OP-ED

Why Obama Made the Right Call on Berwick

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.”

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54 replies »

  1. not sure how they develope the rates they report. something i do need to read up on some day

  2. Nate- crunch numbers all you want- it wont really matter. Pain is the most common reason people seek health care- and it costs the country 300 billion/year. Few physicians are required to have any education in pain care and according to Dr Landis – a member of the pain consortium treatments for pain are “woefully inadequate” So what difference does it make how jhospitals save money or bill when doctors are incapable of successfully treating the most common reason people seek medical care pain.

  3. “I’m looking at a bill we audited a few months back. Billed charges were $282,260.85. After reducing to cost plus we allowed $93,421.52. $188,839.33 was denied as excessive.”
    So, if this was a case where you paid the hospital 125% of costs, it implies that their costs were $74,737.22. If they were paid their full billed charges of $282,260.85, their profit margin would have been 73.5% which, presumably, is what they would expect to collect from people without insurance but with significant assets. It’s outrageous on its face. Hospital billing practices need a lot more focus and attention, in my opinion. Yet, PPACA doesn’t allow the IPAB to go after them for a decade. Go figure.
    Just for clarification, do you have a sense for how uncompensated care, which varies significantly among hospitals, is handled in developing the Medicare cost reports? I appreciate the discussion and feedback.

  4. when hospital’s bill everything goes back to a department or revenue code. The UB92 has general master categories. If you get the bill itemized every single service and supply is broken out on its own line. A big bill can have hundreds if not more lines.
    Our audit partners go line by line, review each one and cross reference it to the hospitals cost to perform/deliver as they report to the government. They then tally up what it supposedly cost the hospital to provide the services they did.
    I’m looking at a bill we audited a few months back. Billed charges were $282,260.85. After reducing to cost plus we allowed $93,421.52. $188,839.33 was denied as excessive.
    Rev Code 120 Med Surg ICU Bed they charged for 6 at a total cost of $23,100 we allowed $10,854.

  5. “When we audit bills now we request bills itemized by revenue code.”
    Nate – I don’t understand what this means. Could you provide some more color and, perhaps, a specific example? Thanks.

  6. sadly we don’t get to choose our generators, unless you buy a hampster and wheel yourself, and NV is seeing huge growth so capital projects are a recurring cost.
    wonder how many hampster it would take to power a house?

  7. Nate,
    Allowable costs would include the cost of capital within the 125% that you referred to but I would add the following comments.
    First, the notion of “prudently incurred costs” does not mean a hospital should feel confident that its payment rates will reflect wildly extravagant construction costs. If a community hospital, for example, doubles its size for $1,000 per square foot when everyone else in the region is building comparable space (when needed) for $500-$600, the excess construction costs should be disallowed unless it can be shown to be unique or highly specialized in some way. If higher cost hospitals had higher payment rates, price (and quality) transparency and tiered in network co-pays should help to move business to lower cost facilities especially the more routine work that everyone can probably do well.
    Second, if there are too many beds in the market and some hospitals are operating at well below efficient capacity utilization, their unit costs will be higher but prudently incurred costs should be based on a normalized efficient occupancy rate.
    Finally, with respect to capital projects, spending to replace what wears out or becomes obsolete will cost considerably more than the non-cash depreciation allowance because depreciation is based on historical costs while new spending is in current dollars. Such so-called maintenance capital spending alone could easily exceed depreciation charges in most years by 20%-30% or even more with the possible exception of information technology related spending where the secular trend in prices is down.
    Even in the utility space, I think regulators can make the distinction, at least to some extent, between prudently incurred costs and excess costs due to inefficiency and extravagance. Besides, in the new utility world, there are plenty of competitors in most markets able and willing to provide customers with the generation piece of electric power which is the most capital intensive piece of the utility business. The transmission and distribution piece, where the local utility will have a natural monopoly, is much less capital intensive and therefore, unlikely to be wildly expensive compared to other similar geographies – terrain, population density, underground vs. above ground wiring, etc.

