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
James
Jun 28, 2011

I believe that Mr. Berwick would most likely have been confirmed had he been able to have a hearing. In the end, most of the time congress will defer to the chief executive on matters relating to picking their “team”.

Guest
Jun 28, 2011

Obama threw Berwick under the bus instead of letting him have his day in front of the Senate. The Senate Democratic leadership (quite an oxymoron) has done nothing to help. Harry Reid wouldn’t know leadership if it smacked him across the face.

On the other hand, a hearing likely would become a political circus, fueled by national media that are either too afraid or too lazy to look beyond the superficial mudslinging. As a journalist myself, I’m ashamed that the national media was so bad in reporting about health reform that they’re complicit in the public’s thinking that health insurance is synonymous with health care.

Guest
Jun 28, 2011

I bet he has changed his mind since he has had recent failures and problems.

Guest
James
Mar 24, 2011

I said at the time (and posted it, as I recall) that the decision to side-step confirmation with a recess appointment would do a long-term disservice to Mr. Berwick. It was a short-term gain, but came at a cost later. It would have been better to hold the hearings when the appointment was first proposed, let Mr. Berwick answer any criticism in public, and then vote.

Guest
nate ogden
Mar 21, 2011

” Don Berwick is revered among health care professionals who have worked in health care improvement–which involves improving efficiency, lowering costs, improving quality, and increasing accessibility of health care services.”

What does this have to do with CMS? CMS is not a health care provider, they are a health care payor. He has no experience or qualifications to run a health care payor.

” Sure, CMS is a payor,”

a payor? They are the largest payor in the world. Its also their primary and most important duty. Your not talking about some side business or related company that generates a couple percent revenue, payor is the big one, that is the one thing they need to do right before all else.

“politicians have repeatedly and explicitly forbade it to negotiate prices”

Correct becuase they dictate prices. When Medicare was originally passed they promised to negotiate fair prices for doctors but that got in the way so they just repealled that part of the law and telling providers what they would be paid. Much easier when you don’t allow the other side a say. How long till they do the same with Rx?

“Cigna can make plans that squeeze out the sicker population to raise their bottom line. CMS can’t.”

While technically true your point is wrong. Medicare waanted to push people off on private insurance so they just passed a law saying private insurance is primary. That wasn’t enough so they made it illegal to incentivse people to go on Medicare. Don’t forget the second M, the whole reason States and Feds require 26-30 years old kids be covered on parents policy is to get sick Medicaid patients off the rolls. CMS has been far more effective in pushing off bad risk then any private insurer.

What is Berwick’s qualification to address fraud? He has none. Wouldn’t the CEO of a major insurer that has dealth with issues like that for 10-20 years be better qualified?

“but the British government spends a fraction of what we spend in the US per capita and achieves universal health coverage where no one is turned away.”

THis is a lie. Try getting expensive cancer drugs. Try getting no emergency surgery, putting someone on a 12 month waiting list is just the same as turning them away. Try having a 20 week premature baby and being told they won’t treat the baby becuase they are to young. They turn away babies to die every week.

It would be nice for a change if people pimping the NHS actually knew how the NHS worked, Berwick included. Either that or your all just rank dishonest and hide the flaws for your political gain. Personally I hope its ignorance not politics.

Guest
Evy
Mar 19, 2011

While Obama was hyped up to be more than he was, I still prefer him over McCain/Palin. Obviously, this is a political preference and I don’t intend to convince you.

On the other hand, Don Berwick is revered among health care professionals who have worked in health care improvement–which involves improving efficiency, lowering costs, improving quality, and increasing accessibility of health care services. He has NEVER played in politics. Perhaps there are other people who have qualifications to do this job, but no one is as good for the job as Dr. Berwick; he is a visionary leader in health care improvement and has done more for our understanding of systems based changes (taken directly from businesses, e.g. the airline industry, the Toyota production line, methods like Six Sigma) than anyone else. And if some think that his singularity is sad for this country, then it is sad.

The idea that a business executive would be better is also misleading. Sure, CMS is a payor, but it is far more than that. CMS is not out to undercut competitors; in fact, politicians have repeatedly and explicitly forbade it to negotiate prices (for drugs, for example) like a normal payor, for fear of hurting the private markets. Cigna can make plans that squeeze out the sicker population to raise their bottom line. CMS can’t.

As for fraud, it’s unfortunate that people try to defraud CMS. Unfortunately, CMS is the easiest, largest target to defraud. Fraud usually takes the form of something like this: open up shop offering info on “free” Medicare-paid health care equipment, like wheelchairs, scooters, or diabetic shoes. Get Medicare enrollees to give you their information so you can “check if they are covered”. Charge Medicare for the equipment that the enrollee did not receive.

Medicare fraud is much greater than Medicaid fraud, and the reason is most likely because older, sicker people are easy to defraud. The elderly are less likely to check and ensure that their provision of benefit receipts from CMS are accurate (which outline what has been paid on their behalf) and are easier targets of identity theft. I get the same documents from my private insurer, outlining the claims that have been made on my behalf. But as a young professional, I check to make sure everything is correct and I’ll be sure to alert my insurer if they aren’t correct (because I’ll eventually pay for that in premiums). Would my grandma be up to doing the same? No way! The response to this unfortunate situation is either A) make it harder to be reimbursed by CMS (such a move is opposed by hospitals and providers) or B) police fraud like the mafia and give the law enforcement department of HHS more money to do this.

