Dr. Berwick’s Last Stand?

Kaiser Health News (KHN) reports that “the nomination of Dr. Donald Berwick to run the agency overseeing Medicare appears to be languishing.”   Friday, KHN’s “Health Policy Week in Review” quoted a story that appeared in the New York Times a few days earlier:

“Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader. But a battle has erupted over his nomination, suggesting that Dr. Berwick faces a long uphill struggle to win Senate confirmation. Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall’s elections, and Dr. Berwick has given them plenty of ammunition. In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system.”

KHN also points out that according to The Hill, although Senate leaders are nearing an agreement to allow more than 60 Obama nominees to be approved to begin work, Berwick is not on the list  . “‘He will not get unanimous consent,’ a spokesman for Senate Minority Leader Mitch McConnell (R-Ky.) told The Hill.

I am not at all persuaded that Berwick’s confirmation is in trouble. As the highly-respected president and CEO of the Institute for Health Care Improvement, Dr. Berwick enjoys support that ranges from the AARP to three former directors of the Centers for Medicare and Medicaid (CMS) who served under Republican presidents. “This is not really about Don Berwick,” John Rother, executive vice president for policy and strategy at the AARP told McClatchy Newspapers. “In ordinary times, the nomination of somebody with Don’s record and standing in the field would not be controversial.” Thomas Scully, who led the CMS under President George W. Bush agrees: “He’s universally regarded and a thoughtful guy who is not partisan. I think it’s more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now.”

Berwick also enjoys warm endorsements from the American Association of Family Physicians, the American Medical Association, and the American Hospital Association. He is known for his ability to listen to other medical professionals, hear their concerns, and collaborate with them.

That said, I do think that conservatives will do their best to postpone the confirmation hearing. And the longer they defer the hearing, the more time they will have to try to demonize Berwick.

Plucking Quotes Out of Context

The Times suggests that “Berwick has given them plenty of ammunition,” implying that it might be Berwick’s own fault if his opponents turn his words against him. But, in fact, Berwick chooses his words with great care. He  hones his speeches; he is not a loose cannon.

Nevertheless, conservatives are adept at “cherry-picking” quotations, plucking one or two sentences out of context to suggest, for example, that Berwick would like to “ration” Medicare. And in a world of “cut and paste” journalism, truncated quotes are repeated over and over, until they become facts.

The Columbia Journalism Review’s Trudy Lieberman recently described how the myth-making machines works: “Republican senators are out of Berwick’s scalp and have begun using the specter of medical rationing as the way to turn him into a headhunting trophy. They like to bring up[certain statements that Berwick has made] like this one: “The decision is not whether or not we will ration care. The decision is whether we ration care with our eyes open.”

As Lieberman points out “opponents usually omit the last sentence of the quote, “And right now, we are doing it blindly.” Ripping two lines out of context, critics also tend to ignore the first sentence of Berwick’s statement. Here is what he actually said, in a 2009 interview with Biotechnology Healthcare: “We make these decisions all of the time. The decision is not whether or not we will ration care. The decision is whether we ration care with our eyes open. And right now, we are doing it blindly.”

Rationing “With Our Eyes Wide Open”

In context, it’s clear that Berwick is saying that we already do ration care, but we do it wantonly, according to ability to pay, without regard to whether the patient needs the treatment. Berwick suggests that we should decide which treatments to pay for “with our eyes wide open” –looking at medical evidence about risks and benefits. If even a small pool of patients who fit a particular medical profile would be helped by a service or product, they should get it: “’Evidence-based medicine’ is not just a catch phrase;” he writes, “it is a promise we want to make to our patients – to use all the care – and only the care – that can help them.”   Somehow this last sentence never seems to show up in the hundreds of blog posts and news stories that have been written about Berwick in the last two months.

Usually we think of “rationing” as restricting consumption of a commodity that is in short supply. But in fact, the root of the word “ration” is “reason” and this is much closer Berwick’s meaning. His aim is to make the system more rational by using medical evidence to distribute products and services.  The goal: “to get the right care to the right patient at the right time.”

His aim is not cut  to Medicare, but to improve it by eliminating some of the waste that clogs our bloated system—the unnecessary, often redundant tests, the ineffective, unproven treatments that expose patients to risk without benefit . . . and the hospital errors that, too often, lead to longer stays, more medication, another surgery.

In December, Berwick made his agenda clear when he challenged an audience of doctors and hospital administrators to reduce the number of tests and treatments that their patients undergo “by 10 percent”:  “Do that without a single instance of harm, without rationing effective care, without excluding needed services for any population you serve.” (Hat tip to McClatchy Newspapers’ reporter David Goldstein for calling attention to Berwick’s words)

But do we have the medical evidence needed to cut waste without lowering the quality of care? Yes, says Berwick: “Through modern clinical epidemiology, technology assessment, and clinical research, we have developed powerful new tools to assemble, digest, and judge the evidence-base for clinical practice. Rational care plans can emerge, based firmly in scientific evidence, and drawing on research published in hundreds of journals that serve as the basis for the expert opinions and guidance of professional medical societies.”

At the same time, he would not impose comparative-effectiveness research (CER) on doctors and patients. In the Biotechnology interview, he agrees that “mandatory compliance with CER directives could be dangerous, if you overdo the tightness of the connection between the knowledge of effectiveness and the rules of compliance. Then you get into the ‘proletarianization’ of medicine — physicians, payers, and patients being told what to do instead of being able to use their own judgment. There’s a balance here between advisory declarations with enough knowledge that they really have some force, and requirements.”

Trudy Lieberman Calls for Context and Clarity

At the end of her column in the June 14 issue of the Columbia Journalism Review, Lieberman notes that conservatives have a way of making a sound-bite their own: “As we reported in the March/April 2010 issue  of the Columbia Journalism Review, when the discussion of ‘death panels’ made its way into the media, the press let right wing ideologues set the agenda and spread misinformation, allowing weeks to pass before refuting their false claims. By then it was too little too late.

“This time, we’d like to see the media act as leaders instead of followers.” Lieberman writes. “For starters, they can begin to quote Berwick accurately . . . None of this business about selective quotes that opponents will inevitably use.”

Unfortunately it may once again be too late.

If you Google “Berwick” and “the decision is not whether or not we will ration care,” you will find those two lines culled from a 1200-word interview have been repeated more than 10,000 times. One wonders how many reporters actually read the piece in Biotechnology Healthcare— and how many were simply repeating what they read in another paper, or on another blog.

How Cherry-Picked Quotes Wind Up in the Mainstream Media

No surprise, the  truncated quote often shows up  on avowedly conservative blogs such as NetRight Daily, Redstate.comAmericans for Prosperity, and  Frontpagemag.com. As well as in local newspapers such as The Trentonian

But you’ll also find it in a Boston Globe Op-ed written by Jeff Jacoby, a Globe columnist, and  in the news article published last week in the New York Times.