  8. Your comments only prove the system is intent on continuing its self maximizing behavior. Its a psychopathic system which hurts the rest of society. Lets get to the cause and not the symptoms. Lets train health care industry to be more human compassionate and other regarding-only then will we have a better system that is more focused on the good of the public

  9. when you say recover the cost of capital would allow for that in the calculating of cost or expect that be paid from their 25%? I would love to see Paul’s take on that. I have a very good friend who works for the local power company. Never ever ever would I duplicate the utility system of cost plus on capital projects. They undertake capital projects just so they can get their 10%. Those capital projects they do undertake are the most inefficient boondoggles imaginable becuase it drives their profit. Why do something for 50 million when you can turn it into a 200 million project.
    Capital projects can be funded from profits like the rest of us in my opinion.
    When we audit bills now we request bills itemized by revenue code. The work is being done now. I don’t see where there would be start up capital but do see hospitals quickly reviewing their procedures to see where they can game the system.

  10. “I don’t like doing it this way but it would be very easy to accomplish by saying any hospital receiving federal funds can’t bill more then 125% of their cost.”
    Nate,
    I like this idea conceptually. However, I recall Paul Levy, CEO of BIDMC in Boston, commenting that while his hospital can quantify exactly what it cost to provide every service it offers, the need to allocate indirect and joint costs to various departments requires a degree of subjectivity and judgment. Unfortunately, every institution tackles this issue somewhat differently. He noted that when he was a regulator of utilities, the regulatory body attempted to develop uniform protocols that all utility companies would use so that apples to apples comparisons could be made between and among companies. I think the same thing would need to happen with respect to hospitals if we were to go to a utility like rate setting model. Under such a system, every hospital should be able to recover all reasonable and prudently incurred costs, including the cost of capital. At the same time, no payers, including Medicare and Medicaid, should be able to get away with paying less than 100% of costs. It would undoubtedly take some time, effort and money to get every hospital on the same page with respect to cost accounting, at least within a given state if not nationally.

  11. More pilpul for the sake of pilpul. Whoever you put their- including Berwick will engage in self-maximizing feudalistic behavior and minimize the voice of the people health care is supposed to serve- and this is the tragic flaw in the system. As Einstein indicated you cant solve problems with the same consciousness that created it. The experts like Berwick will serve the expert class and continue the dominium over non-experts- and so the tragic anti-pattern in health care will continue-rearranging the deck chairs on the Titanic wont solve the problem.

  12. If you were a social business trying to cut your costs, you would have another constraint – no off-loading of expenses to beneficiaries. That would make it much tougher to solve the problem, but still possible.
    The only suggestions that make sense from that point of view are #3 and #5, albeit somewhat modified. For #3, no balance billing should be allowed. Patients should not find themselves having to fight hospitals in court. This translates into the Maryland solution, give or take a little. For #5, there should be no need to have people dying just to maintain hospital incomes and share holder dividends. These folks need to tighten their belts significantly before we are at a point where we face “selection” lines in health care.

  13. “How will your free market principles deal with that? (I really want to know; not just being sarcastic.)”
    You sure your not being sarcastic? That was a very sarcastic font you typed that in. Since you stood up to Matt on my behalf I’ll give you the benefit of the doubt. Speaking of which first LeBron then Matt, talk about a bad day and getting piled on.
    If only I had a free market, (various ideas for discussion, not necessarly in favor of all of them);
    1. Reimburse hospital services at HP levels and make member responsible for the difference. (Illegal under new OOP limits)
    2. HP’s plan was to early to the game. I know I will get attacked for this but insurance premiums are not to high, to support this blasphamy I would hold up HP and my services. Their are equally good if not better alternatives available for much less and people CHOOSE to spend their disposable income on the less efficient insurance program. Everyone wishes they could have Morton at Sizzler prices but that isn’t a national emergency. Our politicians should have stayed out of it and allowed the market to work. If at some point access to Partners became more expensive then people were willing to pay they would have chose the HP plan and the market would have performed exactly as it was suppose to.
    I still have groups that I can guarantee savings to while offering the exact same benefits that pass. That’s not a flaw in our system it’s poor or elective buying decisions.
    3. Codify usery billing. Treat all hospitals as non contracted and reimburse 125% of their cost. If they try to balance bill patients 400% markup then declare it usery like they do with bank interest rates. I don’t like doing it this way but it would be very easy to accomplish by saying any hospital receiving federal funds can’t bill more then 125% of their cost.
    I would envision the result to be very basic low cost care with the selling of perks at additional cost, like private rooms for example.
    4. Allow annual and lifetime caps, makinmg it a law that hospitals can try as much experiemental and excessive care as they want and insurance has to pay for it alone will drive up rates 10-20%. 5 million dollar claims are going to become as common as 1 million dollar claims when lifetime limits where increased in the 90s. The size of claims directly tracks to the maximum allowed benefit, does anyone want to argue what we have recieved for the additional $4,000,000? While we have tried to do more have we really improved outcomes commensorate with cost?
    5. Define what is reasonable care knowing a very small percentage of people might die when spending millions might have saved them. mortyality is real and life does have a cost, we need to admit it and peg it.
    Thats all for now, I would type more but I need to go fight with a hospital over a $318,000 back surgery bill that should have only cost $100,000.

