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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.”
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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
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 apparently strongly disagree with your atatement. They’ve spent much time studying what is called “amenable mortality” for which the USA is getting worse and worse. See the quote from one of them and plenty of other recent information at my new Answer web page.
Here is the question …
Why is the USA 19th out of 19 countries in its ability to minimize deaths under age 75 due to preventable diseases?
Here is the answer …
http://www.medicareforall.org/pages/Preventable_Diseases_Performance
Thanks again for spurring me to action on this important topic.
Bob the Health and Health Care Advocate
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 them to exercise in teh neighofhoods where they live and junk food is the most affordable filling food available.
Then, they die early of preventable chronic diseaes.
All the corporate “wellness” programs in the world will not save them. (They don’t have jobs at corporations which tend not to hire fat people who smoke or take drugs.)
We need a major investment in public health& education and a new war on poverty. (The war on poverty of the 60s did actually greatly reduce poverty. Now, it’s back up.)
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 at a distance. No monitor tech watching monitors? Was this the first arrhythmia that was ignored? Just wondering and you should too, before the blind defense is offered.
The JC is a hospital trade group. Are you naive or what?
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 do not mean HIT systems, but process of care systems) as much as possible to minimize human error. Dr. Berwick understand this; do you?
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.
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!
“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 of other people have well controlled hypertension, diabetes, obsessive-compulsive disorder, etc. Some are indeed quite sick but many millions who generate large healthcare costs in the aggregate are not. These are people who appreciate the miracles of modern medicine including prescription drugs.
According to recent data from IMS Health, prescription drug sales in the U.S. topped $300 billion last year, up only 5% from the prior year of which about 2% was utilization and 3% was price. Approximately 75% of the 3.9 billion prescriptions filled were generics though they account for only about 20% of the dollars spent on drugs. The top three therapeutic drug categories in 2009 were anti-psychotics, proton pump inhibitors, and statins. Costs are probably growing most rapidly for cancer treatment and that is the current focus of lots of research activity, along with Alzheimer’s which the drug industry considers the “holy grail.” There are no effective treatments for Alzheimer’s yet.
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.
“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 conclusions based on essentially the same set of facts. Getting sued is extremely stressful and time consuming – depositions, testimony in court, etc. Even when the doctor prevails in the end, it’s an experience that virtually anyone would go to great lengths to avoid including ordering lots of unnecessary tests to CYA.
To me tort reform means special health courts with judges with the requisite knowledge and the ability to hire neutral experts to sort through conflicting scientific claims. It would also include robust safe harbor protection from lawsuits for doctors who follow evidence based guidelines where they exist. It means bringing objectivity and consistency to rulings that can be relied on around the country and that would have the power of precedent. Juries are just not equipped to make these judgments. If I were a doc, I wouldn’t want to have to go through a case under the current system but would feel much more comfortable with a health court system that would work like bankruptcy court or tax court. Those cases are not decided by juries and medical disputes should not be either.
Margalit – I think the worried well do indeed consume a lot of healthcare but I don’t have specific data that would quantify it precisely. Regarding care during the last two years of life, roundly 2 million people die each year in the U.S. or 4 million in a two year period which is about 1.3% of the population. The vast majority are elderly. I don’t have any data on this either but my gut guess would be that end of life care, defined as care delivered in the last two years of life accounts for perhaps 10% of healthcare costs at the low end and 20% at the very high end. Care for premature babies can be very expensive and most pull through. Heart bypass surgery and hip replacements are expensive and most people who get those live for quite some time afterward. The same is true for many cancer treatments including breast and prostate cancer. The controversy surrounding how to proceed between providing aggressive treatment, hospice or palliative care in end of life situations mainly involves cancer patients in the hospital setting and Alzheimer’s and dementia patients in the nursing home setting. Remember that all hospital care, including outpatient services, account for about 31% of healthcare costs while long term care, including care provided in nursing homes, assisted living facilities and patients’ own homes account for another 10% or so of total costs.
“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?
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 warranties for work done would make Administrators more pro active in reducing repetitive readmission. Torts are the last vestibules of corrective actions; that apply any accountability for ones actions and or inaction’s. It is the only safety net provided to a individual to be applied toward a exorbitant medical and living expense that is no fault of their own.
