Who Is Don Berwick (and Why Is He Following Me?)

Who Is Don Berwick (and Why Is He Following Me?)



The rumors that I wrote about Friday are, in fact, true. President Obama will name Dr. Donald Berwick, president of the Institute for Health Care Improvement (IHI), to run Medicare and Medicaid. Berwick, who is a professor of pediatrics and healthcare policy at the Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health, will have to be confirmed by the Senate Finance Committee.

Just how tough will the confirmation hearing be? I’m not worried. Berwick can handle himself.

Granted, yesterday the New York Times called Berwick “iconoclastic,” i.e., someone who “smashes sacred religious images” or “attacks cherished beliefs.”   But most who know him describe him a “visionary” and a “healer,” a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. healthcare.

Berwick stands at the center of a healthcare movement that would reform the system from within. In 2005, Modern Healthcare, a leading industry publication, named him the third most powerful person in American health care. In contrast to others on the list, Berwick is “not powerful because of the position he holds,” Boston surgeon Atul Gawande noted at the time.  (Former Secretary of Health and Human Services ranked no. 1, while Thomas Scully, the head of Medicare and Medicaid services captured the second slot.) “Berwick is powerful,” Gawande explained, “because of how he thinks.”

Listen to some of the clips below, from the film Money-Driven Medicine, produced by Alex Gibney, and based on my book, and you’ll understand what Gawande means. Soft-spoken, and charismatic Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it  could be.

Berwick isn’t just another ivory-tower philosopher. He’s “an extraordinary leader when it comes to inspiring people and creating the will to move forward,” Dartmouth’s Dr. Elliot Fisher told me in a phone conversation Friday. “And he can teach people how to do it. He has demonstrated his ability to teach people how to implement change in a complex system.”

That is precisely what the Institute for Healthcare Improvement (IHI), the non-profit organization that Berwick co-founded in 1991 does, spearheading pilot projects aimed at “continuous quality improvement.” IHI targets problems like asthma care or safety in coronary surgery and then invites teams of medical workers from hundreds of hospitals to collaborate in what Berwick describes in his book Escape Fire, as “results-oriented, clock-ticking projects, which may last six months or a year.”

Berwick outlines the process: “A hundred teams working to improve cardiac surgery outcomes; 70 teams working to reduce Emergency Room waits . . .—guided by teams of faculty from around the country or around the world, meeting regularly in learning sessions . . . going home, sharing what’re learning, coming back together here, sharing again.”

IHI’s website (www.ihi.org) offers an abundance of resources. a team of health care professionals can sign up online courses that focuses on reducing Clostridium difficile infections, lowering the number of heart failure readmissions or managing advanced disease and palliative care. The interactive, two- to- four month web-based courses are called “expeditions” and include: check in calls every two weeks for faculty to provide advice and mid-course adjustments;   ongoing opportunities to share with and learn from other participating organizations; opportunities for periodic check-ins with faculty.

Alternatively, readers who visit the website and scroll down to “How Did They Do That?” and discover that Models of Low-Cost, High-Quality Health Care Do Exist in the U.S.

So Berwick does that it can be done—and how to do it. Many of IHI’s initiatives have succeeded. But he also understands that reform not something that will happen in 2014 when the government flips a switch. It’s a process that already is happening –and that will continue in the years to come.  Much depends on people on the ground.

The Will to Excellence

Berwick’s vision is generous. He is convinced that there are enough like-minded people within the health care professions to create a revolution: “The will to excellence is present everywhere in Health care,” Berwick told an audience at the National Forum on Quality Improvement in Health Care. “The will to do well, the quest for pride, the joy of achievement, the warmth of serving –these are natural capital, human traits. Not of all human nature, not all of the time, bu enough, plenty enough. We can waste them and deplete them,” he adds, referring to low morale in many parts of our health care system. “But the will to have pride in work is not scarce; it is everywhere abundant.”