  14. Nate;
    The issue with Partners (I assume you know they are Mass General + Brigham and Womens’) is that they ARE
    ” a company run[‘s] efficently to make a profit and compete I understand that, I can see the goal and the outcome.”
    All agree that they have executed that business model very well – by buying up suburban hospitals and arm-twisting the insurance companies into 2x larger reimbursements for the same care due to their market share. (No one knows if their care quality is higher, lower or the same as others, b/c they don’t release any data.At least your Cleveland Clinic does that)
    They also admitted themselves that they “have a cost problem” – e.g. their costs are higher b/c they don’t have to worry about costs, when their income is so high. In addition they have apparently highjacked the local politics so as to be basically untouchable.
    So while they are succeeding very well as a business, our taxes are indirectly helping to pay their exorbitant rates because no one else can compete with them to drive their costs and prices down. How will your free market principles deal with that? (I really want to know; not just being sarcastic.)
    The feds are investigating them for anti trust but we know how that often works. Whaddya bet they’re negotiating their way out of it as we speak.

  15. Nate,
    There are a few complicating factors regarding Partners and their market power. First, the vast majority of people with employer provided health insurance in Massachusetts very much want Partners in the insurance network so the employees can have access to MGH and The Brigham. Harvard Pilgrim actually offered a lower cost insurance plan that specifically excluded Partners and it just didn’t get much traction in the local marketplace.
    I would like to see disclosure of health outcomes including infection rates and risk adjusted surgical outcomes as well as contract insurance reimbursement rates. I know that some insurers fear that this could raise costs as providers who are paid less clamor for higher rates while those who are paid more won’t willingly accept any reduction. Sometimes we need to take some risks to move forward, however.
    As I’ve said many times before, I’m also a big fan of tiering. If people want to use Partners or other expensive providers for routine care that others can handle just as well but at a much lower cost, let the members pay a significantly higher co-pay for the privilege, or at least enough more to get their attention. Another complicating factor in the Massachusetts market, as I understand it, is that Partners won’t sign contracts that call for higher in network co-pays at their facilities.
    There is a clear need, in my opinion, for regulators to step in and forbid Partners and all other providers from interfering with insurers who want to require differential co-pays among in network providers and also to mandate disclosure of contract insurance reimbursement rates. I’ve heard one theory that the labor unions use their clout with the state legislature to oppose these initiatives because they fear that the ultimate result will be more restrictive health insurance benefits than they have now.
    All in all, it’s a complicated issue with a lot of moving parts. What frustrates me is the selfishness of every interest group from consumers to doctors and hospitals to insurers, drug and device manufacturers and trial lawyers. Everyone wants to solve the problem at someone else’s expense. It won’t work.

  16. its all about motives. When a company run’s efficently to make a profit and compete I understand that, I can see the goal and the outcome. When a company is ran to do good you lose that. Its to squishy and opaque.
    I realize not everything in life can be measured and completly understood, in those cases I like it to be isolated and minimized.
    ” Think of Partners as the example of the status quo. How can incentives be constructed to make them behave more like BIDMC, for instance?”
    Kick them out of the network. Problem solved overnight. But 100% off the table and not even an option becuase it is ran for politics not business. The only effective solution is elimination. If they rob you under normal medical why do we think they wont be dishonest under incentives?