The Times story is instructive; it shows how much confusion a few familiar quotes repeated out of context can create.  The article does not set out to bludgeon Berwick.  It begins by describing him as “a man with a mission, a preacher and a teacher who has been showing hospitals how they can save lives and money by zealously adhering to clinical protocols for the treatment of patients.”  (Though, at the very end, the lead wobbles. Is “zealously” adhering to protocols good or bad? Hard to say.)

New York Times’ reporter Robert Pear goes on to suggest that Berwick faces a “long uphill battle to win confirmation.” And in describing the “ammunition” that Berwick has given his opponents, the reporter  notes that Berwick “has spoken of the need to ration health care . . . and has confessed to a love affair with the British health care system.”

Throughout the piece, rationing becomes a leitmotif: “The Senate Republican leader, Mitch McConnell of Kentucky, describes Dr. Berwick as an ‘expert on rationing.’  Senator Pat Roberts, Republican of Kansas, calls him “the perfect nominee for a president whose aim has always been to save money by rationing health care.’ . . . Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, said he had no doubts about Dr. Berwick’s academic and professional qualifications, but wanted him to explain his comments on rationing.”

Pear acknowledges that, according to administration officials “Republicans have taken his comments out of context.”  But the reporter doesn’t seem to buy that argument, noting that, “In fact, many of the comments have been repeated, with slight variations, in Dr. Berwick’s articles and lectures over the years.”  Then, Pear offers an example:

“In an interview, last year in the journal Biotechnology Healthcare, Dr. Berwick said, “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”

Oh no, not again. The same two sentences—cast in the future tense—with no hint that we already ration care and do it in an irrational way. Ironically, Pear is using a snippet that has been ripped out of context to counter the argument that Republicans have taken Berwick’s comments out of context.

Pear does give Reid H. Cherlin, a White House spokesman, a chance to explain: “Rationing is rampant in the system today, as insurers make arbitrary decisions about who can get the care they need. Don Berwick wants to see a system in which those decisions are transparent, and the people who make them are held accountable.”

But because the quote omits the two sentences that frame the statement, a reader may well be left with the impression that Berwick favors “transparent rationing.” In other words, as one of his critics puts it, “we’ll know who is on the death panel.”

An alert readers will notice that, the middle of the article, Pear offers two  good examples of what Berwick actually means by “rationing”:  “In his book, Escape Fire: Designs for the Future of Health Care, Dr. Berwick sharply criticized ‘the dangerous, toxic and expensive assumption that more is better.’ He insists that the nation can cut health costs without harming patients because vast sums are misspent. . . .” He explains how Berwick would “ration” end-of-life care: “Long before the uproar over ‘death panels’ last year, Dr. Berwick was urging health care providers to ‘reduce the use of unwanted and ineffective medical procedures at the end of life. Using unwanted procedures in terminal illness is a form of assault’” he said in 1993 at the annual conference of his institute. ‘In economic terms, it is waste.’”

But as the Times’ article moves forward, it continues to see-saw.“’I have said it before, and I’ll stand behind it, that the waste level in American medicine approaches 50 percent,’” Berwick declared in an interview in the journal Health Affairs in 2005. “Dr. Berwick has championed efforts to ‘reduce the total supply of high-technology medical and surgical care’ and to consolidate services in regional centers,” Pear adds.  Does this mean that Berwick views “high tech surgery” as “waste”?

If only reporters would quote one or two other lines from the same 2005  Health Affairs interview: “Innovation is absolutely crucial, and I don’t think we should slow down our investment in better technologies,” Berwick said.  But, he explained, “we have a learning disability in this country with respect to the difference between technologies that really do help and technologies that are only adding money to the margins of the companies that make them, without essentially paying their way in value. . . One of the drivers of low value in health care today is the continuous entrance of new technologies, devices, and drugs that add no value to care. If we had strong national policy, it would allow us to know the difference,”  he adds, referring to the fact that, under current law, the FDA does not ask drug-makers or device-makers to show that a new product is in any way better than –or even as good as—products that are already on the market.

As the Times’ story rolls toward a conclusion, the emphasis seems to falls on restricting healthcare in order to save money: “On more than one occasion, Dr. Berwick has suggested a need for a cap on total health spending, with limits on annual increases.

“In speeches and articles celebrating the 60th anniversary of Britain’s National Health Service in 2008, Dr. Berwick said he was ‘in love with the N.H.S.’ and explained why it was ‘such a seductress.’

“The N.H.S. is not just a national treasure,’ he wrote; ‘it is a global treasure.’”

“Among its virtues, he told a British audience, is that ‘you cap your health care budget.’”

Some might well call this type of reporting “balanced.” But as a reader trying to thread my way through a controversy, I find it dizzying. I want to know: is Berwick’s idea of “rationing” a threat to Medicare, or not?  If I were a Medicare patient, I would be nervous.

If Berwick said one thing in one speech, and something else in another speech, one would have to say that that the fault is his. He changes the message, depending on the audience. But the truth is, if you look at any of the conservatives’ favorite “pull-out quotes” in context, you’ll find  that the message is the same: “rationing” is never about cutting care that would help a patient.  Don Berwick wants to save money by improving Medicare.

Berwick’s “Love” For the U.K.’s National Health Service

If you think conservatives are fond of the phrase “rationing with our eyes wide open” imagine what they do with Berwick’s declaration of love for the NHS.  “I am romantic about the NHS,” Berwick said in July 2008. “I love it. All I need to do to rediscover the romance is to look at health care in my own country.”

In May, Kansas Sen. Pat Roberts read the lines on the Senate floor and then asked, rhetorically: “Why is this important? Because the NHS rations health care.”

At the beginning of this month David Catron reprised the quote in the American Spectator, followed by several paragraphs denouncing the NHS as “a third-world operation that employs Soviet-style central planning to produce terrible care and worse outcomes.  . . . if confirmed, this man will do real damage.”.

Two weeks ago, right-wing pundit Betsy McCaughey used the same familiar lines in a New York Post.Op-ed, explaining that Berwick likes the NHS for its “central planning, frugality, wealth redistribution and rationing.”

Fox & Friends, The Boston Globe Op-ed, the New York Times article, and virtually all of the blogs cited above bring up Berwick’s admiration for the UK’s healthcare system.  Google “Berwick” and “love” and “NHS” and you’ll get 18,400 results..

What most fail to mention is the context. Berwick made the speech on the occasion of the NHS’ 60th birthday. Quite naturally, he had some nice things to say. You don’t go to a birthday party and begin your toast by roasting your host.

