By BOB WACHTER, MD

The recess appointment of Don Berwick to lead CMS can be seen as a cynical act of political opportunism, sidestepping the Congressional approval process using a tactic worthy of Machiavelli, or Karl Rove. Or it can be viewed as a pragmatic decision by Obama to avoid a lengthy and exasperating re-litigation of the healthcare reform debate.

Death Panels. Been there, done that. So I’m going with Choice #2.

The right side of the blogosphere has erupted, painting Berwick as an effete academic who would have withered under the Klieg lights and piercing questions of the likes of John Ensign and Jim Bunning. Those of us who know Don have no doubt that he would have more than held his own in debating the lessons of England’s healthcare system and the necessity of clear-headed rationing choices. Don is serious, hyper-articulate and intellectually nimble; in a real debate with members of the Senate Finance Committee, all my money would have been on him.

But the Berwick “situation”, like they say on Jersey Shore, demonstrates a larger challenge. In the old days, when Medicare was a dumb payer of invoices, its chief could be a bureaucratic functionary, charged only with making the trains run on time. But today we need the Centers for Medicare & Medicaid Services (CMS) to be so much more: promoting new and innovative care (medical homes, accountable care organizations, healthcare IT) and payment (bundling, pay for performance, “no pay for errors”) models, extracting waste and fraud from the system, facilitating new levels of transparency (by healthcare organizations, hospitals, and individual doctors), catalyzing new ways of training future doctors (Medicare funds most of the nation’s residency training slots); the list goes on. In fact, the healthcare reform bill grants CMSextraordinary new powers to develop and implement these ideas.

In that context, CMS’s head honcho now needs to be someone with a point of view, passion, and a backbone. Although I guess there might be a healthcare version of Elena Kagan – a brilliant, charismatic leader who manages to come with a scanty written and oral footprint to be dissected and distorted – it seems unlikely that a healthcare figure with the Right Stuff won’t have a voluminous record that gives evidence that the person, at times, has done battle with the status quo. I certainly hope so.

So we’re stuck: The very things that make Berwick right for the CMS role also make him a target in today’s political environment, where all serious debate is trivialized and caricatured via talking points and schoolyard name calling. (This week’s na na na na na was calling Berwick “Rationer-in-Chief.” One can hardly resist a comeback like, “And so’s your mother.”) In such an environment, the ends do justify the means. In making this recess appointment, Obama did not bypass a substantive airing of Berwick’s qualifications to run the most important healthcare organization in the country. Rather, he avoided a sandbox brawl. As Jonathan Cohn wrote in the New Republic,

For the record, a serious conversation about Berwick’s qualifications and plans would have been worthwhile. I’ve heard even people sympathetic to Berwick question whether his administrative experience is adequate. But, again, it’s hard to have a serious conversation when one of the two political parties refuses to be serious.

The Dems were well within their rights to use the recess appointment mechanism (as the Bushies did hundreds of times in their day), just as they were to use the reconciliation mechanism to pass the healthcare reform bill. Of course, the GOP is now completely free to paint the Berwick appointment as unacceptably anti-democratic. Who’s right? Who cares? The voters will ultimately decide.

But while we’re mulling it over, CMS will have its first permanent boss since 2006, and we’ll have healthcare’s most innovative and influential leader at the center of the action, when the need to improve the quality, safety, and efficiency of care has never been more pressing. I look forward to seeing how Don tackles these challenges – I think he’ll be terrific.

I’d be lying if I didn’t admit that – as a healthcare political junkie – I’ll miss watching the Senate hearings. But I’ll try to catch a little World Wide Wrestling tonight on the tube. That should give me my fix.

Robert Wachter, MD, 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.”