Why Berwick Matters

Why Berwick Matters

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Two cover stories in this week’s Time magazine debate a provocative question: Is America in decline?

Both the yes and no arguments are made persuasively, and I found myself on the fence after reading them, perhaps leaning ever-so-slightly toward the “no” side (optimist that I am). Sure, times are tough, but we’ve got the Right Stuff and we’ve bounced up from the mat before.

Then I considered the political fracas over Don Berwick’s appointment as director of the Centers for Medicare & Medicaid Services (CMS), and decided to change my vote, sadly. Yes, America is in decline, and this pitiful circus is Exhibit A.

Berwick, as you know, is a brilliant Harvard professor and founding head of the Institute for Healthcare Improvement. He is also the brains and vision behind most of the important healthcare initiatives of the past generation, from the IOM reports on quality and safety, to “bundles” of evidence-based practices to reduce harm, to the idea of a campaign to promote patient safety.

President Obama’s selection of Berwick to lead CMS last year was inspired. In the face of unassailable evidence of spotty quality and safety, unjustifiable variations in care, and impending insolvency, Medicare has no choice but to transform itself from a “dumb payer” into an organization that promotes excellence in quality, safety and efficiency. There is simply no other person with the deep knowledge of the system and the trust of so many key stakeholders as Don Berwick.

But Berwick’s nomination ran into the buzz saw of Red and Blue politics, with Republicans holding his nomination hostage to their larger concerns about the Affordable Care Act. In the ludicrous debate that ultimately culminated in Obama’s recess appointment of Berwick, the central argument against his nomination was that he had once – gasp – praised the UK’s National Health Service. Interestingly, without mentioning Berwick by name, Fareed Zakaria pointed to this very issue to bolster his “decline” argument in Time:

A crucial aspect of beginning to turn things around would be for the U.S. to make an honest accounting of where it stands and what it can learn from other countries. [But] any politician who dares suggest that the U.S. can learn from – let alone copy – other countries is likely to be denounced instantly. If someone points out that Europe gets better health care at half the cost, that’s dangerously socialist thinking.

I’ve argued that President Obama was right to use his recess appointment power to install Berwick as CMS director, and hoped – naively perhaps – that Don would win over his critics by the time his appointment expired in December 2011. And, in his eight months in the role, Berwick has done a terrific job. As always, his speeches on healthcare reform have been articulate and thought provoking (though one can see a heavy bureaucratic hand tamping down Don’s characteristic flair and penchant for provocativeness). He has appointed excellent people to key leadership positions, fleshed out some of the new CMS programs such as Value-based Purchasing and the Innovations Center, and will announce a major initiative in patient safety in the near future. Impressively, Berwick has accomplished all of this with at least one hand and several fingers of the other tied behind his back: doubt about his own future at CMS, uncertainty about the fate of the Affordable Care Act, and an unrelentingly hostile reception by the Republicans in Congress.

But my hopes were dashed by this week’s statement by Sen. Max Baucus (D-Montana) that Berwick’s is simply not confirmable by the Senate. This announcement followed a letter sent to the White House last week by 42 GOP senators, who argued – disingenuously – that Berwick’s “lack of experience in the areas of health plan operations and insurance regulation raise serious concerns about his qualifications for this position.” If the White House pulls the plug, he is likely to be replaced by his deputy, Marilyn Tavenner, a nurse administrator who ran two suburban hospitals for HCA and was Virginia’s Secretary of Health. The American Enterprise Institute blogger Joseph Antos praised her, sort of:

Tavenner has a reputation for making the trains run on time…. More importantly, [she] would not act as if she has a mandate to upend the health system, because she doesn’t.

In all likelihood, Tavenner would sail through her confirmation hearings, precisely because she won’t cause a stir.

But we need a stir!