  17. Barry;
    A cogent analysis as usual. However, I think the rigorous systemization of health care delivery can and will reduce costs on all fronts, and fortunately this is Berwick’s area of strength. The difficulty is getting buy-in from providers other than a few of the converted such as Intermountain, Virginia Mason and Beth Israel Deaconess. Think of Partners as the example of the status quo. How can incentives be constructed to make them behave more like BIDMC, for instance? Forcing them to make their quality indicators public (which might surprise a lot of patients) compared to their prices would be a good first step.
    Although I believe reform of fee for service reimbursement by Medicare by bundling (essentially DRG’s for all) is also necessary, this is a political sticky wicket. If I were Berwick I would go for my first paragraph right out of the gate. My big fear is that the government’s own “system” will drag him down…..

  18. The federal government will have every bit as much difficulty moving Medicare towards becoming a more accountable business as it has in its efforts to privatize Social Security.
    Unfortunately, I’m becoming more and more convinced that like the future of Social Security, those of us who remain years away from realizing Medicare “benefits” will need to start planning to pay much more for our retirement health care needs just as we’re already doing for our retirement incomes.
    It’s all about numbers, and as the proportion of those collecting benefits rises relative to those who are of working age to pay into the Medicare trust fund pool, something has to give financially.
    Dr. Berwick is smart enough to realize this and has enough of an established reputation in the health care field not to be overly distracted by politicians or public opinion polls. His challenge is to begin to change Medicare to a model which is sustainable, e.g., not a source of unlimited health care funding and benefit, but a solid sustainable foundation of basic senior health care coverage.
    A government run health care system such as Medicare may not be cutting edge, but I’m at least hopeful that it can be fair in its dealings with providers and seniors while not giving away the store.

  19. I actually don’t think the postal office is a good example because, unlike Medicare, the post office delivers actual services. This is more like the NHS. Medicare does only collections (not even) and pays for services rendered by private businesses. I wouldn’t want Medicare to deliver care.
    I do agree that health care cost per service is the problem, but being the largest purchaser of such services, Medicare is in a unique position to influence supplier prices. Personally, I think that while some prices should go up significantly, others can be comfortably driven down. Couple this with fraud reduction, administrative simplifications and changes in care management, which is probably where Dr. Berwick comes in, and I think “fixing” medicare is very doable.
    Nate, I don’t know why my suggestion terrifies you. I was not suggesting privatization of Medicare. Just a change in governance structure to make it look and run more like a “real” business (constantly manage costs down, reduce payroll, live within your budget, be creative, innovate, attract bright young employees, stuff like that…). I thought the notion would appeal to you.

  20. your hypothetical organization would scare mer to death margalit. Every company must be accountable, what you describe would be accountable to no one. It reminds me of “movements” Supposedly nobel endeanvers meant to help that almost always do nothing but harm. If your idea was to pass I see Al Gore dumping AGW now that he made his fortune, and starting a healthcare company. Following him would be google promising to do no harm.
    The post office was a great example. Another would be network solutions and the monoply they had on internet registrations as they guarded the collective good.
    I believe this is why Obama failed and so will Berwick. It’s very easy when you have never worked in business and never had that level of responsibility to think you can imagine something and implement it without problems. What sounds good on paper and makes all the sense in the world seldom translates to reality.
    My sister was an officer in the Army and occasionally helps out in my business. I remember more then once her getting completly perplexed wondering why I don’t tell my clients to all do something a set way so our job wouldn’t be so time consuming. She just didn’t grasp that in the private world orders usually go ignored.

