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

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

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By MAGGIE MAHAR

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?)"


Guest
bev M.D.
Mar 29, 2010

Test comment: are you there, THCB?

Guest
bev M.D.
Mar 29, 2010

Wow, it’s back! Now, Maggie – Jeff Goldsmith put on Facebook that Berwick has neither the patience, nor discipline, nor experience for this job. I don’t know the man except by reputation – your thoughts? Would a manager deputy be the solution? It seems it would be easier to find a manager than a visionary such as Dr. Berwick.

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Barry Carol
Mar 29, 2010

For traditional hospitals, improving quality and processes in ways that save money usually benefits payers and patients but not the hospital itself. Indeed, hospitals generally lose revenue as Virginia Mason in Seattle can tell you from experience. A truly successful quality program might look something like the following over the long term: We’ve significantly reduced infection rates and surgical complication rates as well as readmission and mortality rates. Doctors are no longer referring patients for imaging and surgery who don’t need them. We’re providing far less futile care at the end of life while our palliative care program is among the best in the business. Since tort reform was implemented, defensive medicine is way down. Bottom line: our revenues declined 20% and we need to lay off 20% of our staff and close some of our facilities. How do you think the Board will react to that presentation? While an individual hospital might be able to offset the revenue loss with greater patient throughput, the hospital sector overall will need to shrink materially if we are eventually successful in improving quality while reducing costs. While that would be a great thing for the society and the economy, I don’t expect hospital executives or Boards to embrace the objective.
The underlying problem at its core is that hospitals are built to generate revenue. They are extremely capital intensive businesses like hotels, cruise ships, airlines with enormous fixed costs. As hospitals lead in the building of accountable care organizations by buying up medical practices, even if the doctors are salaried, their “productivity” will be closely monitored and there will be plenty of pressure to generate revenue for the mother ship. Those that don’t, especially primary care doctors, will be viewed as “not earning their keep.”
While there are plenty of knowledgeable people who disagree with me, I would prefer to see insurers’ contract reimbursement rates for doctors, hospitals, imaging centers and labs publicly disclosed and, to the extent that we can appropriately measure quality, especially for hospitals, those metrics, including infection rates, mortality rates, complication rates and 30 day readmission rates should be disclosed as well so referring doctors will have the information they need to steer patients to the most cost-effective provider instead of their golfing buddy or the hospital he has always used because he and his predecessors always used it. If patients still want to use a more expensive or less cost-effective provider or even a more expensive accountable care organization, they should pay a higher co-payment or coinsurance percentage for the privilege. This tiering approach has worked well in the prescription drug space. I think it can work in the rest of healthcare as well but we need to try it to find out.
That all said, I’m pleased to see Dr. Berwick appointed as CMS Administrator.

Guest
Mar 29, 2010

Bev M.D.–
Good to hear from you.
Berwick actually has plenty of management experience. He ran quality improvement for Harvard’s Health Care System (now Harvard Pilgrim) for about 7 years.
That gave much experience in dealing with a bureaccracy,etc.
In addition, IHI itself is a huge international organizationAnd Berwick has demonstrated his skills in helping enormous heatlhcare organizations improve care.
I suspect Goldsmith got this idea from Robert Pear’s Sat. article in the NYT. Pear described Berwick as a “scholar” –not at all who Berwick is. He’s at Harvard, but he’s a systems person (someone who has studied improving systems) with a degree in public health as well as an M.D. And he runs an enormous international organization that helps launch pilot projects all over the world.
He is not someone who sits in his study and writes.
Pear is a longtime NYT journalist, but not an expert in healthcare and so I’m afraid he often gets facts wrong in healthcare stories. (I’ve written about a couple of his pieces on HealthBeat.) Also, he probably had to report and write this piece very quickly— the rumor that Berwick might be appointed came out Thurs.) These days, because money is so tight in the newspaper business, newspaer reporters just don’t get the support they need, even veterans like Pear working at places like the Times.
As for “patience and discipline”– I’ve been observing and reporting on Berwick for seven years. . . . Patience and discipline are two of the words that come to mind when I think of him.
The problem with Facebook (which can be useful) is that it allows anyone to say anything about anyone.
One also should consider “Who is Jeff Goldsmith, and why would he be saying these things about Berwick?”
Goldsmith is not a doctor, a nurse or a public health expert. He has a Ph.D. in Sociology.
Goldsmith’s Speaker’s Bureau bills him as “America’s premiere health care futurist” and explains that he owns Health Futures, Inc., “a firm specializing in corporate strategic planning and forecasting future health care trends.”
He charges $15,000 to $20,000 per speech.
Goldsmith also wrote disparagingly about Accountable Care Organizations like
Intermountain, in Health Affairs in Aug of 2009. (“Accountable Care Organizations: Not Ready for Prime Time”)
Autl Gwaande, DArtmouth’s Elliot Fish and Jon Skinner and Mark McClellan are all major fans of accountable care organizations. And, in fact, ACOs are working.
But they’re not a major source of profits for health care entrepreneurs like Goldsmith..
I don’t know Goldsmith. Probably he’s a perfectly respectable hard-working entrepreneur. But I don’t take his criticism of Berwick seriously.