From the moment of his nomination, Berwick’s plight has been a sad spectacle. I was particularly disheartened by the way he was treated during his testimony before the House Ways and Means Committee. It is too long and painful to watch the whole thing; if you’ve taken your Compazine, try a 5 minute stretch that begins precisely an hour into the testimony, as Representatives Davis and Reichert bait Berwick with a combination of hyperbole and rhetorical foolishness (“I’m not interested in an academic salon answer…”) that would make a middle school playground argument seem positively Shakespearean.

In the face of this kind of nonsense, I know of several superb physician-leaders who were offered positions in CMS – for roles that should have been once-in-a-lifetime opportunities to shape national policy – but turned them down. “Who needs this?” one told me. And they’re right.

The smart money is that the White House will fold on the Berwick appointment. The legendary Lucian Leape emailed many of Don’s colleagues yesterday, including me, asking that we sign on to a letter to the president in support of Berwick. Lucian wrote:

Watching the hearings and reading the statements being issued by the Republicans on this matter has been both disappointing and disgusting as we see our eminently qualified colleague disparaged by those who have no appreciation for what he has done and can do for our health care system.

I gladly signed this letter, and I hope you’ll do what you can to turn this around. Please contact the White House, your senators and representatives, and the media, and tell them that Don Berwick is the best hope we have to improve our healthcare system. Tell them that the Senate should hold hearings on his appointment, letting the chips fall where they may. Tell them to start acting like grown-ups.

If this good and great man is thrown under the bus, you’ll have all the evidence you need that our society is, in fact, in decline. Let’s not let this happen without a fight.

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38 Comments on "Why Berwick Matters"


Guest
Mar 12, 2011

To his extremist “Republican” critics (and their companion nitwit Tea Bag rabble contingent), teh phrase “brilliant Harvard professor” is the dispositive Exhibit A. Full Stop.
___

“Medicare has no choice but to transform itself from a “dumb payer” into an organization that promotes excellence in quality, safety and efficiency.”

These people don’t CARE about any of that. They simply want to eviscerate it.
___

“..[he has] fleshed out some of the new CMS programs such as Value-based Purchasing and the Innovations Center, and will announce a major initiative in patient safety in the near future…”

All of which are summarily dismissed a priori as oxymoronic.

The U.S. is indeed in decline, for reasons going well beyond just health care. We are a nation in severe denial, a condition aggravated by the willful self-(and patron) serving tactics of the Right.

Guest
nate ogden
Mar 12, 2011

The fact remains CMS is the largest payor in the world and he has ZERO qualification to run such an organization. All of his postive traits qualify him to manage a division of Medicare engaged in the actions he has experience in. Its not surprising you anti business liberals have no clue how successful orgainizations are managed, in your world efficency and success doesn’t matter you just raise taxes more.

Berwick belongs in some department someplace working on quality and saftey issues. Before Medciare goes spending any more money to improve quality and increase cost even further they need to reign in their fraud and inefficiences, something Berwick doesn’t even have a single day of experience doing.

Guest
Mar 12, 2011

Nate, “in YOUR world of AHIP butt kissing, efficiency and success doesn’t matter, you just raise the 8 figure executive compensation package more (while raising premiums).”

BTW, Berwick was not tapped to be a “manager.”

Guest
Marcia Messer
Mar 12, 2011

Nate,
I respectfully disagree. You underestimate the ability of Don Berwick. I cannot think of a person more qualified for the position. As per the IOM report, poor quality, inefficiencies and ineffective management of population health are all drivers of rising cost of healthcare.

I do agree we need to reign in fraud.

Guest
nate ogden
Mar 12, 2011

What do you feel in his background qualifies him to run the largest insurance company in the world?

Compare his background to that of the CEOs of;

Anthem
United
CIGNA
Aetna

They are nothing alike. Why do you feel his disparet background which is nothing like those running similar entities qualifies him?

Guest
nate ogden
Mar 12, 2011

BobbyG not that you need any help looking like an idiot but I make my living competing with AHIP members. When I succeed they lose. I get business by pointing out AHIP member lack of efficency. No one in my industry is making 8 figure compensation packages.