  21. “Nate, by “social business” I mean “a non-loss, non-dividend company designed to address a social objective.”
    Margalit – I think the U.S. Postal Service fits this criteria. From 1936 to 1958, the cost to mail a letter first class was three cents. It’s currently $0.44 and will increase to $0.46 on Jan. 2, 2011. When the USPS was weaned off federal subsidies and instructed to cover its costs from postal revenue alone starting in 1970, the first class mail rate was raised from $0.06 to $0.08. While it has competition from United Parcel Service and Federal Express in package delivery and priority mail, it has always had a monopoly on first class mail. Over the last 40 years, first class mail rates increased roughly in line with the Consumer Price Index (CPI) despite no need to pay dividends or stock options and with no very highly paid executives. Now, the combination of the recession, e-mail and electronic payments are driving first class mail volume down sharply and the USPS is projected to lose $7 billion this year alone.
    In healthcare, some 85% of U.S. hospital beds are controlled by non-profit entities. Yet, hospital costs are the fastest rising segment of healthcare costs, especially in markets where the hospital(s) have significant local or regional market power. While they have to charge enough to cover their costs in order to stay in business, the absence of the need to pay dividends or $10 million plus pay and stock option compensation packages to CEO’s doesn’t seem to have helped them on the cost front.
    As for Medicare waste, the definition is in the eye of the beholder. Since most hospitals already claim that Medicare payment rates don’t fully cover their costs, especially for outpatient services, I don’t see how Medicare can significantly reduce costs without reducing utilization of healthcare services and, to some extent, combating fraud. Aside from fraud mitigation, the only other ways I can see to reduce utilization are tort reform to reduce defensive medicine and a more sensible approach to end of life care including strongly encouraging every beneficiary to execute a living will or advance directive and to change the default protocol in the absence of a living will to either apply common sense depending on circumstances or no heroics from the current default of “do everything” because we’re worried that we will be sued if we don’t. We might also, like the UK, ultimately need to refuse to pay for new cancer drugs and other medical treatments that simply cost too much relative to the life extending benefit they are likely to provide or relative to the cost of existing treatments that can accomplish the same objective.
    I don’t think getting rid of waterfalls in hospitals will save any money to speak of and even if the two dozen most senior executives of every insurance company all worked for free and the savings were used to reduce health insurance premiums, the reduction would be little more than a tiny fraction of 1% — a rounding error. Insurance premiums and Medicare costs are high and rising because healthcare costs are high and rising faster than overall inflation. It’s about as simple as that.

  22. Nate, by “social business” I mean “a non-loss, non-dividend company designed to address a social objective. The profits are used to expand the company’s reach and improve the product/service”. This is not some sort of loosely defined social club or charity. It is a capitalist business just like any other, only its prime directive is to solve a social problem, not to make money, and its primary and only concern is those it serves. Obviously, since it must be self sustainable just like any other non-government business, it must also be lean and mean. Medicare is anything but. We all keep saying that there is plenty of fat and inefficiency to squeeze out, so you will need some really savvy business folks to accomplish that, AND keep the customers happy. I don’t think it’s impossible considering the power Medicare and Medicaid have on every financial aspect of the delivery system.
    Dr. Berwick is great for being the visionary leader, but he will need a team of extremely talented business folks to execute on that vision, and finding them (not that anybody is even looking) will be very hard.

  23. ” So, I would say that your typical insurance CEO is ill equipped to run a social business, which Medicare most certainly is, or should be.”
    Should the social and commodity aspects be combined though? This is one of governments faviorte ways to make messes. For example, using the tax code to incentivise people to buy homes and have kids. Using college loans to get people to go to college that would be better served by trade school. Reinsurance, life insurance, auto insurance, are all commodities. We should be looking to deliver insurance as lean and efficient as possible. That does not mix with social agendas.
    Medicare’s social endeavers should be spun off and ran by someone with experience running social clubs, i.e. those that have ran medicare since 1965.
    “Nate, the private insurance industry has been making “ends meet” by raising rates 6%-10% compounded yearly while not having to address system costs or system quality – at least in favor of premium payers.”
    Peter when the federal government says you must now insure these sick dependents to age 26 becuase we can’t afford to pay for them under Medicaid what exactly do you want private insurance to do? When the government shifts the cost of those over 65 and working? When Medicaid underpays and shift cost? When the government taxes you and forces you to set up money losing HIPAA plans and large risk pools. Your ignoring the cause to prop up your narritive.
    “Tell me which private insurer has well paid/paying lobbyists able to pressure it’s executives (who don’t run for elected office) into constantly changing it’s business model so that no one is unhappy.”
    Peter your not even trying to think before you type. They are called politicians and there are 1000s of them and they are many times more powerful then any lobbyist becuase they don’t need to convience you they can force you to change.
    Don’t like PPOs get any willing provider law.
    Want to lie on your app without fear of recission get no recission law.
    Want someone else to pay for your experimental treatment with 5% chance of success get mandatory coverage requirements.
    Which private insurer Peter? EVERY SINGLE ONE OF THEM!