When my time comes and I meet my 007 (License to Kill). I hope they have the Spine to tell me that they are putting me Down. If you cut off all my limbs and your patting yourself on the back for saving my life. Please realize that this type of care is outside the realm of average people to manage personally and Financially. I would rather be put down than burden my Family with the results of medical Errors and Hospital Acquired Infections.
Until,another avenue is opened to address medical Harm and provisions are made to deal with medical errors for patients. Torts Must Be upheld!
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 still well after the expenditure. They are still worried, but reassured for a time. They are breaking the bank. The availability of reassurrance on demand has driven costs through the roof. But every once in a while, one of these nice people will get really sick. Whoe to the physician who did not get that scan. Enter John Edwards. And so it goes.
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.
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.
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 their patients are considered disruptive by current regimes who have maintained incompetence by continually and quietly cutting corners to the endangerment of patients.
If physicians are paid for performance, will they be able to care for more or fewer patients; and will they make as much or more for caring for fewer patients than on a fee for service basis?
Our system is short tens of thousands of physicians and from now on millions of patients will be added to government program roles [7,000 a day to Medicare and some 31 million over the next 3 years to Medicaid and Health Exchanges.
Regardless of the payment system, where will we find the physicians [and nurses and other caregivers] to provide care to a growing and aging population? Will we have better care for fewer selected groups and declining VA clinic type care for everyone else?
Berwick has promise, but I’m afraid he’s going to get incredibly frustrated dealing with the bureaucracy. He has a big enough ego to have a bit of problem; his approach to quality has its holes and flaws. I wonder how much of this appointment was political show and how much sincere support will be there when it’s needed.
Wellness, as jd points out, is key. Research shows that 75% — that’s not a typo — of health care costs are accounted for by *preventable* chronic diseases. Unless and until this country gets a handle on that, health care costs will continue to skyrocket and quality will get left behind in the push to control them.
Margalit, health care may begin with primary care, but health begins with healthy behavior completely outside the medical-industrial complex.
We still don’t put anywhere near enough effort into wellness. The reform legislation makes small starts in that direction but most of what we need to do is at a cultural and public policy level. More walkable communities, for example. Just sayin’
I don’t know enough either about the IOM study or Dr. Berwick, so I can’t comment on that.
However everything else Dr. Simon said is right on.
We need to stop paying doctors by-the-numbers (CPT) and start paying for time and complexity. I’m not a fan of P4P, particularly since we are only pretending to know what the second P means.
Health care begins with Primary Care and reform should begin there too. Not to mention that this fruit is hanging so low that it is practically hitting us on the head.
I know only very little about Dr. Berwick, basically only this post and the recent one from MM.
MM summary of the “health affairs article” was (very helpful as I don’t have access to my institutional subscription and) eye opening, or better, alarming. MM: “The truth is that most care is driven by the supply-side, not by the consumer’s desires or demands.” I thought that MM interviewed many doctors for her investigative journalism – has no one told her that unreasonable patient expectations are commonplace (in a nutshell: “this body part hurts. I need a scan of this body part, and if negative, another scan/test” or “I need ABx for my cold”). Has anyone told Dr. Berwick about the widespread phenomenon of middle aged individuals having great difficulty accepting palliative care (a completely understandable phenomenon that is related to family dynamics and the grim reaper’s reminder “you are next”)?
Yes, maybe he wants to be just a provocateur, to bring us out of our comfort zone (and yes, maybe there are feasible patient centered solutions, maybe the end-of-life scenario could/should be adressed differently, maybe ahead of time whenever possible) … but any rational being who has followed the recent breast cancer screening debate (with very many saying: “If I want to be screened, I am entitled to get reimbursed for it on 3rd party payor expense, regardless of the cost/benefit ratio”) would wish for someone who is a provocateur going into the opposite direction. In fact, advocating extreme patient centered care is not really provocative. For instance, it is the competitive ploy of the large “non” profit health care provider that I used to work for. And the back bone of direct to consumer advertising of the HC industry.
Maggie,
Have you been drinking IHI kool aid? You are dreaming of a world that will never be.
