Ezekiel J Emanuel's research while affiliated with University of Pennsylvania and other places

Publications (487)

Article
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While the degree of COVID-19 vaccine accessibility and uptake varies at both national and global levels, increasing vaccination coverage raises questions regarding the standard of prevention that ought to apply to different settings where COVID-19 vaccine trials are hosted. A WHO Expert Group has developed guidance on the ethical permissibility of...
Article
The Access to COVID-19 Tools Accelerator (ACT-A) is a multistakeholder initiative quickly constructed in the early months of the COVID-19 pandemic to respond to a catastrophic breakdown in global cooperation. ACT-A is now the largest international effort to achieve equitable access to COVID-19 health technologies, and its governance is a matter of...
Article
COVID-19 vaccines are likely to be scarce for years to come. Many countries, from India to the U.K., have demonstrated vaccine nationalism. What are the ethical limits to this vaccine nationalism? Neither extreme nationalism nor extreme cosmopolitanism is ethically justifiable. Instead, we propose the fair priority for residents (FPR) framework, in...
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Vaccines provide powerful tools to mitigate the enormous public health and economic costs that the ongoing SARS-CoV-2 pandemic continues to exert globally, yet vaccine distribution remains unequal among countries. To examine the potential epidemiological and evolutionary impacts of ‘vaccine nationalism’, we extend previous models to include simple...
Preprint
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Vaccines provide powerful tools to mitigate the enormous public health and economic costs that the ongoing SARS-CoV-2 pandemic continues to exert globally, yet vaccine distribution remains unequal between countries. To examine the potential epidemiological and evolutionary impacts of 'vaccine nationalism', we extend previous models to include simpl...
Article
In recent years, public and private payers have been experimenting with new payment methods to drive better care at lower costs, including primary care services. The urgency has been compounded by COVID-19. Over the past 12 months, the pandemic has revealed major weaknesses in a health system built on fee-for-service (FFS) payment tied to face-to-f...
Article
Over the past decade, the US has made progress on the core problems of access, cost, and quality involving health care. Although it is valuable, this progress seems inadequate compared with the magnitude of the challenges. Approximately 20 million individuals in the US have received insurance coverage because of the Affordable Care Act (ACA),¹ yet...
Chapter
Der Philosoph und Jurist Govind Persad ist Assistenzprofessor am Sturm College of Law der University of Denver, USA. Zu seinen Forschungsinteressen zählt die Verteilung und Priorisierung knapper medizinischer Güter unter Bedingungen ökonomischer Ungleichheit. Der 2015 verstorbene Philosoph Alan P. Wertheimer lehrte bis 2005 Politikwissenschaft an d...
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Importance As COVID-19 vaccine distribution continues, policy makers are struggling to decide which groups should be prioritized for vaccination. Objective To assess US adults’ preferences regarding COVID-19 vaccine prioritization. Design, Setting, and Participants This survey study involved 2 independent, online surveys of US adults aged 18 year...
Article
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Importance: Informed consent is a fundamental element of research ethics. The COVID-19 vaccine trials are high profile trials that have enrolled more than 100 000 participants. Consent documents must be succinct and understandable to ensure informed voluntary participation. Objective: To assess how well informed consent documents of the COVID-19...
Article
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Restrictive measures imposed because of the coronavirus disease 2019 (COVID-19) pandemic have resulted in severe social, economic and health effects. Some countries have considered the use of immunity certification as a strategy to relax these measures for people who have recovered from the infection by issuing these individuals a document, commonl...
Article
As the world reflects upon one year since the first cases of coronavirus disease 2019 (COVID-19) and prepare for and experience surges in cases, it is important to identify the most crucial ethical issues that might lie ahead so that countries are able to plan accordingly. Some ethical issues are rather obvious to predict, such as the ethical issue...
Article
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Importance The average health outcomes in the US are not as good as the average health outcomes in other developed countries. However, whether high-income US citizens have better health outcomes than average individuals in other developed countries is unknown. Objective To assess whether the health outcomes of White US citizens living in the 1% an...
Article
Background: Under the Bundled Payments for Care Improvement (BPCI) program, bundled paymtents for lower-extremity joint replacement (LEJR) are associated with 2% to 4% cost savings with stable quality among Medicare fee-for-service beneficiaries. However, BPCI may prompt practice changes that benefit all patients, not just fee-for-service benefici...
Article
Background Medicare used the Comprehensive Care for Joint Replacement (CJR) Model to mandate that hospitals in certain health care markets accept bundled payments for lower extremity joint replacement surgery. CJR has reduced spending with stable quality as intended among Medicare fee-for-service patients, but benefits could “spill over” to individ...
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In Reply We agree with Mr Gondi and Dr Wadhera that CMS should use rigorous study designs in the evaluation of payment innovations. We have long supported the use of RCTs and mandatory enrollment to ensure rigorous evaluations.¹ The original Comprehensive Joint Replacement program is one excellent example.² Unfortunately, the Trump administration s...