But Berwick’s detractors ignore the second half of the 3,000-words speech which begins: “Is the NHS perfect?  Far, far from it. I know that as well as anyone in this room.  From front line to Whitehall, I have had the privilege to observe its performance and even to help to measure it.  The large scale facts are most recently summarized in the magisterial report by Sheila Leatherman and Kim Sutherland sponsored by The Nuffield Trust called The Quest for Quality: Refining the NHS Reforms.  They find some good news.  For example, after ten years of reinvestment and redesign, the NHS has more evidence-based care, lower mortality rates for major disease groups (especially cardiovascular diseases), lower waiting times for hospital, outpatient, and cancer care, more staff and technologies available, in some places better community-based mental health care, and falling rates of hospital infection.There is less progress in some areas, especially by comparison with other European systems, such as in specialty access, cancer outcomes, patient-centeredness, life expectancy and infant mortality for socially deprived populations. In other words, in improving its quality, two facts are true: the NHS is en route, and the NHS has a lot more work ahead.”

Berwick then devotes 1250 words to “ten suggestions” as to how the National Health Service could do better.

He begins by urging the NHS to “put the patient at the center – at the absolute center of your system of care.   . . . It means asking, “How would you like this done?” It means asking, “How can I help you?” and then you fall silent and you listen.”

He goes on to tell the NHS that it should  “strengthen the local health care systems – community care systems – as a whole.”  In addition, he argues that NHS must “reinvest in general practice and primary care.  These, not hospital care, are the soul of a proper, community-oriented, health-preserving care system.  General practice, not the hospital, is the jewel in the crown . . . “

Berwick explains that the many “governmental and quasi-governmental organizations concerned with assessing, assuring, and improving the performance of the NHS need to collaborate. . . . they do not work well with each other. The nation lacks a consistent, agreed map of roles and responsibilities that amount, in aggregate, to a coherent system of aim-setting, oversight, and assistance.”

Finally, Berwick exhorts the NHS to “train your health care workforce for the future, not the past. That workforce needs to master a whole new set of skills relevant to the leadership of and citizenship in the improvement of health care as a system – patient safety, continual improvement, teamwork, measurement, and patient-centered care, to name a few.”

The speech ends with a question: “Would it not be thrilling in the next decade for the NHS – the National Health Service – to live fully up to its middle name?” If someone other than Berwick had said this, it definitely would have sounded snarky. Coming from Berwick, it was meant as inspiration, and my guess is that the audience took it that way.

Nevertheless by the time Berwick finished with his “10 suggestions, I can only imagine that his audience was exhausted at the thought of how much work lies ahead. If this is “love” it is what they call “tough love.”

Does Berwick want to model Medicare on the NHS? I don’t think so.

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 Institutional 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.

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50 replies »

  1. Wow that was strange. I just wrote an really long comment but after
    I clicked submit my comment didn’t show up. Grrrr…

    well I’m not writing all that over again. Regardless, just wanted to say superb blog!

  2. I have been puzzled as to why this man who is apparently universally respected among health care professionals has become such a political lightning rod. Then I read the NHS speech at the link this article so helpfully provided. Now I understand perfectly, and I am against him too.
    A respected researcher who has operated in the ivory tower can be quite dangerous when given power. He truly does think the NHS is the ideal model, and I do not want it to be the ideal model for me. I am happy to have the results of his research provided for information but I do not want them forced upon me.
    What we are missing is that everyone in the UK does not HAVE to be subject to the NHS. The NHS is wonderful for those who cannot afford better, and perhaps that is what we need to do in order to provide health care to all Americans. But in the UK, if you want different, or better, care and you can pay for it, you can. I don’t think that is where the US is going.

  3. “Nate’s rants are just that. He regularly tries to distort anything that anyone who does not share his ideology says. He is usually wrong.”
    “He is usually wrong.”
    “He is usually wrong.”
    Cut and paste is the most powerful editor working today. Using individuals own words against them and being able to do so in minutes instead of the next day’s addition, weekly or monthly issue will come to be far more corrective then the overpaid ideologues sitting in those chairs now.
    Everyone should be free to say what they want, that faux conserative at WaPo for example, but they should be accountable for it. For to long to few controlled public discussion and kept truth in the dark, a new day be dawning. It will be a messy and sometimes mean metomorphesis and some reputations will surely die, but soon enough we will know who is educated in which they speak and who is not.

  4. am I allowed to make a sound?
    swoosh swoosh swoosh (thats the sound head saking makes isn’t it?)
    tisk tisk tisk
    who needs words, sounds are worth atleast 10-20. I wanted to make a stickman with his tongue sticking out and a thought bubble saying I told you so but it was really really hard. I regret spending so much time on grammer and spelling to the detriment of my artistic skills:(

    Not according to OWE-bama (D).
    WASHINGTON – Bypassing Republicans eager to grill an administration official over the new health care law, President Barack Obama is planning to appoint the head of Medicare and Medicaid without Senate hearings.
    Obama intends to use a so-called recess appointment to put Dr. Donald Berwick in charge of the Centers for Medicare and Medicaid Services, a White House official said Tuesday night.
    The decision means Berwick, an expert on patient care, can assume the post without being confirmed by the Senate, which is in recess for the July Fourth holiday. He could serve through next year without Senate confirmation.
    Republicans had indicated they were prepared to oppose him over comments he had made on rationing of medical care and other matters. Democrats wanted to avoid a nasty confirmation fight that could reopen the health care debate. Berwick was nominated in April but no confirmation hearing had been scheduled.

    You can run — but you can’t hide from Nov. 2, Mr. (D).

    ” .. But reptiles are not so good at thinking things out. And that’s evidenced by dooshes who gravitate to the same rants no matter what the topic ..”
    Gee, God .. does that include those with Bush Derangement Syndrome? Or you have deigned that only (D) have 1st Amendment rights?
    The public is so much smarter than PhD-English Mahar (D) and her crew (D), it is not funny, any more.
    Can’t take the heat — out of the kitchen. When the public’s money is involved — NO ONE has been appointed as God’s replacement (including OWE-bama). Get used to it — whining is so visually jejune.

  7. you have personally been down the rabbit hole to confirm that Bill? Are you still down the rabbit hole or have you returned? They could have started to spell it differently when you left.

  8. At least down the rabbit hole, “lizards” is spelled correctly.

  9. This is like a bad nightmare, apparently 69% of the population are really lisards…who else thought V was just a TV show 15 years ago instead of a documentory?
    “The new survey found that just 29% believe last year’s economic stimulus plan has helped the economy while 43% believe it hurt. Not surprisingly, there is little appetite for another round. By a 69% to 15% margin, voters believe tax cuts is a better way to create jobs rather than more government spending.”
    Maybe Alice, e-patient Dave, and the 15% should stay down the rabbit hole?