Time and again, Berwick has seen IHI’s pilot projects work –without any financial incentives for the medical professionals involved.  Hospital workers want change. Many are horribly frustrated  to find themselves laboring in an system where the left hand and the right hand often fail to communicate, making  much of their work seem  redundant or even pointless. Berwick recognizes that these professionals would like nothing more than to turn their hospitals into efficient workplaces. And that such an opportunity might well be worth more than a 2 percent raise.

Indeed, a year ago at the American Medical Group Association meeting, Berwick compared physician performance bonuses to exhorting [doctors and nurses] “to do better,” and said both were “very poor cousins” to healthcare system redesign.  As he told Kaiser HealthCare News in an interview today: “I think we need to create more consequences for good and bad performance. But we have to learn our way unto that. . ..  The danger is that you create ‘games and gaming’—which we can ill afford.”

In a 2005 interview published in Health Affairs, Berwick expressed his concerns: “I would draw a very dark line between the incentives that apply to organization .  .  . where I do want incentives in place — and incentives for individuals. . . . I want it to be good for an organization to be safe, and I want it to be good for an organization to manage chronic illness carefully . . .”  He applauds the pilot projects in the health reform legislation that encourage Medicare to “bundle payments to doctors and hospitals,” with a  bonus added to the bundle when teamwork leads to good outcomes at a lower price.

But “at the individual level,” he insisted, I don’t trust incentives at all . . . I think it feels good to be a good doctor and better to be a better doctor. When we begin to attach dollar amounts to throughputs and individual pay, we are playing with fire.  The first and most important effect may be to disassociate people from their work.”

Here, I think Berwick is putting his finger on a potential problem in the current reform movement. Recently, I have talked to both doctors and nurses who were troubled by the new emphasis on “productivity” in organizations where they work.  How many patients have you seen today? As Berwick put it in 2005, “We’ve got to support the underlying culture and the underlying system that makes healing, not scoring, the objective.” Today, he added, “we need to stop paying for through-put.” (At the same time, he recognizes that primary care physicians must be paid more. Anyone concerned on that score should listen to the first clip from the film below)

When I was writing Money-Driven Medicine, I discussed the issue of “pay-for-performance” (which is quite different from paying an organization for good outcomes) with former Medicare director Bruce Vladeck: “Quality and improvement strategies need to focus on reinforcing the norms and values of professional responsibility rather than on undermining them through the exercise of economic muscle,” Vladeck said. “Unless we can continue to assume that most providers and administrators want to do the right thing for most patients most of the time,” he added, “we are all sunk and no amount of economic incentives can salvage the situation.”

Tapping into that underlying professionalism, Berwick has said, is “like drilling for oil. There is so much pent-up need in the health care work force that, even without financial incentives for individuals, health care workers are eager to make a change.”

To some, Berwick may sound out of touch. Over the past twenty years, the notion that pride in a job well done drives excellence has been dismissed as simply sentimental. People are motivated, we are told, by money. We’re all rats on a wheel, looking for the cheese. That’s what makes people “tick” Dr. Robert Galvin, director of Global Health at General Electric, told Berwick in that 2005 Health Affairsinterview. If we want a CEO to perform, a seven-figure salary is not enough. We must give him stock options. In this context, Berwick may sound naive.  But when I was writing Money-Driven Medicine, I didn’t find anyone in the health care industry who wanted to call him that. The sheer authenticity of his presence commands tremendous respect.

“The Enemy is Disease”

Meanwhile, Berwick understands the role that money plays in our highly-competitive for-profit system all too well.

At one of IHI’s National Forums, Berwick recalled phoning a hospital in Houston to learn about its reportedly successful innovations in pneumonia care. He was told that “the gains are enormous but the methods cannot be reported to the public—excellent pneumonia care offered the hospital local competitive advantage.”