Article
There is a dire need to produce a safe and effective coronavirus disease 2019 (COVID-19) vaccine as quickly as possible to avert an enormous burden of morbidity and mortality. This need for speed has thus far resulted in significant deviations from standard approaches to vaccine research and regulatory approval. Yet, pandemics do not obviate the ne...
Article
The US has nearly 4.5% of the world's population but accounts for more than 40% of global drug spending. With the upcoming 2020 election, a top priority of many voters is to better control drug prices and reform the pharmaceutical market. In this Special Communication, the drug price mechanisms and government regulations used in 6 representative pe...
Article
In Reply My Viewpoint argued that all preclinical medical education courses will be conducted online.¹ I predicted it would take years. Just weeks later, COVID-19 mandated online preclinical education.
Article
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The Fair Priority Model offers a practical way to fulfill pledges to distribute vaccine fairly and equitably.
Article
Research Objective Through the Comprehensive Care for Joint Replacement (CJR) Model, mandatory bundled payments for lower extremity joint replacement (LEJR) have produced 3‐4% episode cost savings with stable quality. Though CJR targets Medicare fee‐for‐service patients, it may prompt broad care delivery changes that “spill over” to other, non‐Medi...
Article
Background Cardiac interventions account for a significant share of overall healthcare spending and have been the focus of several large-scale interventions to develop effective bundled payments. To date, however, none have proven successful in commercially insured populations. In 2018, we worked with Hawaii Medical Service Association (HMSA), the...
Article
Coronavirus disease 2019 can lead to respiratory failure. Some patients require extracorporeal membrane oxygenation support. During the current pandemic, health care resources in some cities have been overwhelmed, and doctors have faced complex decisions about resource allocation. We present a case in which a pediatric hospital caring for both chil...
Article
The US health care system requires major changes to make health care more affordable and higher quality. In the decade since passage of the Patient Protection and Affordable Care Act (ACA), alternative payment models have become central to this effort. These models are designed to replace existing fee-for-service payments with a reimbursement struc...
Article
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Objective To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or hea...
Article
Patient-centered care should be a defining feature of the health care system, and no time is more critical for having patients at the center of care than at the end of life. At this difficult and deeply personal time for patients and their families, it is paramount that the preferences of patients and their families be respected and their experienc...
Article
On April 30, 2020, the Centers for Medicare & Medicaid Services (CMS) released an unprecedented emergency policy waiver to increase capacity in response to coronavirus disease 2019 (COVID-19): Hospital outpatient departments can now relocate health care services to off-campus sites or even into Medicare beneficiaries’ homes. For the duration of the...
Article
During the WHO-GloPID COVID-19 Global Research and Innovation Forum meeting held in Geneva on the 11th and 12th of February 2020 a number of different ethical concepts were used. This paper briefly states what a number of these concepts mean and how they might be applied to discussions about research during the COVID-19 pandemic and related outbrea...
Article
Public health emergencies require real-time, accurate information to guide effective responses. Rapid publication of information can, therefore, advance both the scientific validity and the social value of research conducted in these contexts. Consequently, medical journals place a high priority on rapidly publishing reports on these emergencies, w...
Article
Policy makers are increasingly using performance feedback that compares physicians to their peers as part of payment policy reforms. However, it is not known whether peer comparisons can improve broad outcomes, beyond changing specific individual behaviors such as reducing inappropriate prescribing of antibiotics. We conducted a cluster-randomized...
Article
Background Oncology care is expensive and exhibits substantial variation in cost and quality across clinicians and patients. Unlike many conditions with established bundled payment programs, cancer care includes a mix of inpatient and outpatient care that precludes hospital-based designs. In 2018, we worked with Hawaii Medical Service Association (...
Article
Medical education is currently undergoing a gradual but significant change. Part of the ongoing transformation is reducing the time of education by shortening the preclinical education period from 24 months to 12 to 15 months and, therefore, potentially reducing the total time of medical school.¹ Another change is more training in the predominant s...
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Importance Despite substantial research, the drivers of the widening gap in life expectancy between rich and poor individuals in the United States—known as the longevity gap—remain unknown. The hypothesis of this study is that social mobility may play an important role in explaining the longevity gap. Objective To assess whether social mobility is...
Article
In November 2019, The Wall Street Journal reported that Google had acquired access to millions of patient records through a partnership with the nonprofit hospital chain Ascension.¹ Coming just months after Google and the University of Chicago were sued over a similar arrangement, news of the Ascension deal renewed debate about the ethics of health...
Article
Medicare has reinforced its commitment to voluntary bundled payment by building upon the Bundled Payments for Care Improvement (BPCI) initiative via an ongoing successor program, the BPCI Advanced Model. Although lower extremity joint replacement (LEJR) is the highest-volume episode in both BPCI and BPCI Advanced, there is a paucity of independent...
Article
Objective: To evaluate whether the implementation of a new population-based primary care payment system, Population-Based Payments for Primary Care (3PC), initiated by Hawaii Medical Service Association (HMSA; the Blue Cross Blue Shield of Hawaii), was associated with changes in spending and utilization for outpatient imaging in its first year. M...