  10. Dave can you pass this on to Alice for us?
    “Germany’s cabinet is poised this week to approve a 2011 budget as part of a four-year programme of public spending cuts meant to serve as an example to other European governments without jeopardising the country’s increasingly robust economic recovery.
    Briefing papers for Wednesday’s cabinet meeting, released by Berlin on Sunday, argue that by curbing spending – rather than increasing taxes – the €80bn ($100.3bn, £66bn) savings programme would differ “fundamentally” from previous fiscal squeezes and offer “noticeable, better growth possibilities”.”
    Read this part a couple times a day…every day….for the rest of your life
    argue that by curbing spending – rather than increasing taxes –

  11. I’m on the verge of declaring myself officially tired of the anti-cerebellum discourse in the comments on this blog.
    I don’t mind passion, but I object when idiots like Glenn Beck and his viewers [anywhere on the spectrum] appeal to the reptilian brain. I understand the electoral psychology: reptilian appeals (tears, shrieks, fight or flight) get people worked up and evoke fast response, which is useful when you want people to vote.
    But reptiles are not so good at thinking things out. And that’s evidenced by dooshes who gravitate to the same rants no matter what the topic.
    Why bother discussing? What can one say to someone who’s convinced (like an alarmed reptile) that there’s mortal peril, and won’t be persuaded by thought?
    In honor of those souls, here’s a marvelous Alice in Wonderland cartoon, updated for today. From CollegeHumor.com – where else?

  12. I always wondered Maggie what are these other things of which you speak? What are us men who attack you lacking that make us so mean spirited and misogynist?
    I’ll wager this is one of those times you choose to keep quite. Your at least inteligent enough to not dig yoruself in any deeper on this one.

  13. “When I refer to “trolls” I talking about people filled with hatred–of President Obama, of health care reform, of the government, of me”
    Maggie do you admit then your a troll of a different stripe? Its your hatred of Bush and Conservatives and your constant fabrications and lies that cause people to react to you the way they do. Your a political bully crying that someone got feed up and puched you back.
    I have seen a small handful of accurate and honest post from you and the comments under those post where friendly and productive. It’s sad that you can’t make the connection between your hateful work and the hateful responce it illicits.
    Its a sad reflection on Journalism in this country that people like you feel entitled to hurt people and propogandise while entitled to censor any dissent.
    It’s very simple maggie, if you don’t like being attacked then stop attacking people. Or do it on your own blog where you can delete anyone that disagrees.
    For the record Maggie you still hold the title for most hateful personal attack on here;
    Posted by: maggiemahar | Apr 7, 2010 8:29:15 PM
    “Another part of the odd, obsessive focus on me (I’m just not that important) may be misogyny”
    “Intelligent women do get some men riled up. Other men really like intelligent women. In my experience, it all depends on how confident the man is –not so much about his intelligence, but about other things.”
    Please do keep on complaining about your responces, it says far more about you then it does those that respond.

    Nate, you’re doing God’s work.
    How many personal bankruptcies might be avoided is unpredictable, as it is not clear how often medical debt plays a back-breaking role. There were 1.1 million personal bankruptcy filings in 2008, including 12,500 in Nashville, and more are expected this year.
    Last summer, Harvard researchers published a headline-grabbing paper that concluded that illness or medical bills contributed to 62 percent of bankruptcies in 2007, up from about half in 2001. More than three-fourths of those with medical debt had health insurance.
    But the researchers’ methodology has been criticized as defining medical bankruptcy too broadly and for the ideological leanings of its authors, some of whom are outspoken advocates for nationalized health care.

    Nate — good job, catching liars. Keep it up.
    As Ted Williams might have said: “liars never win, and winners never lie. $@$@#$% it!” And what lovely, honest city did Shoeless Joe Jackson play in?

  15. IT’S A SHAME
    That alleged “journalists” (D) are not required to admit that they are mere political tools (D).
    Ditto Commonwealth studies (D).
    Political deceivers (D) will NEVER win, while free people live in the USA.
    Don’t like it in the USA, (D)? Why don’t you (D) move to the land of perfection, in Europe (S)? They deserve you, more than us.

  16. IT’S A SHAME
    That alleged “journalists” (D) are required to just admit they are political tools (D).
    Ditto Commonwealth studies (D).
    Political deceivers (D) will NEVER win, while free people live in the USA.
    Don’t like it in the USA, (D)? Why don’t you (D) move to the land of perfection, in Europe (S)? They deserve you, more than us.

  17. e-patient Dave-
    Thanks, I’m always disappointed when trolls derail what could have been a much better thread.
    I’m not talking about people who disagree with me. Barry C., Margalit, Bev M.D. and others who comment on TCHB sometimes (or often) disagree with me.
    When I refer to “trolls” I talking about people filled with hatred–of President Obama, of health care reform, of the government, of me
    (which is particularly silly becuase I’m not that important in the larger scheme of things.)
    It doesn’t matter what the post is about, they revert to their obsession–Obama, the govt’, whatever– with rants, personal attacks,hyperbole and nonsensical assertions until others just give up and go away.
    It’s a shame.
    Glad you joined in, and have a good 4th.

  18. ” .. I’ve got to say, my slutty two-bit-blog-troll comments brand every word of my thoughts as airheaded ..”
    Yup. You need treatment. Pity.

  19. J.S., who are you?
    I’ve got to say, your slutty two-bit-blog-troll comments brand every word of your thoughts as airheaded. Why do you even bother? Do you think the hours you put in here change the world in ANY way?
    There, I joined in. 🙂 Have a nice Fourth, all!
    p.s. Seriously, J.S., who are you?

    ” If this were true why would THCB cross-post me? ”
    Because they share the same political bias….

    1. Yes .. lot of bias .. which is so blatant and obvious, Helen Keller could have seen it .. facts, they are subjective to this crew .. and why on Nov. 2, and Nov. 6, 2012, voters will throw these bozos (D) out of office, for their costly delusions ..
    2. Yes .. a very good question .. at least Matthew has intensely studied health care .. not just relied 100% on secondary sources ..
    REALITY: U.S. health care is now a full-blown DISASTER.
    No one with a BRAIN will invest one penny in new improvements, while all the lawsuits and legislative counter-measures wind through the system.
    Shovel crap in — get crap back, OWE-bama. Duh.
    OWE-bama is now an LBJ, mired in a Vietnam of HIS making — not Bush’s.
    If he had any integrity, he’d announce he’s a one-termer, like LBJ did. But he’s from MOB-town Chicago — he figures he and Valerie Jarrett can STEAL the election. Then pigs will fly.

  21. ” IHI runs workshops to helps hospitals and doctors implement the “triple aim.”
    Statements like this show you someone that has never spent a day in their life managing a business. To equate a workshop to actually implementing in real life is a joke. If it was as easy as following a workshop every business would be well ran, have no sexual harrasement complaints, no worksite injuries, and all be praticing six sigma. Maggie has offically jumped the shark. To hear you say something like that must make your old Barron’s collegues cring.