He was stunned. “The enemy is disease,” he told his audience. The competition that matters is against disease, not one another. The purpose is healing.” Yet “in the storm of the health care crisis,” Berwick acknowledged “it is so easy to forget why we trouble ourselves in the first place. It is so easy—frighteningly easy—to become trapped in the sterile thesis  . . . that our true, deep purpose is to gain and preserve market share in a vacant terrain of others whose purpose is precisely the same.”  In other words, it is so easy to forget the patients.

In part 2 of this profile, I’ll talk about what Berwick has to say about fragmentation–and variations in care in different parts of the country. Why can’t the Kaiser Permanente model work everywhere. What does he mean when he says that we haven’t even tried “transparency”? What will Medicare ask of U.S. hospitals? Just how much waste does the think there is in the system? How quickly can Medicare move to eliminate that waste?

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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79 Comments on "Who Is Don Berwick (and Why Is He Following Me?)"

May 12, 2010

I am a mere layperson, a disabled American who is forced to rely on Medicare and to be honest, this man as head of CMS scares the you know what out of me.
He said the following in a speech in 2009:
“Any health care funding plan that is just equitable civilized and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent healthcare is by definition redistributional.”
“NICE is extremely effective and a conscientious, valuable, and — importantly — knowledge-building system [which has] developed very good and very disciplined, scientifically grounded, policy-connected models for the evaluation of medical treatments from which we ought to learn.”
“I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country.”
I have read about enough of the horror stories of government run health care and the rationing that goes along with it to be very afraid of someone with this mentality to be in charge of my healthcare.
He may have improved the quality of health providers within our healthcare industry, but that doesn’t mean he is a good choice to run our healthcare industry.

May 12, 2010

He does not advocate a government takeover? Have you listened to his speech 2008 in the UK, he absolutely thinks we should have nationalized healthcare. And we should redistribute the wealth, a true marxist.

Apr 21, 2010

Don Berwick called pay for performance a “toxic daisy chain” and a blunt instrument.
Listen to the horse’s mouth:

Apr 14, 2010

Mass AG Martha Coakley gave Caritas Christi health system a hard time before the Catholics cut a deal with hell hound Cerberus Capital Management. For the backstory:

Apr 13, 2010

Berwick’s #2 has an interesting history as head of Virginia’s Health & Human Services.

Apr 12, 2010

PEU Cerberus agreed on March 25 to buy Caritas Christi Health Care, a hospital operator affiliated with the Archdiocese of Boston, in a private-equity deal valued at $830 million.
Caritas hospitals are nonprofit community hospitals according to Guidestar. They will convert to for-profit facilities under Cerberus ownership. Besides adding debt to finance the deal, these hospitals will now be taxable. If they’re like Triad or HCA, expect interest expense to put a hurt on profits for a year or two.
Just as Cerberus ran Chrysler into the ground, they can do likewise for health care.
While Maggie makes inane comments about the for-profit model, a Catholic system sold out, changing stripes.

Apr 10, 2010

KKR plans to double its money on HCA. That’s after milking the company via dividend distributions in the interim.
Someone has a profitable business model, which will increase costs.
Taking HCA private added over $1 billion in annual interest expense. How much will new shareholders expect in dividends? Wait for the prospectus.

Apr 8, 2010

Carlyle hired an ex-Wyeth CEO as Senior Adviser:
“We see a range of opportunities in the U.S. and globally for private capital to help strengthen and improve the efficiency and effectiveness of the healthcare sector,” Essner said in a statement.
Essner’s hire comes in the backdrop of private equity firms looking to recruit industry veterans to manage their portfolios.
On Wednesday, former Procter & Gamble Co (PG.N) Chief Executive A.G. Lafley joined private equity firm Clayton, Dubilier & Rice as a special partner.

Apr 2, 2010

The Carlyle Group’s David Rubenstein expects health reform to produce 30% annual returns for his private equity underwriter (PEU):

Apr 1, 2010

More on those plan making shadow bankers. From FT:
So, apart from secondary buy-outs, where will the private equity deals of the future come from? Bain’s report identified four promising areas for new investments: energy, healthcare, the Asia-Pacific region and distressed investing.

