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.
“Dr. Berwick is a trusted and respected voice among hospitals, as well as within the larger health care community,” Umbdenstock concluded. “His knowledge of our health care delivery system, its strengths and weaknesses make him uniquely suited to implement provisions in the recently enacted health care reform law.”
Of course, not everyone inside the health care system agrees with him on everything. Berwick is a strong proponent of patients’ rights and some physicians believe that he goes too a far in an article titled “What ‘Patient-Centered’ Should Mean: Confessions of an Extremist” that appeared in Health Affairs last spring.
Patients, on the other hand, are likely to appreciate Berwick’s description of how a hospital can rob a patient of his dignity, leaving him with a sense that he has no control over his own destiny: “Ask patients today what they dislike about health care, and they will mention distance, helplessness, discontinuity, a feeling of anonymity—too frequently properties of the fragmented institutions in which modern professionals work and train.”
In the end, while reformers will disagree on various specific points, the vast majority of doctors, nurses, hospital administrators and other knowledgeable actors in our health care industry respect Berwick’s victories at IHI. And they agree with him on this: we are squandering billions of health care dollars on products and procedures that aren’t helping patients. In many cases, we know where the low-hanging fruit is. You can smell it because it’s rotting. (See Dr. George Lundberg’s post on The Health Care Blog here )
In other cases, we’re over-paying for cutting-edge drugs, devices and procedures that are no better —but far more expensive —than the treatments they are trying to replace. For years, we have been living in a Health Care Bubble. Now, someone who understands medicine must prick it –very carefully. Many in the industry trust Berwick to do the job.
As Confirmation Hearings Approach, Conservatives Prepare for Combat
But while the medical cognoscenti back Berwick, Republicans are dressing for battle. Alone again, just as they were in their vociferous opposition to health reform legislation, conservatives view the Senate hearing required to confirm Berwick’s nomination as an opportunity to “re-litigate the health care debate,” says Senator Max Baucus, chairman of the Senate Finance Committee that will vote on Berwick. “I think he’ll be confirmed,” adds Baucus, who hopes to schedule the hearing before the July 4 recess, “but there are some people who will bring up a lot of questions.”
Bob Moffett, a health care specialist with the conservative Heritage Foundation agrees: “There’s no issue here with his talent, him personally, his skills, or his academic credentials, He could be the greatest thing since Albert Einstein, and the hearings are going to be difficult because they are going to ask him some very serious questions about the bill.”
Already, three Senate Republicans have begun hammering Berwick: Mitch McConnell of Kentucky, Pat Roberts of Kansas and John Barrasso of Wyoming. In particular, they object to his praise for health care in the UK.
On the face of it, Barrasso would seem to have the credentials to comment on Berwick. As he is fond of pointing out, he is a physician who has practiced medicine for more than two decades. This should make him keenly aware of the problems in what we euphemistically call our health care “system.” But no, as he declared at the White House Health Care Summit, Barrasso is convinced that the U.S. has “the best health care system in the world.”
To make his case, he often points to the example of his wife, Bobbi, who was diagnosed with breast cancer that had spread to one of her lymph nodes in 2003. Thanks to timely care, her life was saved. In Britain, according to Barrasso, it takes 18 weeks to schedule cancer surgery and she probably would not have gotten the care she needed. In the UK, he suggests, a woman with breast cancer is much less likely to survive. This just isn’t true.
Breast Cancer Mortality Rates in the U.K. and the U.S.
To be fair, Barrasso is repeating the conventional wisdom, but as is so often the case, the CW is wrong. According to the American Cancer Society’s (ACS) Cancer, Facts and Figures 2009, 25 out of 100,000 American women die of breast cancer in a given year. In the U.K. 26.7 women out of 100,000 are killed by breast cancer, reports Cancer Research U.K. and the U.K.’s Office of National Statistics.
The mortality rates “aren’t that different,” says Stephen Finan, senior director of policy for the American Cancer Society Cancer Action Network “and it’s hard to parse out what causes that difference.” Many factors can lead to a slightly higher or lower number of deaths due to cancer in various countries, including genetics, the environment and lifestyle choices. For example, fewer women die of breast cancer in Italy and Australia than in the U.S.—and we don’t know why.
Looking At the Wrong Numbers
Why do so many people believe that breast cancer is more likely to be fatal in the UK? In large part this is because they are looking at five-year survival rates, not mortality rates, and as Steven Weiss, Director of Communications at the American Cancer Society’s Breast Cancer Action Group observes “survival rates … are not a very reliable comparison.” His group uses mortality rates.
There are two reasons why death rates are a far better measure of a nation’s success in treating the disease. First survival rates tell us only how many women were still alive five years after being told that they have breast cancer. If a women is diagnosed, and then dies in an accident two years later, the fact that she didn’t live five years tells us nothing about the quality of her cancer treatment. This factor becomes extremely important for the many women over 75 who will develop breast cancer, but wind up dying of another disease two or three years later.
Secondly, while the UK’s National Health Service does cover mammograms for women ages 50 to 70, women in the US have more frequent mammograms starting at a younger age. These tests picks up slow-growing cancers earlier– as well as pre-cancers that might never progressed to disease and might even have disappeared up on their own. (As Naomi has pointed out this raises some concerns about frequent mammograms leading to unnecessary biopsies, radiation and surgeries.)