  22. “That’s what I meant when I said that it wouldn’t be Obama’s style.”
    This seems to be happening a lot. When you get caught in a lie, you spoke to quick or didn’t word it right. When I caught these on your blog you would just delete the comment and never “clearify” your intent. Now that 4-5 people on THCB are taking notice to what you say your forced to issue these, “clearifications” every time you post anything. For a professional writer you sure seem to have a lot of trouble expressing yourself.
    ” I can’t think of a post of equal importance that has been filled as a recess appointment, can you?”
    What other post has he filled this important since this is one of the most important post in DC?
    “Finally if you’re going to link to the Huffington Post piece you might want to include this comparison of Bush and Obama.”
    No one is questioning if Bush did recess appointments, we are addressing your false claim, oops I mean misunderstood, claim that Obama never would, you bringing up Bush is just deflection, well I was wrong but he was worse….this isn’t grade school.
    “”There is a key difference, however, between 2005 and 2010: the amount of Senate obstruction. As White House spokeswoman Jen Psaki noted today:”
    No actually the key was Dems had 60 votes and still couldn’t clear his nominees. That is just weak government from an ineffectual leader…organizer actually.
    ” President Obama has shown that he is serious about getting the right team in place to create jobs”
    When exactly do they plan to start creating these? 16,000? in June? I think we would have been better off leaving the positions vacant and splitting their salaries amoungst the unemployed.
    “He is usually wrong.”
    Funny you never have an examples of me being wrong, lots of clearification on what you meant to have said and if you had said what you know meant you said then I would be wrong, but never any cases of me actually being wrong.
    ” chose to make an issue out of a relatively minor point–I’m not sure why. The exact name of the HMO, or whether Harvard owns it didn’t matter.”
    Did he manage a department in a tens of million organization or run a billion dollar health plan, no difference, minor point. You can’t be serious Maggie. Thats like writing a letter to the editor of a small town paper or having a book published….well maybe those actually aren’t that different.
    ” If this were true why would THCB cross-post me? ”
    Because they share the same political bias….

  23. Nate , Steven Motew–
    Nate– I was aware of those recess appointments. Obama had a huge number of nominees waiting and waiting and something had to be done (see quote from Huffington below)
    Can you name one that was as important as head of CMS–or even close??? That’s what I meant when I
    said that it wouldn’t be Obama’s style. This is one of the most important jobs in D.C. I can’t think of a post of equal importance that has been filled as a recess appointment, can you?
    Secondly, I said I could be wrong. If the administration believes that Senate conservatives will be able to delay Berwick’s confirmation hearing too long it might feel that it has no choice but to make a recess appointment.
    Finally if you’re going to link to the Huffington Post piece you might want to include this comparison of Bush and Obama.
    “There is a key difference, however, between 2005 and 2010: the amount of Senate obstruction. As White House spokeswoman Jen Psaki noted today:
    [A]t this time in 2002, President Bush had only 5 nominees pending on the floor. By contrast, President Obama has 77 nominees currently pending on the floor, 58 of whom have been waiting for over two weeks and 44 of those have been waiting more than a month. And cloture has been filed 16 times on Obama nominees, nine of whom were subsequently confirmed with 60 or more votes or by voice vote. Cloture was not filed on a single Bush nominee in his first year. And despite facing significantly less opposition, President Bush had already made 10 recess appointments by this point in his presidency and he made another five over the spring recess.
    Sen. Harry Reid echoed this sentiment in a statement: “Nominees under President Obama have fared worse than others in recent memory. Regrettably, Senate Republicans have dedicated themselves to a failed strategy to cripple President Obama’s economic initiatives by stalling key Administration nominees at every turn. With the recess appointments of these highly-qualified individuals, President Obama has shown that he is serious about getting the right team in place to create jobs and protect the American workforce, and I support his decision.”
    Stephen Motew–
    Golly, I guess I touched a nerve–though I’m not quite sure where. I suspect that another post must have set you off.
    As to the suggestion that Nate and tcoyote show that my posts are filled with misinformation . .
    Nate’s rants are just that. He regularly tries to distort anything that anyone who does not share his ideology says. He is usually wrong. (See Matthew’s replies to Nate, . At this point, I usually ignore his comments.)
    Tcoyote, on the other hand, chose to make an issue out of a relatively minor point–I’m not sure why. The exact name of the HMO, or whether Harvard owns it didn’t matter. That Berwick wasn’t in charge does matter, though it turns out that in this case the CEO was merely as “manager” (as Bev has defined manager–someone from the advertising and cosmetics businesss) and Berwick, who was VP for measuring quality, was actually trying to fill a leadership position–i.e. improve quality. The manager/CEO didn’t want him to do that.
    To use this error to suggest that my posts are fill with false speculation and misinformation is ludicrous–and dangerously close to libel. If this were true why would THCB cross-post me? (See THCB’s kind words at the end of the post.) And by “false speculation,” I suppose you mean my speculation, on THCB and elsewhere, that the legislation would pass–without needing Republican votes–or that Berwick would be appointed head of CMS . . .
    My point in mentioning the HMO and Berwick’s experience there is that that he was dealing with a large bureaucracy and was very frustrated. So he knows what bureacracies are like– and won’t drown–or be eaten alive (as some have suggested) by CMS. I agree with Bev– he won’t set out to be bureaucrat-in-chief. He’s not an insurance company exectuive and that’s not why he’s getting this appointment.
    His ability to inspire and help implement structural reform–focusing on process, efficiency, patient safety and patient-centeredness is what is important.
    Meanwhile, earlier on this thread, you wrote: “Berwick falls short of presenting true implementation of his ideals.”
    This is not a minor error. It is a good example of presenting misinformaiton on an important issue.
    IHI is all about implementation. Berwick is not a theorist: IHI runs workshops to helps hospitals and doctors implement the “triple aim.” And he has had real success, on the ground.

  24. Speaking of speculation and blatantly false information, Dr. Jones; here is Dr. Berwick’s present status:
    ” Dr. Berwick is Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School and professor of Health Policy and Management at the Harvard School of Public Health. He is also a pediatrician, an Associate in Pediatrics at Boston’s Children’s Hospital, and a Consultant in Pediatrics at Massachusetts General Hospital.” He is also, of course, CEO of IHI.
    As I recall, the alarm death at MGH was on an adult unit. Tell me again his connection to this event?
    Also, he did not “write” the IHI report; and your assertion that its conclusions are flawed is a matter of disagreement, not fact. If you google this, which I have done, you would find this out, instead of listening to old propaganda.
    What is with you MD guys – you want somebody like Daschle running CMS instead? Then you’d REALLY have someone who understood M.D.’s – not. Be careful what you wish for.

  25. Berwick is slick. Got paid about $2 million from his “non profit” and wrote the flawed treatise on medical mistakes at the IOM. Then, a patient died on a heart monitor at his MGH is Beantown in a state of neglect. Where was Berwick when the patient needed him You mean to say Berwick had no idea of the hodgepodge of care at the monitored cardiac units of his Harvard hospitals?