Finally, the NHS is an incredible system. We all gripe about our own system, but very few Brits come to the US for healthcare to escape the “awful” NHS. It is also a system undergoing changes and challenges of its own, but the British government spends a fraction of what we spend in the US per capita and achieves universal health coverage where no one is turned away. Sure, perhaps your elective surgeries take longer, but if you have the money, you can go to a private hospital and pay out of pocket. You can do that in any country, even in the US. Your health insurance won’t pay for that CT scan? Pay $1000 yourself. However, if you hope to be subsidized by the government or insurance, then you may have to wait. That seems fair to me.

Guest
nate ogden
Mar 18, 2011

Same people claiming Berwick is the best person for CMS and the country would be terrible if he doesn’t get the job said the same thing about Obama and look at the joke he turned out to be. Unqualified, unable to perform his duties, unless you call him the golfer-in-chief, and scared to actually make any decisions. Obama is a perfect example of someone put into a job they don’t have the qualifications for, Berwick is no more qualified to run CMS then Obama was to be President.

And don’t miss the latest heart warming story out of Berwick’s NHS

http://www.dailymail.co.uk/health/article-1366801/Premature-baby-dies-mothers-arms-hospital-staff-refused-help-him.html#ixzz1GsiazP2F

Maybe our healthcare spending wouldn’t be twice as much if we let all of our premies die like they do, some how this fact never gets mentioned by liberals making the twice as expensive argument

Guest
Bruce
Mar 16, 2011

Maggie Mahar has it right about everything except that ‘Congress rejected Berwick.’
That hasn’t formally happened yet. I hope that enough of those mistakenly opposed to his confirmation change their minds to vote for something good for America—the confirmation of Donald Berwick as the CMS head.

Guest
Mar 16, 2011

I wrote a similar commentary about Berwick this week. http://www.meaningfulhitnews.com/2011/03/14/berwick-political-saga-is-attack/

How the person who’s probably done more to save lives than anyone else alive today gets vilified as a granny killer and uninterested in anything but socialism is beyond me.

Guest
Mar 16, 2011

Bob–

Thanks for witing this.

It isgood to be reminded that people who actually know Berwick– and understand the problems in our health care system– recognize what a loss this is.

As you suggest, the fact Congress rejected Berwick says something about where this country is at this point in time. Berwick is too honest, and too intelligent to be accepted by Washington. And very few people of his calliber are willing to serve in a government ruled by the politics of hate.

Guest
Mar 15, 2011

nice article, thank you so much…

Guest
Bruce
Mar 14, 2011

Where’s the civility, folks?

Guest
Mar 13, 2011

I have no doubt that Dr. Berwick would be an appropriate candidate to lead CMS, but I have no doubt that there are probably several dozen others that would be as appropriate.
What is happening now in DC is not personal, it’s business, the business of obstructionist politics on both sides. If we really want a talented person to run CMS, it will have to be someone pre-vetted by both sides, someone who is equally liked and disliked by both sides. Does this imply compromise on quality for this clearly political appointment? Probably not, since I do believe there should be quite a few interchangeable folks that could be successful. If we argue that Dr. Berwick is the one and only, then we really are in a world of hurt in this country.
So as frustrating and painful as this may be for some of us, let’s get on with filling that crucial role at CMS as soon as possible.

Guest
Mar 13, 2011

Janice,

Why do you feel it necessary to attack Bob and me for the work going on in our hospitals (or, in my case, my former hospital)? I don’t think either of us has ever claimed perfection. I do think we have both claimed that we have learned a lot about quality, safety, and process improvement over the years; and that we are always happy to share what we have learned. Indeed, both of our blogs are full of examples of both what has worked and what has not.

And why do you use language like “Dandy Don” in such an important discussion. Can’t we stick to the merits of the issue without ad hominem attacks? I have never heard Don talk about computer systems as the “savior of safety.” Indeed, Don’s point is often that we need to understand the work flow in clinical settings, improve that work flow, and then have computer systems that support it.

Bob’s point in this article had as much to do about the quality of the discourse in DC as anything. I am afraid that you have inadvertently shown an example of what is not so helpful as we all try to figure out what might make the US system better and stronger.

Guest
Janice Reverson, RN
Mar 13, 2011

Berwick has failed the citizens in the United States because he promotes the EMR and CPOE as the savior of safety, when those instruments of care are intrinsically unsafe. To make matters worse, they have never been evaluated for safety, efficacy, and usability. He has gone along with the sham the HIT vendors have perpetrated on the US. Dandy Don would be welcomed if he demanded accountability of the devices that are directing the care of the patients he cares so much about.

If Paul Levy is promoting transparency, let’s hear about the debacles and more simply the errors of computerized care at his hospital. He is not spouting that overall outcomes are better at BIDMC nor are his costs down. Bob ought to do the same from UCSF. What actually did happen with GE Centricity, Bob? How many deaths were there?

Paul, tell us about the use of robots and the volume of prostate surgery at BIDMC, and Bob, you do the same at UCSF.

Guest
Mar 13, 2011

“EMR and CPOE … those instruments of care are intrinsically unsafe.”
___

And, YOU know this with empirical precision precisely how? Enlighten us.