  24. “A leader with actual experience would know eventually your ends must meet…”
    Nate, the private insurance industry has been making “ends meet” by raising rates 6%-10% compounded yearly while not having to address system costs or system quality – at least in favor of premium payers. Try that with Medicare, hell try that with Social Security which is a much easier fix. Every time Medicare attempts to “make ends meet” political pressure is brought on it because getting costs under control steps on well lobbied toe$. Tell me which private insurer has well paid/paying lobbyists able to pressure it’s executives (who don’t run for elected office) into constantly changing it’s business model so that no one is unhappy.

  25. WHAT IS A ‘SOCIAL BUSINESS?’
    Bottomless pit of TAXES?
    TAXPAYERS who do NOT complain?
    Hospital unions who do NOT go on strike?
    MDs who VOLUNTARILY take wage CUTS/FREEZES?
    The unlimited DEMANDS of EVERYONE in the world are satisfied?
    Fabian Socialism or Utopian Socialism?
    ROTFLOL at the naive INCOMPETENCE and BLUNDERING of OWE-bama, Pelosi, Reid, et. al. They’ve made Jimmy Carter (D) look competent.
    When you ROB from Peter to pay Paul — you get Paul’s vote. But Peter will get you, eventually. Count on it.

  26. “Medicare must be ran like a business”
    Nate, I would agree with this statement if you would qualify the type of business. Unlike Anthem, or any other payer (profit or non-profit makes little difference), Medicare cannot be run to maximize profits and cannot be managed by industry standard tools, i.e. increase premiums, cut benefits and keep the sick ones out. So, I would say that your typical insurance CEO is ill equipped to run a social business, which Medicare most certainly is, or should be.

  27. GREECE
    The Greek government had to turn over its crappy state-owned enterprises to its lenders — the Chinese Communist Party.
    The ChiComs (S) are firing the deadwood (D/S). Now, the Greek Communist Party (S) is protesting.
    I can’t make this stuff up.
    LOL at the total incompetence of Owe-bama (D). What a huge mess he’s created.

  28. WRONG
    ” .. While the democrats could be wrong on the health care reform approach,I know what kind of a health care plan I will have with the republicans-none ..”
    Anyone with a brain (non-Democrats) knows that Newt wanted to work a deal with Slick Willie (D) to fix health care.
    Then Slick (D) met Monica (D). That’s on Slick (D). No one else.
    You think the Dopey-crats (D) are the solution? Be my guest — I’ll retire, strand hundreds of contractors, and let OWE-bama pay my bills. Just like Greece (D). How about them apples?

  29. A thought to discuss…
    Should CMS be broken up? Is the financial delivery of healthcare similar enough to the study of care and everything else they do that one organization and one person should do it all?
    I’ll revert to what I know, one of the reasons self funding works so well is fragmentation. You can go0 out there and pick the best claims payor and pair them with the best PPO, then hire the best care managers and review firms. You can buy bundeled packages but they are usually a convienance not a supperior product.
    Should we seperate the study from the delivery? Get industry experts to manage the bulk of the plan and allow the academics to do pilot projects and studies on portions of the population.

  30. Peter, Lets take Anthem for example, why are their customers, many seniors and business owners, any different then seniors and their demands. Anthem also has provider issues just like Medicare. Something private insurance does have the medicare does not is accountability. Anthem can’t go 30 trillion in the negative and stay in business.
    A leader with actual experience would know eventually your ends must meet, you might be able to lose money for a year or two but you can’t have unfunded liabilities a large multiple of your annual revenue. Medicare is a financial failure, it delivers care fine. Governments are not known for their financial prowless.
    Medicare must be ran like a business, it can not become a financial blackhole or it will take the entire economy with it.