  26. “but do you really think “editorial oversight” has caused traditional media to be more factual??!!”
    Seeing as how there is no editoral oversight how do we know? We do know that a lack of editoral oversight correlates with a decline in factual reporting

  27. Dr. Motew, your comment made me laugh out loud. Where have you been on this blog all these years??!! I don’t believe all of what Maggie (or anyone else) says any more than you do, but do you really think “editorial oversight” has caused traditional media to be more factual??!! Caveat emptor, as with all things. What you really want is censorship to agree with your own view of the world – nuh-uh. I’ll filter the speculation, thank you.

  28. The editorial oversight of posts here is lacking. How can legitimacy be assigned to blatantly false information and speculation filling these posts such as pointed-out by Nate and tcoyote above?
    At the very least list Mahar’s posts as Op-Eds rather than stories or ‘news’.

  29. “As for Obama making it a recess appointment. . . That doesn’t sound like Obama’s style–or Berwick’s. He’s not going to sneak into Washington.”
    Oh really Maggie?
    “President Obama’s decision to bypass the vacationing Senate and directly appoint 15 nominees” It has been 3 months who could possibly remember all the way back then.
    “something that a Republican might think Obama would do.”
    Seeing as how Republicans are intelligent enough to read then yes they might think think Obama would since he already has. Ignorance much be such a simple and relaxing place.

    ” .. The person with experience will be the MANAGER – Dr. Berwick will be the LEADER ..”
    News-flash: “Vision” has NEVER paid one DEBT. Working does. And the OWE-bama blah-blah-blah crowd does NOT have a clue about how to make things work without HUGE TAXES. Ridiculous.
    Nov. 2 — can’t wait. One legislative line will fix this MESS — “The OWE-bama DEFORM theory is hereby repealed immediately.”
    Then a REALITY-BASED plan can be approved.

  31. Bev M.D.
    Thank you. You are absolutely right. A bureaucrat can “manage” CMS– we need someone brilliant, with Berwick’s courage, inspirational ability, and know-how when it comes to helping hospitals and doctors raise the quality and lower the cost of healthcare.
    Tim & Tcoyote
    Tim -The difference is between “rationing acccording to ability to pay” on the one hand and “using medical reserach to distribute the ‘right care to the right patient (based on patient’s medical profile) at the right time.”
    If you don’t see that the first is “irrational rationing” while the second is “rational rationing,” I don’t know what to tell you.
    And guidelines for evidence-based medicine will not be created by “Government” (Congress or the exectuive branch bureaucrats) but by panels of medical researchers, doctors and other using comparative-effectivness reserach.
    Sorry if I was speaking too loosely. To me the name of the health plan, or who owned it wasn’t important. (If I were writing a post, I’d look it up. When writing comments I often say “if memory serves.” In this case, what I wrote was based on a conversation I had with Berwick a couple of years ago–and memory didn’t serve well enough–though I don’t think these details are important.
    What is important is that he was in charge of quality for Harvard’s Community Health Plan.
    Technically, Berwick was VP for “measuring quality” in the HMO. To me, this seems the most important job in a HMO which is why I remembered him as being at the center of the organization.
    The actual CEO of the Harvard Community Health Plan was “a businessman with a background in advertising and cosmetics.” (Boston Globe)
    Suffice to say Berwick knew more than he did about health care.
    Berwick saw his job as not only “measuring quality” but “improving quality.”
    “By 1985, Berwick was traveling around the country, meeting with leaders of other industries that had boosted their performance by revamping operations. Lessons learned at places like Bell Labs became the seeds for his institute.”
    The CEO running Harvard Community Health Plan didn’t approve. He wanted Berwick to measure quality, not try to improve it. “Don and I didn’t see eye to eye on this,’ his former boss, Tom Pyle, told the Boston Globe.”
    In 1989, Berwick quite the HMO.
    I remeber him telling me it was the most frustrating job he ever had– a medical bureaucracy where everyone was sending memoes to everyone else, and nothing was getting done.
    But his experience there inspired him to create IHI. It was the turning point in his career.
    When he becomes director of CMS, he’ll make the job his own. I doubt very much that he’ll see the job as about running the CMS bureaucracy. (See Bev M.D.’s comment. )He’ll want to implement reform throughout the Medicare system– evaluating the pilot projects, rolling successful pilots out nationwide (which under the legislation, CMS has authority to do, without going through Congress.)
    He’s an active, hands-on kind of guy. As a friend who knows him well said in a recent e-mail: “He has brains, guts and moxy.”
    He also has more than a passing acquaintance with Washington and the politics of health care and healthcare reform in D.C. He has served as : “Vice chair of the U.S. Preventive Services Task Force (1990-95); board of trustees member, American Hospital Assn. (1996-99); member, President Clinton’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry (1996-99); chair, Agency for Healthcare Research and Quality National Advisory Council (1999-2001); member, Institute of Medicine (2002-present)”
    How do I know that he’ll be confirmed? I have some good sources in D.C., and some feel for the politics–both the Republicans, and the current administration. If you recall, I was certain that reform legislation would pass when others had given up.
    I also was certain that no Republican would vote for it, and that Obama, Pelosi and Reid would pull it off at the very end, just the way they did. Pelosi is a Pol’s daughter; she enjoyed the fight, and she fought to win. (I knew politicians of her father’s generation when I was a young child growing up in Syracuse. Went to many “Last Hurrah” funerals.) Obama had too much at stake to let it go–and I thought Rahm would lose the argument. Reid rose to the occasion.
    And I predicted that Berwick might well be Obama’s nominee for CMS. (The rumor at the time was that he had turned down the job.) This was based on knowing Berwick, how perfect he would be as the point man implementing Medcare reform, and the people who would be advising Obama on this appointment. Healthcare is the one area where he has very good advisors. And when Obama waited so long to fill the slot, it was clear that he was going to pick someone strong and controversial. He wanted to first win the war over the legislation before dealing with the battle over confirmation.
    I know Berwick, know how likeable he is, and can imagine how he would handle himself during a confirmation hearing. I also know how many different constituences support him –and not just in the medical community. Employers, the AARP, etc– see the press release I wrote about in an earlier response.
    Not too many Congressmen want to offend that many groups. And their support for Berwick is both strong and deeply-felt.
    As for Obama making it a recess appointment. . . That doesn’t sound like Obama’s style–or Berwick’s. He’s not going to sneak into Washington. To be perfectly candid, that sounds more like something the Bush administration might have done (part of the “executive presidency”) and something that a Republican might think Obama would do.
    I could be wrong about this. Perhaps a recess appointment is the way only to get Berwick into office in a timely fashion. Time is of the essence and while I don’t believe the Republicans have to power to block him, they do have the power to drag this out.

  32. Outside Steve jobs name a large company successful ran by a visionary. Majority of the time it fails. The person that comes up with the ideas hardly ever is able to implement them. History is littered by failed business ran the way you want. One of the hardest parts of owning a growing business is knowing when to step aside and hand it over to a manager.
    “Dr. Berwick has deep and wide knowledge of the subject.”
    He has no knowledge of how to run a major health plan. That is the problem, the day to day minutia of running such a large organization will eat him alive, just like it has Obama.