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In Reply We agree with Dr Kemble and colleagues that physician engagement is essential for successful payment reform. Unfortunately, their letter has many misrepresentations about the new 3PC model introduced in Hawaii.
Chapter
This book has sought to inform efforts to improve systematic, evidence-based priority-setting by assessing the state-of-the-art of methods for priority-setting, engaging with the fundamental normative issues at stake, and providing specific recommendations for improving current practice. This final chapter, written by the eight editors of this volu...
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Importance An increasing number of hospitals have participated in Medicare’s bundled payment and accountable care organization (ACO) programs. Although participation in bundled payments has been associated with savings for lower-extremity joint replacement (LEJR) surgery, simultaneous participation in ACOs may be associated with different outcomes...
Article
In 1992, the Centers for Medicare & Medicaid Services (CMS) introduced the Resource-Based Relative Value Scale (RBRVS) as a new system for physician payment. Rather than paying physicians their “usual, customary, and reasonable”¹ charges, this system was designed to pay physicians based on the time, technical skill, and mental effort required to pe...
Article
Purpose: The Oncology Care Model (OCM) is Medicare's first bundled payment program for patients with cancer. We examined baseline characteristics of OCM physician participants and markets with high OCM physician participation to inform generalizability and complement the ongoing practice-level evaluation of the OCM. Methods: In this cross-sectio...
Article
To the Editor In their study of overlapping surgery, Dr Sun and colleagues concluded that “among adults undergoing common operations, overlapping surgery was not significantly associated with differences in in-hospital mortality or postoperative complication rates but was significantly associated with increased surgery length.”¹ However, their repo...
Article
Importance Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated. Objective To evaluate whether the 3PC system was associated with...
Article
Even though relative value units guide 70 percent of physician payment, little research has assessed their accuracy. We analyzed actual service time for total hip and knee replacements at two academic hospitals in the period January 1, 2013-October 1, 2016, using electronic health record time-stamp data, and we compared that time with the Medicare...
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An amendment to this paper has been published and can be accessed via a link at the top of the paper.
Article
The US Food and Drug Administration (FDA) is caught between Scylla and Charybdis, with competing pressures to speed drugs to market and to ensure they are safe and effective. On one side, patients, families, and advocates are clamoring for faster approval of new drugs that offer treatments for serious and life-threatening diseases. They believe tha...
Article
Artificial intelligence (AI) and its many related applications (ie, big data, deep analytics, machine learning) have entered medicine’s “magic bullet” phase. Desperate for a solution for the never-ending challenges of cost, quality, equity, and access, a steady stream of books, articles, and corporate pronouncements makes it seem like health care i...
Article
e18017 Background: The Oncology Care Model (OCM) is Medicare’s first bundled payment program for patients with cancer. Because practices voluntarily enrolled in the OCM in 2016, there may be differences between OCM-participating and non-participating oncologists that impact the OCM’s generalizability. We examine baseline characteristics of OCM part...
Article
Background Pay-for-performance (P4P) has been used expansively to improve quality of care delivered by physicians. However, to what extent P4P works through the provision of information versus financial incentives is poorly understood. Objective To determine whether an increase in information feedback without changes to financial incentives result...
Article
The majority of Americans believe that lowering drug prices should be the top health care priority for the federal government. Yet drug costs as a proportion of the country's medical expenditures have increased substantially in recent years. Because drugs are basic necessities, and because how much society should contribute toward providing basic n...
Article
There is some good news on cost control in the United States. In 2017, the last year for which data are available, health care expenditures were 17.9% of gross domestic product (GDP).¹ This is similar to the 2010 level of 17.3% when the Affordable Care Act (ACA) was signed into law. On April 22, 2010, one month after enactment of the ACA, the US De...
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Importance: Despite limited effectiveness of pay-for-performance (P4P), payers continue to expand P4P nationally. Objective: To test whether increasing bonus size or adding the behavioral economic principles of increased social pressure (ISP) or loss aversion (LA) improves the effectiveness of P4P. Design, setting, and participants: Parallel s...
Article
In 2016 Medicare implemented its first mandatory alternative payment model, the Comprehensive Care for Joint Replacement (CJR) program, in which the agency pays clinicians and hospitals a fixed amount for services provided in hip and knee replacement surgery episodes. Medicare made CJR mandatory, rather than voluntary, to produce generalizable evid...
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In Reply We agree with Ms Bilinski and Dr Hatfield about the difference between failing to reject and accepting the null hypothesis. In our study, we failed to reject the null hypothesis that BPCI participation was not associated with differential changes in LEJR surgery volume.¹ Although we also agree that our analysis of beneficiaries within 306...
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What is a reasonable price for society to pay to give a patient with cancer 1 extra year of life without tumor growth?
Article
Since the passage of the Affordable Care Act, there has been an unprecedented pace of testing new payment models to increase health care value. These models have been directed across the continuum of health care professionals and organizations, including physicians, hospitals, and post-acute care facilities. Collectively, these models aim to combin...
Article
Greater safeguards are needed to address the personal safety, security and privacy risks arising from increasing adoption of neurotechnology in the consumer realm.