Uncategorized

Don Berwick: An Activist Takes the Reins at CMS

While the health reform bill will have many effects, one of its most profound will be to unshackle the Centers for Medicare & Medicaid Services (CMS). Under the legislation, CMS is now far freer to undertake a variety of pilot programs and demonstration projects designed to improve quality, safety and efficiency, and to convert the successful ones into policy. And, if that wasn’t enough for those who have long been praying for a more activist CMS, we now learn that President Obama will select Don Berwick, the world’s most prominent advocate for healthcare quality and safety, to be the next CMS administrator. Although I’ve sparred a bit with Don over the years on matters of philosophy, I think he is a superb choice.

Don’s story is well known – a Harvard pediatrician and policy expert who became passionate about improving healthcare well before it was fashionable, he ultimately left his full-time academic perch to pursue his calling. In 1991, he founded the Institute for Healthcare Improvement, which ran on a shoestring for its first decade, fueled largely by the considerable power of Don’s vision and personality.

Then came the IOM reports on safety and quality (reports that Don had a major hand in crafting), followed by a national movement that promoted transparency, pay-for-performance, tougher regulatory and accreditation requirements, increased media and legislative interest, and voila: IHI became the essential organization – a source of networking, best practices, conferences, sustenance, courage, and more. To many in the quality and safety world, IHI became their church, and Don its Pope.

I admire Don enormously, and have no doubt that the world is a far better place thanks to his, and IHI’s, work. I’ve seen scores of examples of Don’s impact over the years, at hospitals, nursing homes, and clinics in the U.S. and around the world. Just recently, I spoke at a large Indiana patient safety meeting. Don had filmed a video greeting to the group, which was projected over lunch. These things are always awkward – people rarely cease their conversations to listen to a disembodied speaker. But when Don’s face came up on the screen, everybody stopped what they were doing, riveted by the force of his vision and his unique ability to touch and inspire people doing the hard work of change. His effect was astounding; it always is.

My mild beefs with Don and IHI have come from the fact that he has generally put his nickel down on the “Just Do It” side of questions regarding the importance of evidence in patient safety and quality. Although IHI’s 100,000 Lives Campaign promoted many key practices and energized thousands of providers and leaders, the choice to turn Rapid Response Teams into a national standard of care was, in my opinion, premature, backed by insufficient evidence that such teams really work. And IHI’s assertion that the campaign saved 122,300 lives crossed that crucial line that separates scientists from spin-meisters.

Moreover, when I hear Don speak, I often find myself awed by his poetic words and powerful ideas but shaking my head in mild disagreement. The latest example: I find Don’s version of patient-centeredness, described in his article aptly entitled “Confessions of an Extremist,” to be hard to swallow. In essence, he argues the consumerist view that patients should be able to get nearly anything they’d like, regardless of the evidence or cost. You might recall that he first articulated this idea at the ABIM Summer Forum a few years ago (I wrote about it here), to a mixed audience response (to be charitable). In a healthcare system rapidly going broke, such a philosophy just can’t work.

Don is a brilliant guy, and he understands this, of course. So why articulate this point of view? I believe that Don has seen his role to date as that of the Passionate Outsider, a provocateur trying to push us out of our collective comfort zone. Even when I find myself disagreeing with him, I admire him for that, since it would be far easier, and far less effective, to traffic around the margins of the status quo.

How will Don’s philosophy jibe with the realities of running an organization whose yearly budget is $704 billion, larger than the economies of Denmark and Argentina combined (if CMS were a country, its GDP would make it the world’s 18th largest), an agency slated to run out of money in about 7 years? It’s hard to know.