This is not rocket science, just political pillaging with a tincture of white collar crime. The HIT cronies of Congress and HHS are invading medical care to divert medical care funds in to the pockets of the HIT robber barrons, making impossible claims that Congress believes.
Do what Simon says, Berwick.
Until doctors are compensated for practicing good and cost effective medicine, the inflationary spiral will continue.
Medicare payment gimmicks have been the etiology of the inflation. Payments are 30 to 50 cents on the 1990 dollar whereas overhead has increaed many fold both professionally and at home.
Duh, why are more procedures done? Duh, why do hospital administrators reward their paid docs to keep the scanners humming?
The lives of most doctors are miserable, having to work longer hours and see more patients per hour at lower quality to tread financial water, if that.
If you are sick with multi system illness, you will not do well with NPs and PAs making the decisions for doctors in absentia, who incidentally are billing as if they were there. Bedside actors proliferate in this scheme.
Unless you are a gifted doc with immense multi-tassk and cognitive skills, sick patients are in for a helluva a ride, and never get better. You can not get paid enough by Medicare to properly manage a 75 yo with dka, mi, arf, copd, rf, gib, hbp, and svt.
Patients suffer as more and more doctors abdicate their responsibility and give it to paraprofessionals. They become beholden as employees to unaccountable mega hospital systems’ administrators.
Berwick is slick by crafting the IOM report on flawed small study data that he and his non profit made a handsome profit. He ain’t the messiah as you commenters and wachter imply. Just a smart guy who charged hospitals a lot and got paid a lot at his non profit.
Bob–
I enjoyed reading this post.
As more and more people get to know Berwick, I think they will realize that he is not a “scholar” (as he is described in many headlines)–but a doer–and a teacher. A great teacher, and as you say, I suspect he will use his bully pulpit to educate.
I somewhat disagree, however, in one point: your interpretation of what Berwick means when he talks about “Patient-centeredness.” You suggest that this could well mean spending more to give patients everything they want.
But Berwick is very clear that we spend far more than necessary on health care. He would like to see health care spending become a smaller percentage of GDP–or at worst, stay where it is today.
In the article you link to (and thanks for the link) Berwick seems to be talking less about giving patients everything than ask for than about respecting their wishes in a great many ways that have nothing to do with spending more.
For those who haven’t read the article, Berwick begins with this anecdote:
“Three years ago, a close friend began having chest pains. She headed for a cardiac catheterization, and, frightened, she asked me to go with her. As I stood next to her gurney in the pre-procedure room, she said, “I would feel so much better if you were with me in the cath lab.” I agreed immediately to go with her.
The nurse didn’t agree. “Do you want to be there as a friend or as a doctor?” she asked.
“I guess both,” I replied. “I am both.”
“It’s not possible. We have a policy against that,” she said.
The young procedural cardiologist appeared shortly afterward. “I understand you want to have your friend in the procedure room,” she said. “Why?”
“Because I’d feel so much more comfortable, and, later on, he can explain things to me if I have questions,” said my friend.
“I’m sorry,” said the cardiologist, “I am just not comfortable with that. We don’t do that here. It doesn’t work.”
“Have you ever tried it?” I asked.
“No,” she said.
“Then how do you know it doesn’t work?” I asked.
“It’s just not possible,” she answered. “I am sorry if that upsets you.”
Moments later, my friend was wheeled away, shaking in fear and sobbing.”
Here’s Berwick’s comment on what happened:
“Most doctors and nurses, I fear, would answer that what is wrong with that picture is the unreasonableness of my friend’s demand and mine, our expecting special treatment, our failure to understand standard procedures and wise restrictions, and our unwillingness to defer to the judgment of skilled professionals.
“I disagree. I find a lot wrong with that picture, but none of it is related to unreasonable expectations, special pleading, or disrespect of professionals. What is wrong is that the system exerted its power over reason, respect, and even logic in order to serve its own needs, not the patient’s. What is wrong was the exercise of a form of violence and tolerance for untruth, and—worse for a profession dedicated to healing—needless harm.
“The violence lies in the forced separation of an adult from a loved companion. The untruth lies in the appeal to nonexistent rules, the statement of opinion as fact, and the false claim of professional helplessness: “impossibility.” The harm lies in increasing fear when fear could have been assuaged with a single word: ‘Yes.'”