Guest
Mar 29, 2010

Barry–
I’m very glad–but not surprised–to hear that you are pleased about Berwick being the president’s pick.
You and I come from somewhat different ends of the political spectrum, and disagree about some issues, but your response confirms my belief that any truly intelligent, very knowledgable and thoughtful person person–whether liberal, conservative, moderate or libertarian– would applaud the idea of Berwick directing Medicare.
This is why I think that, while the confirmation process may be very unpleasant, he will be approved.
On the issues you raise regarding hospitals and revenues: This is what I wrote about on HealthBeat today while commenting on Atul Gawande’s upcoming piece in the New Yorker.
As you say, “the underlying problem is that hospitals are built to generate revenues.” Gawande and Berwick understand the problem, and Berwick actually has the beginning of a solution.
We don’t want to reward hospitals (and other healthcare businesses) for Growth. We want to reward them for delivering Value. (The government needs to think like Warren Buffet.)
See this post on HealthBeathttp://www.healthbeatblog.com/2010/03/atul-gawande-in-the-april-5-new-yorker-now-what—maybe-we-should-pay-hospitals-for-empty-beds.htm

Guest
Mar 29, 2010

It will be a very cold day in hell when any given public person has no critics. Even saints had critics. Not that Dr. Berwick is a saint, but I’m sure he has strengths and weaknesses. As long as he can lead the way, we should be good.
Barry, I totally agree with your description of the hospital situation. I believe somebody needs to step in and break those huge monopolies apart, and I believe that the current trend of purchasing private practices needs to be halted. I don’t know if states or federal government have the power to do that, but somebody should look into it.
While price transparency and tiers may help, if in a given metropolitan area all you have is one mega health organization (hospitals and ambulatory clinics), there is very little to be accomplished by transparency.

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Stephen
Mar 29, 2010

Orac knows nothing.

Guest
bev M.D.
Mar 29, 2010

Fair enough reply on Goldsmith, Maggie; thanks. Now here’s another question, regarding your congress lashes itself to the mast post –
I read this morning in Samuelson’s column in the WaPo that “the (new Medicare independent) Board is prohibited from submitting proposals that would ration care, increase revenues or change benefits, eligibility or Medicare beneficiary cost sharing”; quoting the Henry J. Kaiser Family Foundation. Is this true? It sounds more like the old MEDPAC restrictions. If it’s in the new bill, that’s not good.

Guest
Mar 29, 2010
Guest
Joseph Stevens, MD
Mar 29, 2010

Any one who would craft (Berwick did) the To Err is Human Report, extrapolating two small studies to the entire nation and claim 98,000 patients die from medical mistakes per year and have the nation believe that hogwash; and then, position his nonprofit for profit (check what ISI charges hospitals)
business to “solve” the problem is an operator, not a leader. What was his compensation at this not for profit and did he pull down a Harvard sized salary as well? Always a good idea to have a pediatrician manage the medical insurance for the elderly!