  33. Nate;
    No, actually I entirely disagree with you. The person with experience will be the MANAGER – Dr. Berwick will be the LEADER. There is a huge difference between the two. Leaders articulate the vision of the organization, educate and liase with Congress, the White House and the public, and set the strategic direction.
    Managers make all that happen – they’re the how, not the what or why. The implementers, not the thinkers.
    Not to mention, almost all these heads of government agencies are political appointees with little or no experience even in the field they are leading,much less how to run it. My dad was a civil servant in NOAA (and its predecessor, Coast and Geodetic Survey) for 40 years, and used to regularly complain about the know-nothings who were appointed to ‘run’ the place.
    Dr. Berwick has deep and wide knowledge of the subject.
    Management experience can be easily found.

  34. “diverse consumer groups including the AFL-CIO, SEIU, Center for Medicare Advocacy, The Leadership Conference on Civil and Human Rights, Alzheimer’s Association and American Association of People with Disabilities;”
    Maggie doesn’t seem to know what a consumer is, these are all highkly partisan political organizations. None of which are actually involved in delivery or purchase of healthcare except the Unions who do it with someone elses money. There is nothing consumer about them.
    This is the complaint against Berwick, he’s never done anything. He has Obama qualifications and we are all seeing first hand how well that is going. CMS is a huge health plan, why don’t you grasp the common sense of hiring someone who has actually ran a health plan?
    “While I think that Berwick falls short presenting true implementation of his ideals, his visionary philosophy demanding radical change in how we view and deliver health care”
    You hire advisors and consultants with these skills, you don’t hire them to implement them, they have no idea how. Medicare has a 35 year history of be run by politicians and academics and has failure to show for it. Keep repeating the same mistakes you get the same results.
    “Let me add that Medicare covers virtually all effective care.” Like Dental and Vision? Or is that all a waste?
    “The big hole in Medicare is long-term care”
    So its not the limited number of hospital days? Limited blood or other countless policy limitations that would be illegal under private imnsurance? Having actually administered a medicare supp and working with these people, let me guess you did three hours of internet reserach?, Medicare has thousands of holes, some bigger then others and is head to toe rationed already.
    ” if people choose to pay a small tax when they are young. Over time, the money would compound”
    Hum sounds like what they told us about Social Security, who would be gullable enough to buy this a second time….ah thats right about 30 million liberals.
    “because the states are able to decide what to cover”
    Actually no Maggie the federal government sets most of the benefit requirements or you lose their matching funds, something most states aren’t willing to do.
    “The only legitimate concern is his lack of experience in government and in running such a huge organization, which can be easily remedied by judicious hiring of underlings. For vision, there is none better.”
    bev M.D…..wouldn’t he actually be the ideal underling working for someone that had experience running such large organizations?

  35. YES
    Ever see pictures of when the government (D) had to tear down the Cabrini-Green welfare-housing projects (D)?
    That’s your tax-dollars at work. Taxes to build – taxes to tear down. Sick.

  36. I don’t get the context that is being “left out” by those who quote Berwick on rationing. He seems to be saying that we have rationing now, by ability to pay, and what we need is rationing by the government. When I read the wider context of his words I don’t see anything that modifies that characterization.
    The conservative position is that there is no reason to believe the latter will be better than the former, and lots of reasons to believe it will be worse.
    You may disagree — as I guess most here do — but that’s a disagreement about faith in government. The criticism of Berwick’s faith is a legitimate argument.

    ” .. Jesus Maria, Maggie (former journalist). Don Berwick didn’t “run Harvard’s healthcare system, a fairly large bureaucracy”.

    Political Rule No. 1 — never let facts get in the way.
    OWE-bama (D) never does. Unfortunately, elections do happen (at least for now), and he’s about to get a very intense wake-up call on Nov 2.

    ” .. The question is whether this can break through our media’s business model that demands .. the supporters are basically a bunch of do-gooders with decades of experience and commitment to healthcare improvement.”
    Sir, one word: bull.
    Example: yesterday, the MSM was caught red-handed in a gross deception in this op-ed:
    “Left-wing group’s grant will “educate” MSM on Obamacare law”
    ” .. The tipster is right to question the Commonwealth Fund’s ability to provide objective information about Obamacare to journalists. The head of the fund, Karen Davis, is a Jimmy Carter leftover and self-identified “progressive” economist who has long peddled single payer ..”
    Nov. 2, this legislative LIE (D) gets dumped. Not every city is Boston/Cambridge (D) or Chicago/Capone-land (D), not every state is BANKRUPT like Illinois (D).
    Then real reform can start.
    Can’t wait. The LYING has been exposed.
    OK — play the sexism-card. Then the race-card. For the goog-zillionth time. When you are BANKRUPT — what does it matter?

  39. Jesus Maria, Maggie (former journalist). Don Berwick didn’t “run Harvard’s healthcare system, a fairly large bureaucracy”. He was “Vice President for Quality” for Harvard Community Health Plan, a staff job he occupied for around five years more than twenty years ago, and a practicing pediatrician in its staff model medical group. His long overlooked role as a practicing pediatrician may be a crucial element of his qualifications for the CMS job.
    As anyone who has ever visited Boston knows, Harvard doesn’t have a “healthcare system”. Its Medical School is affiliated with the large Boston teaching hospitals in Partners (Mass General and Brigham and Womens) and CareGroup (Beth Israel and Deaconess), who own and operate the clinical services in which Harvard med students train. Don had no management role in either of these organizations or its predecessors. Harvard Community Health Plan was not owned or operated by Harvard University.
    Don is one of the most respected academic advocates of quality improvement in the world, but has no management experience beyond running IHI, a successful foundation and learning collaborative in quality/process improvement in healthcare (recent budget about $35 million). I share your view that the attacks on Don are ridiculous. But he has had no management or political experience at a scale remotely comparable to CMS, a agency that disburses $800 billion a year (a sum larger than the Defense Budget). It’s the third hardest management challenge in the federal government.
    I’m not sure where your confidence that he’ll be confirmed comes from. My spies tell me Obama is considering a recess appointment when Congress goes home for the summer, a move that will provoke a summer firestorm of criticism. The agency has had its mandate massively increased by health reform and desperately needs permanent leadership.

  40. Bev M.D., rbar
    Bev M.D.–
    Thanks very much.
    Yes, Berwick is not at all “nebulous” about what needs to be done. See my reply to rbar below.
    And before running IHI, he was running Harvard’s health care system– a fairly large bureaucracy.
    He has never worked in government, but as head of IHI, he succeeded getting a great many hospitals to particpate in various projects. He has honed his skills as a diplomat– somone able to talk to and listen to a great many people, someone who able to persuade disparate groups, and bring them together.
    Is he tough enough? As someone who knows him wrote to me today: “He has the intelligence, gutsm and moxy” needed for the job.
    You might want to read his book “Escape Fire.”
    Berwick is very clear on how to implement his ideas.
    He has overseen many projects designed to improve “systems” in hospitals in order to avoid medical errors, lift the quality of care, save patients’ lives–and save money, all at the same time.
    Many of these projects have been very successful.
    He understands that we need to re-engineer how we deliver care, by changing the financial incentives for providers and creating a work environment where providers can deliver the best care possible.