Because they are tested more often, American women are more likely to live for five years after the initial diagnosis—even if the outcome is no better. Think of it this way: imagine that my twin sister moves to the U.K. while I remain in the U.S. and receive regular mammograms. When we are 62, I am diagnosed with breast cancer. She doesn’t go for annual mammograms, but finally, at my urging, she is tested when she is 64. We both die of breast cancer at 68. I have survived more than 5 years after being diagnosed, she hasn’t. The outcome is the same, but as a statistic, I help boost 5- year survival rates in the U.S.
Early detection might have saved my life, but in this case, it didn’t. As the American Cancer Society’s Breast Cancer Action Group points out, we tend to assume that early detection is a cure-all. The truth is that while some women are spared thanks to early detection, a fair number suffer from “an aggressive cancer that, no matter how small it is when it is found, cannot be effectively treated with the therapies that are currently available. These women will die of breast cancer eventually, no matter what treatment they are given, unless they die of something else first.”
Finally, as Factcheck.org points out, the notion that breast cancer is much more likely to be deadly in the UK is based on very old numbers that date back to the early 1990s. Since then, “[b]reast cancer survival” in the UK “has risen rapidly and significantly.” Rates in the U.S. have been increasing, too, but at a much slower rate.
Learning from Other Countries
Nevertheless, there’s no doubt that some Senators at the confirmation hearing will castigate Berwick for having praised some aspects of the UK’s National Health Services (NHS). (Conservatives fantasies about health care in the UK’s single-payer system, border on the lunatic. For example, they claim that under the NHS, “women give birth in elevators.” )
Berwick’s critics probably won’t mention the statements he has made acknowledging that the NHS is far from perfect. He acknowledges, for example, that when it comes to mortalities from all types of cancer, the UK’s record is not as good. It reports 172.1 deaths per 100,000 in a given year while in the US just 155.6 individuals die of some form of cancer each year. When it comes to improving the quality of care in the UK Berwick has said: “two facts are true: the NHS is enroute, and the NHS has a lot more work ahead.”
But in contrast to those who blindly insist that we have the best health care system on the globe, Berwick, who has traveled the world, seeing foreign health care system first-hand, understands how much we have to gain by studying success in other nations. Each has something to teach us. Each system has its strengths. No doubt he knows, for instance, that Australia, Austria, Norway, Finland, Sweden and Switzerland all boast significantly lower cancer mortality rates than the U.S. When you compare cancer deaths in developed countries, we rank in the middle—along with Germany, Italy, France and Canada. Meanwhile, when it comes to managing chronic diseases such as diabetes, the U.S. trails many countries—including the U.K.
In a memorable keynote address at an IHI symposium, Berwick put U.S. medicine in a global context—and he pulled no punches: “Let’s start with the basics. America spends 40 percent more dollars per capita on its health care than the next most expensive nation, and more than twice as much as most. For this glut of funding, it gets nowhere near the top health status in the world. . . At $5,000 per person [in 2002 dollars] we leave 45 million souls without health insurance. At under $3,000 per person per year, the United Kingdom leaves no one out—no one—not even illegal immigrants.
“You would think we would be curious,” he continued. “If someone showed up at your door and said ‘I can get you the same car you have today for 60 percent of the price, wouldn’t you be just a little curious?”
Berwick went on to point out that higher quality care in other nations, “goes for specific conditions too, for a few procedures, we are the best on Earth, but not for most. At lower cost—far lower cost—many other nations . . . get better end-of life- care, better mental health care, better infant mortality rates, better asthma control, better physical rehabilitation, better primary [care] prevention, and much more comprehensive primary care than we do.” In other words, even wealthy, well-insured Americans don’t get the best care available anywhere.
“In cystic fibrosis outcomes, we are not the best in the world. We are number two. Denmark is number one.”
“If the world has so much to teach us, why would we not learn?” he asks, bewildered by our lack of interest in the larger world.
Berwick often points out that in other countries health care systems are more “system-like.” Doctors and hospitals collaborate to improve the population’s health. They share electronic records and co-ordinate care. Our system, by contrast, is fiercely competitive and fragmented, with most physicians working in small practices while surgical centers vie with hospitals for the most lucrative cases.
Berwick ended his speech by telling a story about a visitor from Bosnia who had recently taken an IHI colleague aside and asked: “‘I don’t get it. I just can’t figure it out. How do you spend $1.5 trillion’ on healthcare? Berwick’s colleague replied: ‘It’s easy, you just need to make more categories.’ With enough fragments,” Berwick added, “you can waste almost anything.”
Berwick ended this speech by saying: “We really do need to snap out of it. The entire Western world testifies that there are fine ways to provide health insurance to absolutely everybody while investing less than 60 cents on every dollar that we spend today. We need to have the courage and confidence to figure out how to do that ourselves. To say that we spend 15 percent of our gross domestic product on health care and that that is not enough. . . . is ridiculous. It is dishonest. We have enough. We have plenty. What we lack is not social resources, it is honesty.”
Too often in the U.S., we confuse “hype” with “hope.” If we just let some of the hot air out of our health care bubble, and acknowledge the degree to which promotion, rather than medical evidence, drives much of our medical spending, we’ll find out that Don Berwick is right. Universal coverage is affordable.
[Readers can find Berwick’s speech, titled “Plenty,” in Escape Fire: Designs for the Future of Health Care, Jossey-Bass]
Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and International and Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.