But if Don Berwick is at the helm of CMS, you can bet on an ambitious agenda (and the agency has plenty of tools to carry one out, as described in this recent NEJM article) in quality and safety, a larger focus on removing waste from the system, greater efforts to promote transparency but a measured approach to pay-for performance (Don favors the former and has been ambivalent about the latter, as shown here and here), increased attention to capacity building (which is, after all, what IHI has done best), promotion of more physician-hospital integration and care coordination (via new models like Medical Homes and Accountable Care Organizations), and a far more vigorous use of the bully pulpit. In short, while his “extremism” will be tempered, I can’t see Don Berwick being intimidated or beaten down, even by the Washington bureaucracy. In an agency and an industry sorely in need of fresh approaches, that’s got to be a good thing.

In any case, it’ll be one hell of a ride. Or, as Joe Biden might say, a Big F-ing Deal.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”

Livongo’s Post Ad Banner 728*90

Categories: Uncategorized

Tagged as: ,

30
Leave a Reply

30 Comment threads
0 Thread replies
0 Followers
 
Most reacted comment
Hottest comment thread
22 Comment authors
davidBob Haiducek, Bob the Health and Health Care Advocatebev M.D.Joseph Stevens, MDLiam Forde Recent comment authors
newest oldest most voted
david
Guest
david

Don is just another capitalist go along to get along guy -glorifying in his own wisdom withour regard to what the public wants or thinks

Bob Haiducek, Bob the Health and Health Care Advocate
Guest

Maggie Mahar, you gave me good food for thought about public education. After all, as some people say, the ultimate goal is Good Health for All. Thanks very much. You also initiated my creation of a new web page, so I thank you for that also. You indicated that much of the preventable diseases are caused by poverty and not a lack of health care. That is an unfortunate generalization, because it’s not just poor people who are uninsured and underinsured. The very high health care costs impact the majority of Americans. Medical researchers at the University of London would… Read more »

maggiemahar
Guest

LiOLe– Much of that “preventable” chronic disease is caused by poverty–not a lack of health care. Once more of the poor have insurance, we’ll have to acknowledge that if the stress of being poor, having a poor education (which is all that our underfunded public schools in ghettos and poor rural areas) and no future causes people to self-medicate. They’re depressed.They’re anxious. They’re angry. So they smoke (today the vast majority of adult smokers in the U.S. are poor),, they drink, they take drugs. They also eat junk food and get little exercise because there are few safe places for… Read more »

Joseph Stevens, MD
Guest
Joseph Stevens, MD

Bev, my dear, your defensiveness is telling. These are never events. As for the MGH, when was the last time a patient lay dying in bradycardia over many minutes at mid morning in a monitored unit at a world class hospital? Berwick did not see the leak on his dining room table? Something is terribly wrong with their system and his beautiful IHI system is only skin deep. It provides false confidence and great public relations. What were the nurses doing that morning…clicking? Were there not any doctors on the unit? Oh, so solly, they now round with mobile devices… Read more »

bev M.D.
Guest
bev M.D.

Dr. Stevens; Once again I fail to understand your point. Are you saying that these errors would not have occurred if the hospitals in question were NOT heavily wired? If so, what is your alternative solution to the fact of these 2 errors? And how does the fact that these hospitals received IHI certificates make them impervious to error? Most hospitals in which fatal errors occur are Joint Commission accredited – does that immunize them from error too? The point is that human error is inevitable and the science of care improvement has to do with improving systems (and I… Read more »

Joseph Stevens, MD
Guest
Joseph Stevens, MD

IOM: 98,000 deaths
Berwick: IHI improves safety to the 98,000
Congress: HIT and CPOE improves outcomes
Most of those writing and commenting on this blog: Berwick is the man!
Really?
Do not ask the families of these two victims:
http://www.omaha.com/article/20100402/LIVING01/100409916
http://www.boston.com/news/local/massachusetts/articles/2010/04/03/alarm_fatigue_linked_to_heart_patients_death_at_mass_general/
Both hospitals heavily wired, immersed in CPOE, award winning research producing HIT propaganda to influence Congress.
Drs. Wachter and Berwick tell us about these never events. Transparency is needed, not the hollow user blaming excuses of alarm fatigue or programming error. True or false, these hospitals were awarded an IHI certificate.