  41. I’m not sure many people are aware that Don Berwick was personally affected by our screwed up medical system and medical errors when his wife was hospitalized with a “mysterious” and serious illness some time ago. (I gather it was some type of rare spinal infection or inflammatory process, but don’t quote me.) I watched a video of him giving a speech during which he described his frustration at dealing with an intransigent medical system during that time, and you could see he was nearly in tears.
    He is by no means “nebulous” as to where this system needs to go. I’m sorry, but any attempts to derail his nomination can only be purely political, not substantive.
    The only legitimate concern is his lack of experience in government and in running such a huge organization, which can be easily remedied by judicious hiring of underlings. For vision, there is none better.

  42. Stephen–
    Thanks for reminding me to urge everyone to read Berwick’s book, “Escape Fire.” A collection of his speeches, it’s a great read. Not at all wonky. Some wonderful narratives . .and ideas.
    Let me add that Medicare covers virtually all effective care. The big hole in Medicare is long-term care, and in that case, Medicare isn’t rationing, it just hasn’t figured out how to fund long-term care for all of the boomers who will need it.
    Though in the health care legislation there is a voluntary long-term-care payroll tax that could solve the problem, if people choose to pay a small tax when they are young. Over time, the money would compound . .
    Admittedly there are some weird small holes in Medicare that need to be fixed: for instance, it doesn’t cover eye exams unless you have an eye disease (for example, glaucoma). But how would you know you have glaucoma unless you have regular eye exams? This isn’t a case of rationing so much as Congress deciding it didn’t want to get into eye and dental care. But in fact, it costs society far more if a senior on Medicare becomes blind, or if a tooth infection leads to larger problems.
    Medicaid, on the other hand, does ration care because the states are able to decide what to cover, and many states either can’t (very poor states) or won’t (conservative states) provide comprehensive care.

  43. I guess I don’t exactly know what Dr. Berwick stands for. I just read an older speech about his vision for health care, which starts off with a vaguely impressive but ultimately meaningless anecdote about escape fires, and a variety of ill-defined positions (patient care has to be 24/7 … the visit should no longer the central unit of patient care).
    “train your health care workforce for the future, not the past.”
    “patient centeredness”
    – of course, an inspiring high level manager will prefer to speak in inspiring generalities instead of clear policy proposals … but I get the feeling that Dr. Berwick is particularly nebulous.
    Dr. Berwick or anyone else who adjusts the medicare fee schedule will adress a lot of problems and deserve high praise.

  44. The only way out of the U.S. financial health care morass is via an “Escape Fire” as Berwick has identified. While I think that Berwick falls short presenting true implementation of his ideals, his visionary philosophy demanding radical change in how we view and deliver health care earns my support.
    With regard to ‘rationing’, wake-up people if you think it isn’t rampant today. Medicaid in many states refuses to pay for preventative diabetic foot care if provided by podiatrists or ANY invasive treatment of venous disease…just a few examples.

  45. Doc D.,
    His name is Berwick.
    You’ve got it about right. And I don’t think the
    committee will ignore the huge support for Berwick
    coming from so many directions.
    Today, the Campaign for Better Care issued a press release which begins:
    – In an unprecedented and strongly worded letter, some 90 of the nation’s top consumer, purchaser and provider groups have issued a stirring defense of Dr. Donald Berwick, President Obama’s nominee to serve as administrator of the Centers for Medicare and Medicaid Services (CMS). Dr. Berwick has been targeted by opponents of health reform, who have misrepresented his work and distorted his positions.
    “Donald Berwick is one of the nation’s leading experts on our health care system, and he will be a dedicated and effective public servant who works tirelessly to improve care for those who need it most,” said Debra L. Ness, president of the National Partnership for Women & Families, which leads the Campaign for Better Care with Community Catalyst and the National Health Law Program. “It is truly shameful that Dr. Berwick has been the victim of such ugly and baseless attacks, and the target of false charges about rationing. With this letter, those who provide, purchase and receive care are coming together to say that enough is enough, and to urge Congress to reject the distortions and confirm Dr. Berwick.”
    The Campaign for Better Care organized the letter in support of Berwick’s nomination. It was signed by: diverse consumer groups including the AFL-CIO, SEIU, Center for Medicare Advocacy, The Leadership Conference on Civil and Human Rights, Alzheimer’s Association and American Association of People with Disabilities; provider groups including the American Academy of Family Physicians, American Academy of Nursing, American College of Cardiology, American Geriatrics Society, American Society of Consultant Pharmacists; and purchasers including National Business Coalition on Health, Buyers Health Care Action Group, St. Louis Area Business Health Coalition and Wal-mart Stores Inc.
    On the other side, there’s Nate, and a handful of wrinkly Republicans.
    Yes, we’re lucky someone with Berwick’s talents is willing to take on a very, very tough job in our government. I’m quite certain he’ll be approved.

  46. “Seek the truth and the truth will make you unemployable in Baltimore!”
    If Don Berwick, a man of extreme knowledge, wisdom, vision, and integrity, can’t win appointment to run CMS, then the system really is broken – probably beyond repair.

  47. Basically, the lineup is:
    –a bunch of Republican politicians and a handful of the more hackish Republican political operatives vs.
    –Former Republican heads of CMS, a number of left and right-leaning health policy experts, every healthcare quality leader in America and basically every healthcare organization in America.
    The question is whether this can break through our media’s business model that demands nobody actually say “well, the opposition to this guy seems to be completely ginned up for political reasons by people who know nothing about healthcare, while the supporters are basically a bunch of do-gooders with decades of experience and commitment to healthcare improvement.”

  48. I went to the IHI website and studied some of the policy documents for the organization of which Dr. Berman is CEO. Under the rubric of “patient-centered” care, it’s a program of oversight in the patient’s best interest, as determined by the insurance plan or the government. Dr. B’s admiration for Britain’s NHS, and fascination with central planning will have the same results as all such efforts we’ve suffered from since the Revolution of 1917.
    How about patient-“directed” care instead?

  49. “Reid H. Cherlin, a White House spokesman, a chance to explain: “Rationing is rampant in the system today, as insurers make arbitrary decisions about who can get the care they need. Don Berwick wants to see a system in which those decisions are transparent, and the people who make them are held accountable.”
    What a surprise, lets play blame the insurers again, does Cherlin not know Medicare and Medicaid are by far the largest deniars of claims or gloss over the fact? In an article complaing about honesty of arguments maybe you should make an honest argument?
    Macca, WMDs, etc etc, the left has mastered the out of context quote and everything of which you complain