*************************
I don’t run a hospital, so I can’t say whether it would cause a problem if a friend who happens to be a doctor was allowed to go with her.
But certainly, if I were the patient I would have been upset. The answers Berwick was getting seemed to be “That’s not the way we do it.” Period. “Serving the system rather than the patient.” Maybe there is a reason, but it doesn’t seem to have been explained. (legal liability? ) Or, maybe the doctor just didn’t like the idea of another doctor watching her treating a patient.
Given how upset the patient was, I have to think that it would have been better for her health to have Berwick with her. Some people in positions of authoritiy just don’t like to say “yes”. (If we encounter them in some situations, we call them “petty bureaucrats.” If we encounter them in hospials we are mroe likely to call them “professionals”.)
Later in the article, Berwick defines what he means by patient-centered care: “The experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.”
He goes on to suggest that “1) Hospitals would have no restrictions on visiting—no restrictions of place or time or person, except restrictions chosen by and under the control of each individual patient. (2) Patients would determine what food they eat and what clothes they wear in hospitals (to the extent that health status allows). (3) Patients and family members would participate in rounds. (4) Patients and families would participate in the design of health care processes and services.18 (5) Medical records would belong to patients. Clinicians, rather than patients, would need to have permission to gain access to them. (6) Shared decision-making technologies would be used universally. (7) Operating room schedules would conform to ideal queuing theory designs aimed at minimizing waiting time, rather than to the convenience of clinicians. (8) Patients physically capable of self-care would, in all situations, have the option to do it.”
Now, perhaps this would create chaos in hospitals. I certainly would be inclined to limit the number of visitors at any given time–the patient might not want to hurt anyone’s feelings, but patients need rest, and too many guests can get in the way.
But other things– like letting patients wear their own bedclothes. . . Hospital gowns are infantilizing and as long as it’s not hard for a nurse or doctor to get to the patient’s body under the nightgown or pajamas, this seems a small concession to patient dignity. Also letting one (or even two) quiet visitors stay with a patient through the night would be very, very comforting to many patients (and relatives) Most of he other suggestions sound reasonable–and many are excellent (shared decision-making, access to records.)
Finally, Berwick addresses your concerns– if a patients “wants” over-ride evidence-based medicine, won’t this be expensive, and wasteful?
Berwick write: “One e-mail correspondent asked me, “Should patient ‘wants’ override professional judgment about whether an MRI is needed?” My answer is, basically, “Yes.” On the whole, I prefer that we take the risk of overuse along with the burden of giving real meaning to the phrase “a fully informed patient.” I contemplate in this a mature dialogue, in which an informed professional engages in a full conversation about why he or she—the professional—disagrees with a patient’s choice. If, over time, a pattern emerges of scientifically unwise or unsubstantiated choices—like lots and lots of patients’ choosing scientifically needless MRIs—then we should seek to improve our messages, instructions, educational processes, and dialogue to understand and seek to remedy the mismatch. For the same reason, I wish we would abandon the word “noncompliance.” In failing to abide by our advice or the technical evidence, the patient is telling us something that we need to hear and learn from. Honestly, how many of us have ever faithfully taken a full ten-day course of a prescribed antibiotic or never consciously skipped a statin dose? Are we fools who did that? Or did we choose that because of some sensible, local considerations of balance, convenience, or even symptom information that the doctor never had?
“I can imagine just as easily as my critics can a crazy patient request—one so clearly unreasonable that it is time to say, “No.” A purely foolish, crazy, or venal patient “want” should be declined. make for very bad rules for the usual occasions.”
Finally, in terms of the economics of health care, when it comes to big-ticket items (surgery, dying in an ICU) few patients demand these things.
Share-decision-making reserach shows that when patients have a chance to share in decision-making, they decide not to have elective surgery or tests about 20% of the time. Patients are more conservative than health care providers. Here’s Berwick:
“A second objection emphasizes the duty of the professional as steward of social resources. Is patient-centeredness of the type I envision socially responsible? No one can yet know the answer to that question. Pandora’s box may be empty. O’Connor and colleagues’ summary of shared decision making for surgery cuts the other way: more sharing, less invasive care; and the work of Wennberg and Elliott Fisher suggests that supply drives demand, not the other way around. At a minimum, I suggest that becoming responsive to individual needs and wants can give us the information we need for informed social choices to be made where they mostly belong: at the level of public policy.”
