Don Berwick

Brian-KlepperOn Vox, the vivacious new topical news site, staffed in part by former writers at the Washington Post Wonk Blog, Sarah Kliff writes how Donald Berwick, MD, the recent former Administrator of the Centers for Medicare and Medicaid Services and the Founder of the prestigious Institute for Healthcare Improvement, has concluded that a single payer health system would answer many of the US’ health care woes.

Dr. Berwick is running for Governor of Massachusetts and this is an important plank of his platform. Of course, it is easy to show that single payer systems in other developed nations provide comparable or better quality care at about half the cost that we do in the US.

All else being equal, I might be inclined to agree with Dr. Berwick’s assessment. But the US is special in two ways that make a single payer system unlikely to produce anything but even higher health care costs than we already have.

First, it is very clear that the health care industry dominates our regulatory environment, so that nearlyevery law and rule is spun to the special rather than the common interest. In 2009, the year the ACA was formulated, health care organizations deployed 8 lobbyists for every member of Congress, and contributed an unprecedented $1.2 billion in campaign contributions in exchange for influence over the shape of the law.

This is largely why, while it sets out the path to some important goals, the ACA is so flawed.

Continue reading “Would a Single Payer System Be Good for America?”

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One of US President Barack Obama’s key health advisers has just published a review in the aftermath of the Mid Staffordshire hospital scandal. Don Berwick’s review is both thoughtful and reflective but one of his key recommendations – to create criminal sanctions against health staff – will not make the NHS safer for patients.

Many patients, particularly elderly ones, suffered unnecessary indignities and avoidable harm at Mid Staffordshire.

The Francis report into the crisis concluded that patients were routinely neglected by a health trust more preoccupied with cutting costs and meeting targets rather than its responsibility to provide safe care. Patients’ calls for help to use the bathroom were ignored and some were left lying in soiled sheeting or sitting on commodes for hours. Events and failings there will probably go down in history as the blackest and bleakest moment for the NHS.

When the report was published in February, the government committed to appointing a advisory group of patients to consider the various accounts of what happened and the recommendations made by Robert Francis and others. The idea was that they would distill for the government and the NHS what lessons should be learned and what changes needed to be made.

Don Berwick, who worked on the long fought for Obamacare provisions in the US, is director and co-founder of the Institute for Healthcare Improvement in Boston. He was called in by the government to reflect on the Francis report and on patient safety.

Berwick’s review makes ten recommendations including that sufficient staff are available to meet the NHS’s needs now and in the future – staff should be well-supported and able to ensure safe care at all times; quality and safety sciences and practices should be a part of the initial preparation and lifelong education of all health care professionals, including managers and executives; and leaders should create and support learning and subsequently change, at scale, within the NHS.

But most controversial is his final recommendation:

We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.

Berwick proposes the government creates a new general offence of “willful or reckless neglect”, applicable both to organisations and individuals. Organizational sanctions might involve removing leaders and disqualifying them from future leadership roles, public reprimand of the organization and, in extreme cases, financial sanctions – but only where that will not compromise patient care.

Continue reading “Criminal Charges for Providers Won’t Fix the NHS, Dr. Berwick”

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Recent articles highlight challenges with holding providers accountable for the care they deliver. One of the major thrusts of efforts to transform the American healthcare delivery system has been to become more patient-centered and to allow patients to provide feedback that matters.

Emblematic of this is the emphasis on patient involvement in the final rules for the Shared Savings Program accountable care organizations (ACO).

Echoing former Centers for Medicare & Medicaid Services Director Don Berwick’s plea on the behalf of patients (“Nothing about us without us”), the ACO final rules emphasize patient engagement in governance, quality improvement and the individual doctor/patient interaction.

Michael Millenson’s white paper provides a summary of the patient empowerment movement.

The development of the patient activation measure (PAM) and the Center for Advancing Health’s 43 engagement behaviors has allowed us to study patient-centeredness with more specificity. Studies have shown that activated patients are less likely to choose surgical interventions, have better functional status and satisfaction, are more likely to perform self-management behaviors, and report higher medication adherence rates.

Healthcare policy experts and payers have embraced the argument outlined above, and patients’ reports of their satisfaction with both physicians and hospitals have increasingly been used to calculate financial rewards.

Continue reading “Should Your Review of Your Doctor Be Taken Seriously?”

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As both the private and public sector aggressively shift healthcare incentives from a “do more, bill more” to a value and outcome based model, healthcare providers ignore patients role in driving outcomes at their own peril. It is generally understood that patients forget 80-90% of what they are told at the doctor’s office. As incentives no longer reward outcome over activity, this is a disaster financially for health professionals. This will require healthcare leaders to think in a different way. One has to be in denial to think that healthcare reimbursement isn’t entering a deflationary period yet it’s not all doom and gloom for forward-looking healthcare organizations. In fact, it’s a massive opportunity to leapfrog competitors.

As the founder of the Institute for Healthcare Improvement, Dr. Don Berwick stated in an earlier piece:

“The health care encounter as a face-to-face visit is a dinosaur. More exactly, it is a form of relationship of immense and irreplaceable value to a few of the people we seek to help, and these few have their access severely curtailed by the use of visits to meet the needs of many, whose needs could be better met through other kinds of encounters.”

Smart Doctors Recognize Their Inefficiency

If one were to observe a doctor for a month, you would find that doctors have their own FAQ for various conditions, diseases, prescriptions, etc. They are essentially hitting the Replay button hundreds of times a month. Smart doctors are recognizing that there is a better way. The patient and family benefits greatly when the doctor has a mini package of curated content (video, articles, etc.) that is developed for the patients. This is predominantly a manual process today (e.g., writing down web addresses in an appointment or emailing them afterwards).