Liam Forde
Guest
Liam Forde

I suppose since everyone will be covered by the new health care bill, hospitals will be legally able to turn away those with no coverage.
It only seems fair!

Barry Carol
Guest
Barry Carol

“They’re sick-very sick.” I think this is a material overstatement. Millions of people, for example, have heart disease well controlled by medication. I’m one of them. I had a CABG in 1999 and needed a stent in 2005. Since then, my five prescriptions that I take at a cost of about $3K per year if I had to buy the drugs out of pocket allow me to lead a perfectly normal life. I hardly consider myself “very sick.” My son has mild asthma and takes medication on an as needed basis. He leads a perfectly normal life as well. Millions… Read more »

maggiemahar
Guest

Margait–
80% of health care dollars are spent on people sufrreing from chronic suffering diseaes, and by defintion, a”chronic disease” requires treatment over many years ( not just lasting two years). This is what makes chronic diseases so expensive. Much and more of our health care dollars have been shifting toward treating and trying to manage these diseases.
And, as you suggest, these people are not “worried well.” They’re sick-very sick.

Barry Carol
Guest
Barry Carol

“No tort reform, no cost savings. And tort reform is not caps. I need to not get sued in the first place in order to be the bad cop.” Not surprisingly, I’m in complete agreement on this. Democrats in Congress don’t get it because they are far too beholden to trial lawyers. While I’m not a doctor, I can easily project myself into their shoes. The vast majority of bad or unfortunate outcomes are NOT due to negligence or incompetence. The jury system is arbitrary in that different juries in different parts of the country can come to widely varying… Read more »

Margalit Gur-Arie
Guest

“The “worried well” consume a tremendous amount of money.”
They do? I thought something like 80% is spent during the last 2 years of life. So which one is it?

Gary Lampman
Guest
Gary Lampman

No tort reform,No cost Savings?? It is apparent that the focus on Law suits is the Only driving factor for some. The truth is that only a small margin of people who file,actually win a Case. Also, these are those people that have been so egregiously harmed that life saving procedures and financial cost overwhelmingly are unobtainable without redress. The fact is,the Health Care system has no accountability for failures and medical mistakes that are often Fatal.(They are the lucky ones.)Regardless,of outcomes of any procedure and additional corrective procedures. The Patient bears the burden of those (often preventable) Mistakes. Applying… Read more »

MD as HELL
Guest
MD as HELL

Wellness has never, until recently, been any part of accountable expenditures in anyone’s healthcare budget. You are supposed to stay “well” on your own. Prevention by definition has never been healthcare. Early detection is quite a different event. Unfortunately early detection is very expensive. Not many condtions actually cost less when detected early, and the cost of the process where nothing is found is huge. Whether or not early treatment works is a seperate question depending on the condition as well. The “worried well” consume a tremendous amount of money. There is no outcome in caring for them. They are… Read more »

Vijay Goel, MD
Guest

Congrats to Don on moving into the limelight. I hope he’s able to successfully define and drive progress toward a “True North” that we’ve been missing in health care a long time and doesn’t get too pragmatic.
CMS can be an amazing force for change by itself — I hope Don gets down into the hardened (and I believe misguided) RVUs, CPTs, and other boring bits of an incentive system that have taken health care from a healing profession to one that cares more about documentation than people or results.

Willa Wright, MD
Guest
Willa Wright, MD

to the wellness freaks, Wellness counts, but people die from something. Smoking, drinking and now, too much food in the land of good and plenty. The lot of people are struggling, working long hours to maintain a standard of living less than 30 years ago. Food is their comfort. Best wellness strategy: Stay out of hospitals and do not let the care of your loved ones be controlled by electronic ordering, ie, those toxic CPOE systems. As for Berwick, Simon sez is correct. P4P is flawed and easily gamed by hospital administrators. Those few docs who demand good care for… Read more »