I particularly like “Pandora’s box may be empty.” Berwick often makes the point that when talking about health care reform, we often worry about things that we needn’t worry about.
People may well say: “What about end-of-life care? That is very expensive. Do we just do everything that every patient and relative want?”
Here, Berwick emphasizes palliative care. Giving the patient choices, talking to him about death as well as treatment options.
Research suggests that when patients receive palliative care their end of life care is less expensive. They rarely choose to die in an ICU strapped to a bed. Often their choices are more conservative than the decisions that an oncologist would make on his own. (Here I’m talking about palliative care that puts the patient– not the patient’s family–in the driver’s seat.)
Finally, what Berwick says reminds me of something I read recently about “minimally invasive medicine” that
that “fits”—not the doctor’s beliefs or even objective medical evidence, but “the patient’s reality.”
Sometimes patients don’t want a treatment that a doctor believes that he or she needs. The patient feels that it would disrupt his life in way that he is not willing to accept.
I once refused to continue taking a medication that was affecting my eyesight. I flipped out when I realized that I could read the headlines in the Wall Street Journal–but not the story (with my glasses on.) The doctor wanted me to stay the course of treatment, and finally labled me (with some contempt)
“side-effect senstive.”
Again, this is a case where the patient wants less health care. (The truth is that most care is driven by the supply-side, not by the consumer’s desires or demands.)
I wrote about minimally disruptive care it here: http://www.healthbeatblog.com/2010/03/minimally-disruptive-medicine-.html
Bottom line: as always, Berwick provides food for thought.
Gregg, I don’t see how delegation of operational functions like paying claims has any relevance to the sense of urgency to make fixes. The same number of dollars are being spent, according to the same rules that CMS sets, regardless of whether the people processing the claims are government employees or contractors.
“honing in on my T-Grace,” is now my new favorite phrase. As in: “The only reason I went to see Valentine’s Day was to hone in on my T-Grace.”
Everyone else is just jealous of our relationship. We have a bond no one else can even begin to understand.
Savings
Let’s all hope that they do in fact receive that freedom and maneuverability to make substantive changes for the benefit of all.
I’m hoping that in CMS Don will be able to focus on some of the root causes of our problems. Improving the ‘bundle’* for primary care has greater population health impact than all of the hospital focused work the IHI has been emphasizing lately.
We know this work but need permission & funding to do it well. CMS can lead the way in aligning incentives to power superb primary care.
*Primary care ‘bundle’:
Access
Relationship over time
Comprehensiveness
Care coordination
Might there be some justification to re-consider CMS’s business model of subcontracting its charge to the private sector via a regional network of fiscal intermediaries and carriers? Beyond these ‘delegated administrative partnerships’ with the private sector, i.e., mostly the Blues, could this model be responsible for the institutionalized and diffused (i.e, demoralized) sense of the agency’s mission? Though a behemoth in scale, it suffers from an institutionalized sense of ‘powerless’ to steward the change and innovation imperative? This is not new, it dates back to HCFA, IMJ.
Don better get one thing right – providers have to agree to limit care to that which is appropiate to clinical findings. Medicare failed on this count as has just about every other health care program. Pay providers fairly, allow them time with the patients, and in return demand that they control their utilization. Build the health care system around these simple rules to avoid rationing and the health care death spiral.
This post sure did one thing right: I come away from it feeling like I understand a lot better the pros and cons of choosing Berwick. It’s one thing to refer to the work of IHI (and I had forgotten about the 122,000 lives saved claim, so thanks for that), but this is the first time I feel like I have a sense of the man.
I still don’t have a strong sense if he’ll be able to move this 704 billion ton battleship into a decisive role in the war for cost control and quality improvement. Scratch that: I think he will almost surely bring substantial gains in quality if he survives more than 18 months, which I think he will. It’s the cost control part I’m still not confident about, though your and especially Maggie’s posts are giving me a bit more comfort.