Continue reading “The New New Medicine”

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I was surprised when the Opening Ceremonies of the Olympics in London honored two of my favorite institutions:  the National Health Service and the World Wide Web.  I was not surprised when LA Times sports writer Diane Pucin posted the following tweet: “For the life of me, though, am still baffled by NHS tribute at opening ceremonies.  Like a tribute to United Health Care or something in US.” @swaldman responded to the sports writer with “Well, maybe, if United Health Care were government-run and a source of national pride.”

I was not surprised when Meredith Vieira and Matt Lauer of NBC admitted they had no idea why Tim Berners-Lee was being honored by sending out a tweet.  Ever since I read his book Weaving the Web:  The Original Design and Ultimate Destiny of the World Wide Web by Its Inventor (HarperSanFrancisco, 1999), Berners-Lee has been one of my heroes.  Finally locating my hard copy of the book in the guest bedroom where my son Colin used to sleep, I quickly located the marked passage I was looking for:

“People have sometimes asked me whether I am upset that I have not made a lot of money from the Web.  In fact, I made some quite conscious decisions about which way to take my life. These I would not change…. What does distress me, though, is how important a question it seems to be to some.

Continue reading “The Olympics, Doctors, NHS, Transformation, and Heroes: Why the Difference between USA and UK?”

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I’ve heard a lot of shocking things since arriving in England five months ago on my sabbatical. But nothing has had me more gobsmacked than when, earlier this month, I was chatting with James Morrow, a Cambridge-area general practitioner. We were talking about physicians’ salaries in the UK and he casually mentioned that he was the primary breadwinner in his family.

His wife, you see, is a surgeon.

This more than any other factoid captures the Alice in Wonderland world of GPs here in England. Yes—and it’s a good thing you’re sitting down—the average GP makes about 20% more than the average subspecialist (though the specialists sometimes earn more through private practice—more on this in a later blog). This is important in and of itself, but the pay is also a metaphor for a well-considered decision by the National Health Service (NHS) nearly a decade ago to nurture a contented, surprisingly independent primary care workforce with strong incentives to improve quality.

Appreciating the enormity of this decision and its relevance to the US healthcare system requires a little historical perspective.

As I mentioned in a previous blog, the British system cleaves the world of primary care and everything else much more starkly than we do in the States. All the specialists (the “ologists,” as they like to call them) are based in hospitals, where they have their outpatient practices, perform their procedures, and staff their specialty wards. Primary care in the community is delivered by GPs, who resemble our family practitioners in training and disposition, but also differ from them in many ways.

Continue reading “The British Primary Care System and Its Lessons for America”

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Earlier today, Secretary of Health and Human Services Kathleen Sebelius and Medicare chief Don Berwick announced the “Partnership for Patients,” a far-reaching federal initiative designed to take a big bite out of adverse events in American hospitals. The program – which aims to decrease preventable harm in U.S. hospitals by 40 percent and preventable readmissions by 20 percent by 2013 – marks a watershed moment in the patient safety movement. Here’s the scoop, along with a bit of back story (which includes a gratifying bit part for yours truly).

Last July, I attended the American Board of Internal Medicine’s Summer Forum in Vancouver. This confab has turned into medicine’s version of Davos, drawing a who’s who in healthcare policy. One of the attendees was an old friend, Peter Lee, a San Francisco lawyer and healthcare consumer advocate who had just been asked to lead a new Office of Delivery System Reform within the U.S. Department of Health and Human Services. Peter’s charge was to figure out how to transform the delivery of healthcare in America, challenging under any circumstances but Sisyphean given that he’d be pushing the rock up a mountain chock full of landmines comprised of endless legal and political threats to the recently-passed Affordable Care Act.

Fueled by the enthusiasm of being a new guy with a crucial task, Peter took advantage of some conference downtime to convene a small group – about 20 of us – to advise him on what he should focus on in his new role. After soliciting ideas from many of the participants around the table, he turned to me. I decided not to be shy. Continue reading “The Partnership for Patients: The Inside Scoop on a Game Changing Safety Initiative”

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Even Fox News acknowledges that: “In the two months” since President Obama named Dr. Donald Berwick, president of the Institute for Healthcare Improvement (IHI), as his candidate to head the Centers for Medicare and Medicaid, (CMS) not one industry group has voiced opposition to his nomination.

This, despite the fact that Berwick will be charged with beginning to squeeze $400 billion worth of waste and fraud out of the Medicare system over a period of ten years. One man’s sludge is, of course, another man’s bread and butter. One might expect that drug-makers, device-makers, hospitals and others who profit from the current system would join the fear-mongers who have begun the assault on Berwick, claiming that he plans to “ration” care.

But that isn’t happening. In fact the American Hospital Association (AHA) gave Berwick a flat-out endorsement in a May 20 letter addressed to Senators Max Baucus, chairman of the Senate Finance Committee, and Tom Harkin, chair of the Health, Education, Labor and Pensions Committee:

“His work at the Institute for Healthcare Improvement (IHI) has engaged hospitals, doctors, nurses and other health care providers in the continuous quest to provide better, safer care.” wrote AHA President and CEO Rich Umbdenstock. “This includes dramatic advances in quality improvement, patient safety and end-of-life care through IHI’s collaborative, breakthrough series and other activities,” he added, referring to IHI’s success in success in cutting hospital infection rates and implementing better asthma care and coronary surgery improvements with little additional costs. Continue reading “Support for Berwick to Head Medicare Grows”

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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.” Continue reading “Who Is Don Berwick (and Why Is He Following Me?)”

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