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Barry Carol
Mar 30, 2010

Margalit – Even Partners Healthcare in Boston, which is probably the poster child for healthcare providers with huge local market power, has roundly 20% or so of the relevant market in the Boston area, I believe. Presumably, regulators could impose some limits on market share. On the insurer side, I note that Pennsylvania regulators nixed the proposed merger of Highmark Blue Cross with Independence Blue Cross which would have created the nation’s 8th largest health insurer. Both are non-profits, by the say.
I think that transparency enabled by disclosure of provider contract reimbursement rates would be especially useful in areas like diagnostic imaging, the charge for a day in the hospital for situations that are reimbursed on a per diem as opposed to a case rate basis, and common surgical procedures like gall bladder removal, routine childbirth, etc.
For more sophisticated procedures like heart bypass surgery, hip replacement, brain surgery, organ transplants, cutting edge cancer treatment, etc., we should encourage the development of regional centers of excellence and discourage proliferation of capability. In these instances, utility like rate regulation would be appropriate so that in exchange for monopoly or near monopoly status, providers would only be allowed to recover their prudently incurred fully allocated costs including a reasonable return on their capital. At the very least, I would at least like to try robust price and quality transparency before any regulatory move toward full all payer rate setting.
I also want to make two comments on cost shifting. An insurer CEO recently told a small group of investors that of his company’s recent 10% medical trend for hospital charges, fully four percentage points was attributable to cost shifting from Medicare and Medicaid while six percentage points was due to legitimate provider cost increases plus higher utilization. Second, a financial executive for BIDMC in Boston recently noted on Paul Levy’s Running A Hospital blog that Medicare is a reasonable payer for inpatient care at his hospital but a horrible payer for outpatient care. The revenue mix for Medicare patients at BIDMC is 56% inpatient and 44% outpatient. For commercially insured patients, by contrast, the mix is 37% inpatient and 63% outpatient. My interpretation of the numbers is that Medicare is paying costs plus maybe a few percentage points for inpatient care but as much as 30% below costs for outpatient care. Costs are defined as fully allocated costs including the cost of capital (borrowing costs for a non-profit).

Guest
Jeff Goldsmith
Mar 30, 2010

Don Berwick is a personal hero, and one of the people I most admire in the health system. He’s done more than anyone I know to push the quality improvement agenda in health care. I met Don when he was at Harvard Community Health Plan, which was a client. But more importantly, I know the job he’s been selected to fill, and there are legitimate questions about whether it’s a good fit. This isn’t about politics or about my “personal experience”.
Running CMS is perhaps the hardest subcabinet job in government (IRS Commissioner may be almost as hard).
I’ve personally known all but two of the people who have run CMS since the agency was created, and I’ve got a really good idea of what it entails. You spend about half your time away from the office giving speeches and testifying before Congress. You spend a lot of time in the office fending off 535 Congresspeople who have constituent or interest group issues, and many of whom behave like owners. Those two activities sap your energy and divert you from the real challenge of trying to change the two programs you administer.
The rest of the time you get to “manage” over 4000 overworked and demoralized employees who will be there long after you’ve left. The agency’s mandate has been massively increased by the new legislation, and it remains to be seen if they will have the staff to execute. The agency hasn’t had a permanent, confirmed Administrator since Mark McClellan resigned in September 2006. This is, first and foremost, a political job requiring skills in exercising political judgment and relationship management. Secondly, it is a huge management challenge mastering the arcana of the world’s most complicated price control system.
With respect, it’s not clear that Don is qualified to do either of these jobs. Frankly, both the political and bureaucratic challenges are beneath him. It’s a waste of a really valuable person, who could do a lot more good pressing IHI’s agenda than wading into the fetid swamp of Washington DC.
Don was the White House’s first choice for this job, and told them no repeatedly. Glenn Steele of Geisinger, their second choice, told them no about four times. For both men, “no” was the right answer.
Maggie and I can talk about ACO’s some other time. About ten years of my management consulting career was spent trying to do them, to compete with Kaiser all across the west. I’ve donated blood on this issue. It’s not that you cannot pull it off. It’s just not a viable replacement for fee for service payment. Believe me, I’ve donated blood on this one. . .

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Peter
Mar 30, 2010

“A truly successful quality program might look something like the following over the long term: We’ve significantly reduced infection rates and surgical complication rates as well as readmission and mortality rates. Doctors are no longer referring patients for imaging and surgery who don’t need them. We’re providing far less futile care at the end of life while our palliative care program is among the best in the business. Since tort reform was implemented, defensive medicine is way down. Bottom line: our revenues declined 20% and we need to lay off 20% of our staff and close some of our facilities.”
Sounds like single-pay Barry. Can’t wait until I see this happening in hospitals across this country, then we’ll know true reform has come.

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Skeptic
Mar 30, 2010

For a more balanced perspective on Dr. Berwick, I urge readers of this blog to check out Dr. Robert Wachter’s blog:
http://community.the-hospitalist.org/blogs/wachters_world/archive/2010/03/26/is-don-berwick-the-one.aspx

Guest
Mar 30, 2010

Jeff. Maybe you’re right, but the right leader at a government agency can make the difference. Kizer at VA in the 90s? That cop who ran the Boston and NY Police in the 90s too?
And of course Maggie would say you didn’t donate your blood, she thinks you sold it!