Thanks for another dumb ass comment, 3 for 3 making quit the name for yourself. I guess if you can’t debate facts or discuss matters inteligently then you resort to commenting like you do.

Guest
Mar 12, 2011

Yawn. You are too easy, pal.

Guest
Mar 12, 2011

Nate,

You raise a good point about what are exactly the qualifications for the job. But the point I hear Bob making is that 1) we should absolutely hear these out in confirmation hearings and 2) to disparage a man that has so passionately dedicated his life to helping patients not the status quo, points to the politics as usual. And that is sad because we have a crisis of the status quo. Unfortunately I believe the way the White House handled his initial appointment just added to this.

To your point Nate about whether he is capable of effectively managing such a huge organization, I would look at more broadly in terms of the make up of the senior leadership team. Having helped organization with role definition it is not uncommon to place the visionary leader at the top of the organization to set the pace and culture. The COO or Deputy in this case role is then to make sure the train run on time but on the right tracks headed in the right direction. High tech companies use this approach very successfully. I think that is the problem with healthcare we have to many manages and not enough leaders. We have incremental change.

Regardless of what we think of his beliefs, I would encourage the Senate to give Dr. Berwick his due course and I will reach out to my Senators. Bob appropriately identified the harm in the buzz saw of red and blue politics. If that persists those with innovative ideas will clearly not want to raise their voices.

As Albert Einstein said the “The significant problems we face cannot be solved at the same level of thinking we were at when we created them.” Today that statement rings so true.

Guest
nate ogden
Mar 12, 2011

Mrs. Ryan,

Bob’s post was very anti-republican and inflamatory. I don’t disagree with your two points but lets review them.

1. Confirmation hearing, I agree 100% he should have one, why hasn’t he? Democrats control the senate and would be the ones to schedule such a hearing. The ONLY reason there has not been a hearing is becuase Democrats won’t schedule it. Personally I think even if someone gets a recess appointment they should first have to have a hearing. Nothing in this point justifies Bob’s attack on the right.

2. Since Bork this is how things are, I don’t agree it is bad. His supporters want to hold him up as a savior. People like Maggie Mahar created an entirly new religion to worship him. If you disagree with someone that puts him on a pedastool you can’t do so by just saying I disagree. As aggresivly as they anoint him you must counter.

I think visionary leaders are great for small and start up firms, in those cases the size is manageable enough they can effect the business. When you get to be the size of GE or CMS visionaries are not effective. What is killing Medicare? It’s not lack of vision it’s failure to manage day to day operations. They need to stop losing 10% of every dollar to fraud. They need to perform their core functions better. This is not visionary work, this is nuts and bolts roll up the sleeves hard work. This is why founders and visionaries are almost always pushed aside when corporations get to a certain size.

There is still a role for visionaries, its just not at the top.

If Bob cared one bit about getting a hearing he wouldn’t attack Republicans in making his argument for Berwick, and he would get his facts correct. Republicans can only hold up his appointment, his nomination is solely in the hands of Obama and his confirmation hearing in the hands of Democrats, for some reason those facts go left out of his post.

My biggest gripe with his post;

“who argued – disingenuously – that Berwick’s “lack of experience in the areas of health plan operations and insurance regulation raise serious concerns about his qualifications for this position.”

What is disingenuous abou it? Bob can’t argue this point, its true he is not qualified and doesn’t have the experience for this aspect so he tries to write off the entire argument as disingenuous. You can argue how much of CMS is a payor and how much is a health system or care provider but to claim it is a disingenuous argument is just dishonest. You can’t complain about the partisian aspect of it when your in the middle of a political diatribe.

Guest
nate ogden
Mar 12, 2011

Mrs. Ryan how do you feel about the treatment of Sarah Palin?

Guest
DeterminedMD
Mar 12, 2011

Gee, you read this and the adage “if it’s too good to be true, it probably isn’t” comes to mind.