Apr 1, 2010

Senator Grassley got his wish granted by an Illinois court:

Apr 1, 2010

“Liberals see equality as a top priority”
Do you actually believe this crap when you type it Maggie? Or more importatnly does anyone actually fall for this?
Why does a liberal living in NY, MA, NJ, or any other liberal state with high taxes pay less in federal income tax then me even if we make the same amount?
Why did liberal counties get twice as many ear marks as conservative counties?
Why does 40% of the population pay no federal tax?
Why did union debt holders get their claims placed ahead of those before them under existing law?
Why did healthcare reform just grant 10 billion to unions to sure up their health plans they underfunded so they could contribute to political campaigns instead?
Why is it illegal to discriminate against any race but whites?
Why do young people subsidize older people for healthinsurance but when the risk is flipped like on auto insurance they are on their own?
No single piece of liberal ideology is about equality, your entire belief structure is about placing the needs of a few above the effort of the rest.

Mar 31, 2010

When I posted THA CEO Dr. Dan Stultz’s comment I didn’t imply any stench. I once worked for him and found his assessment spot on. Our estate backed health system was going for-profit in 2006. With its resources, it should have been one of the last to change stripes. (The merger with Triad later failed).
SEIU President Andy Stern called employer sponsored health insurance dead and not coming back in 2007. Who knew a health care worker union would be one of the first to cave?
There are many unspoken themes embedded in health reform and they have nothing to do with Red or Blue talking points. A seismic shift is underway from employers to individuals and a tapped out Uncle Sam. While many cheer this move, few are creating graphs.
More people had employer coverage in 1998 (168.5 million) than CBO projects in 2019 (162 million). That’s with over 50 million in additional population.

Mar 31, 2010

Jeff, Bev MD,Alan Private Citizen
Jeff– Liberals see equality as a top priority– they value individual liberties, but tend to put equality first.
Conservatives, on the other hand, emphasize the right of the individual,including an individual’s right to amass as much wealth as possible, and keep it, to hand down to his heirs, without being forced to share it with others in the society.
I don’t think I’m “casting aspersions” on anyone’s character by saying this. Obviously I think the liberal point of view is fairer, but many people would disagree with me.
I’m just saying that we should all own up to the fact that our values and politics shape our views about the economy and public policy. And just as I am willing to acknowledge my priorities, conservatives should acknowledge their priorities.
And none of us should pretend that our analysis of policy or economics is value free (or not influenced by our politics and values.)
Finally, “Ideologue” and “ideological” are words people use to characterize politics that they disagree with. In truth, the word “ideology” simply refers to a set of beliefs.
But “ideology” began to mean “a set of Untrue and Rigid beliefs” during the McCarthy era, in the 1950s, when McCArthy attacked liberals who he viewed as communists..
Liberals were portrayed as “ideologues” who believed in socialism or Communism–which were “ideologies.” Capitalism, on the other hand, was presented as a set of beliefs that are simply True. (Rather like the teachings of the Catholic Church.) Therefore, capitalism couldn’t be an “ideology” and those who believed in American-style capitalism could not be considered “ideologues.”
To this day, some people continue to use “ideologue” and “ideology” as McCarthy did– as a smear, while denying that their own arguments are influenced by their values and politics.
Bev– Yes, Berwick is taking a pay cut to go to Medicare. And, as you suggest, the brouhaha about what he earns is beside the point.
Alan- Didn’t call you a troll. Merely said that you are repeating very peculiar allegations that a troll has been circulating in the blogoshpere
Private Citizen– Yes, people are beginning to focus more on patient safety (washing hands, etc.) Reform is happening on the ground. This is important.
Thank you for focusing the discussion on what matters: patients.

bev M.D.
Mar 31, 2010

Well guess what; doctors have the worst record on washing hands and putting on gowns; in fact they have the worst record on all hospital policies because they don’t believe rules apply to them. So yeah – they do need somebody with an M.D. to tell them, sad to say.