part 3 describes how 21st-century information systems could lower health care costs by $32 billion a year – a conservative estimate ‘just’ over the $26 billion threshold Emanuel believes useful solutions must cross. But most importantly, he closes his third installment with a promise:

Next week, I’ll write about broader, more systemic and bigger ways to save

For about one moment, I thought the author might deliver on his promise.

You see, Ezekiel J Emanuel is not only an erstwhile columnist for the New York Times. He also happens to be a recently-appointed PIK Professor at the University of Pennsylvania. PIK stands for ‘Penn Integrates Knowledge’, and according to the initiative’s official website, is the name of

an initiative conceived by President [Amy] Gutmann to recruit scholars whose research and teaching exemplify the integration of knowledge… The most challenging questions and problems of our time cannot be addressed by one discipline or profession. To comprehend our complex world, we must better integrate the knowledge and the tools from different disciplines and professional perspectives in our research and teaching.

It was on this basis that I believed Emanuel might propose ‘broader, more systemic and bigger ways to save’ in his final column. Specifically, I read ‘broader’ to indicate his intention to transcend the boundary that delineates our national debate on health care. Until, that is, I finished the sentence:

— concierge medicine for chronically ill patients and the bundling of payments

True to his word, Emanuel’s final column focused on how health care is incentivized. Specifically, he proposes a replacement of the fee-for-service model of health care provision with a system that would decouple the ethical imperative to care for the sick from the profit motive.

Sounds to me like a solid place to start the conversation – but a terrible place to end it. Even if bundling represents the single greatest cost-savings opportunity in the American health care system, Emanuel still fails to move the discussion beyond health care and economics. I talk about where I would see that discussion end up at the end of this post, but for the moment I want to focus on PIK: Given that the topics under discussion are ‘health care’ and ‘money’, talking about only those subjects hardly qualifies as Integrating Knowledge.

This failure prompted me to reexamine what exactly Penn expects from its PIK Professors. Fortunately, the official website goes out of its way to denote ‘Penn’s goal’:

to achieve a truly successful partnership between arts and sciences that will benefit our students, our society, and our world.

It then goes on to list PIK Professors, presumably to demonstrate the knowledge they are busily integrating at Penn. The list gets off to a promising start:

John L. Jackson Jr.: anthropology + filmmaking
Jonathan Moreno: medicine + ethics
Christopher B. Murray: chemistry + engineering

But already by the fourth appointment, one could be forgiven for noting that the integration falls somewhat short of Little Rock Central High:

Adrian Raine: psychology + neuroscience
Sarah Tishkoff: genetics + biology
Robert Ghrist: mathematics + engineering
John Gearhart: biology + medicine
Shelley Berger: genetics + biochemistry
Barbara Mellers: psychology, behavioral economics, justice
Philip Tetlock: psychology, politics, organizational behavior

Whoever came up with the idea to integrate genetics with biology or biology with medicine deserves a gold star.

The key to understanding PIK, of course, is a single line the website does not explicitly place in context:

Recruiting and retaining superb faculty members is a key Campaign Priority.

In other words, the goal of PIK is less about ‘students, society, and the world’, than it is about recruiting the kind of faculty member who is related to the former White House Chief-of-Staff, who advised the President on health care, and who manages to land his byline in the New York Times. Maybe this characterization isn’t fair to the other PIK Professors, but how else could Penn expect to attract someone like Ezekiel Emanuel who, through astounding acrobatic feats of intellectual integration, manages to combine the fields of medical ethics, health policy and health care management into a unified field of study?

There’s nothing wrong with creating a special recruitment program to attract top-flight faculty, and I’m glad that someone of Emanuel’s caliber now calls my alma mater home. But maybe it’s time for Penn Integrates Knowledge to consider a name that more accurately reflects its goals. I don’t have any specific suggestions, but Amy would do well to find someone who can integrate marketing and honesty, which I suppose rules out an internal hiring from Wharton.


Were Emanuel to write a fifth column in which he seriously evaluated ‘broader, more systemic and bigger ways to save’ on health care, here’s one place to start:

According to the CDC’s website, chronic diseases like “heart disease, stroke, cancer, and diabetes are among the most prevalent, costly, and preventable of all health problems.”

Consider diabetes, and not just because it’s fun to say. According to the National Diabetes Association, 10% of all health care dollars can be attributed to that disease – over $116 billion in 2007 medical expenditures alone. But when health care waits patiently for patients to develop diabetes, it has already lost. ‘Junk food’ taxes – just one example – could be an important tool in diabetes prevention, but because the national diet falls outside the traditional definition of health care, and pushes for Health Care Reform rarely overlap with the Farm Bill’s five year cycle, the issues are rarely linked on a policy-making level.

An even starker example of this non-overlap is rising antibiotic resistance. The abbreviated story is that antibiotics acquire resistance not because doctors use them too often to treat patients, but because farmers use them too often to treat animals. In 2001, three million pounds of antibiotics went to treat humans, while 24.6 million were fed to livestock – a full 90% of which were intended to stimulate growth rather than to treat illness.

The cost of these practices is huge. Take just one disease, Methicillin-resistant Staphylococcus aureus (MRSA), which killed 19,000 Americans in 2007, or 3,000 more than AIDS. While the disease cost ‘only’ an additional $8 billion to treat in 2007, its growing prevalence means that costs will continue to rise. More worryingly, as whole classes of antibiotics become ineffective, the costs will begin to rise non-linearly, and doctors may be forced to turn to alternative, less-effective methods of treatment.

For all its dysfunction, the EU Parliament recently resolved to end prophylactic use of antibiotics in agriculture, among other important common-sense measures. Meanwhile, PAMTA – HR 1549, the Preservation of Antibiotics for Medical Treatment Act – has over 100 co-sponsors, but has made little headway in the House. It is worth noting that the bill was introduced in March of 2009 – a full year before President Obama’s Health Care Bill passed – but no effort seems to have been made to make common cause of the issues. Political feasibility of course plays a role, but I nevertheless find it instructive that a health care issue like antibiotic resistance is treated as an agricultural issue simply because its primary abuses take place down on the farm.


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