“Berwick, as you know, is a brilliant Harvard professor and founding head of the Institute for Healthcare Improvement. He is also the brains and vision behind most of the important healthcare initiatives of the past generation, from the IOM reports on quality and safety, to “bundles” of evidence-based practices to reduce harm, to the idea of a campaign to promote patient safety.”

“There is simply no other person with the deep knowledge of the system and the trust of so many key stakeholders as Don Berwick.”

And my favorite from the post, ” Berwick has accomplished all of this with at least one hand and several fingers of the other tied behind his back…”

Gee, Robert Wachter, who needs God when you have Don Berwick. Are you his PR guy, or just have so much invested in PPACA surviving that had Obama nominated Dagwood Bumstead for this post he would still get the same radioactive glowing praise as above?

You read posts like this and have to wonder who the authors think the audience is. Oh, I forgot, the Obamacare Tabernacal Choir!!!

Guest
Mar 12, 2011

I do not understand where Nate Ogden comes from when he says Dr. Berwick has no qualifications for managing CMS. It seems to me Dr. Berwick understands very well the principles of affordability, transparency, accountability, availability and evidence based that must underly a responsible health care system. The only thing I left out is universality since that is still not on the table. To implement these principles requires someone with vision who is willing to stir things up and that sounds like something many physicians who are benefitting from the present system and building there partnership cardiac and orthopedic hospitals do not wish to consider. We all need to know where the money is going and that means public disclosure of cost per physician per patient per year of all public funded and subsidized health care.

Guest
nate ogden
Mar 12, 2011

Hu,

If CMS was a health care system then you might be right. CMS is a payor or healthcare plan. CMS doesn’t deliver healthcare they purchase it from healthcare systems. Berwick would be a better fit to manage one of those systems. he is a terrible fit and has no experience managing any plans.

Guest
steve
Mar 12, 2011


“I think visionary leaders are great for small and start up firms, in those cases the size is manageable enough they can effect the business. When you get to be the size of GE or CMS visionaries are not effective”

Cheney went from a govt job to running Haliburton. He worked as a physician, he worked in administrative positions in medical system(s) and runs his own organization where he also studies and reports on health care management. He knows the system from the bottom up. He has studied and critiqued the system for years. He has made contributions through the system to improve quality. I think that he offers a good balance of training and experience. I say give him some number crunchers and let him work.

We are at the point, or close to it, where we need some people with ideas and willing to take some risks to try to fix things. Another caretaker type, while not the end of the world, would be less preferable, but easy to find if he leaves.

Steve

Guest
steve
Mar 12, 2011

Oops, he meaning berwick.

Steve

Guest
Mar 12, 2011

Nate,

You raise good points and I think we need to debate the necessary leadership talent needed at CMS as shown by Steve’s addition to the dialogue. It is a discussion worth having and I am glad you agree on the need for a hearing. I also took away from Bob’s note that it was the White House’s decision whether to proceed or not with Baucus providing more justification to fold. Yes Bob’s note was partisan as he only noted at one point that both sides engage in this activity (the buzz saw of blue-red politics) but the point is this. I see this image of the little kid in the playground who actually might have a brain and something to offer to his fellow students but there are these ridiculous bullies who shout and yell and stamp out anything remotely innovative, different or intelligent. That is our culture. We all own it and we will all be looking at failing healthcare (i.e. country) if we don’t do something about it. And shame on all parties if they don’t hear Berwick out…. the bullies would have won on both sides.

Most importantly Bob’s blog prompted me to write my Senators (Kohl/Johnson) to ask for a hearing. If his goal was to prompt this type of behavior, l believe it was effective.

Guest
Bob Pyke Jr
Mar 12, 2011

I am also a fan of FAREED ZAKARIA .
Sadly he nails it,,,,

Guest
Dr. Mike
Mar 12, 2011

““Cynics beware, I am romantic about the National Health Service; I love it. … The NHS is one of the astounding human endeavours of modern times.”

That quote alone should have disallowed his appointment

Guest
nate ogden
Mar 12, 2011

Wonder if he still feels that way with all its recent failures and problems?