  31. I’m not an oil company executive,a defense contractor,a billionaire or multi-millionaire. I used to rely on an hourly wage. Now,I can’t find a job. The economic mess is not the fault of the current administration. It is the aftershock of the Bush administration. While the democrats could be wrong on the health care reform approach,I know what kind of a health care plan I will have with the republicans-none. Maybe,I’ll get lucky and land a position at the local WalMart for minimum wage. If the republicans get their way, that minimum wage will be greatly reduced.

  32. TWEEDLE-DEE, TWEEDLE-DUM
    As for his “appointment” we all know that Democrats do not have the nation’s interest in mind, just their own political future – so I don’t care if he got a recess appointment as any hearings would just be a stage for Democrat responsibility-avoidance.
    More than $3,600,000,000,000.00 borrowed in 18 months. Thanks, in great part, to Bwarney Fwrank’s (D) undying support for his good-buddies at Fannie/Freddie and the CRA (D).
    We all know the Democrats are killing the USA economically. The USA is on the edge of becoming as mediocre as Europe.

  33. I imagine an insurance industry executive with years of “hands-on” experience could run CMS – as a purely insurance business model, but CMS is not purely an insurance modeled business. Given the attitude of seniors for getting all they want when they want it for free, and with providers wanting all they can get with no oversight, CMS is largely a political behemoth that will take years to turn around. I give Don Berwick great credit for even wanting it. As for his “appointment” we all know that Republicans do not have the nation’s interest in mind, just their own political future – so I don’t care if he got a recess appointment as any hearings would just be a stage for Republican obstructionism.

  34. Nate-i concur with you-the experts in health care are a failure-they have engaged in self maximizing behavior to the detriment of society

  35. 18 MONTHS
    Naive theorists like Berwick (like OWE-bama) are chewed-up and spit-out in D.C. quickly. They speak the truth (‘this is a mess’), which angers fools like Bwarney Fwrank. A death-spiral begins.
    Eighteen months, tops. Having annoyed the Senate, he’ll never get a confirmation hearing for a permanent appointment, during one-term OWE-bama’s last few months in office.
    We have a 45 year history of CMS being ran by academics and people without real world experience, what about Berwick makes him any different?

  36. It’s hard to imagine a better leader for CMS in these troubled times. I don’t really like the recess appointment approach, but avoiding the political circus of a confirmation hearing seems like mercy on anyone who actually cares about the health care system. I’m keen to see if Berwick can start steering the battleship or if it is already too late.

  37. seems everyone agrees Medicare is a mess, who exactly do you blame for it? Berwick is another political appointee just like all the rest. We have a 45 year history of CMS being ran by academics and people without real world experience, what about Berwick makes him any different? Besides the fact he is new.

  38. Dr Wachter- your too into the old fashioned beliefs that experts are angels and will save the day. Patient safety, health care quality and even concern about people with pain is poor. Experts are in charge of our health care industry- and hence it is clear to see experts have failed to adequately sevre the public good with regard to health care. Perhaps the answer lies in not holding the views of experts in high regard as you seem to do-but to see beyond the feudal spell of expertise to having a more genuine committment to our follow man. As the Bible says- knowledge puffeth up -and we dont need another puffed expert imposing his will on the public in the name of some abstraction

  39. Deeds not words are what define us. Transparency, that word just gets looser each time it is applied, eh? Well, if you are going to run a political campaign for President of the USA and repeated state you will be more transparent and responsible than your predecessor, and then pull the same lame inexcusable stunts said predecessor did, What does that say about you the successor? You are up to being as lame and inexcusable as who you insult!
    I am from the school of George Carlin, and in the end, it is not the politicians who suck alone, but the equally down to the task public citizens for cultivating and breeding these idiots who claim to represent us in office.
    And it is that our elected officials do not represent us, but only resent us by having to put on the dog and pony show of elections to convince us to let them stay and screw us further. And you read the commentary here and see why these said officials stay in place. Illuminating and pathetic at the same moment. I agree with Carlin though at the end, he did not vote because (1) it is meaningless as the system is bought and sold, garbage in and garbage out, and (2) he did not vote so he could complain, as those who voted and put in these irresponsible, incompetent, and selfish idiots should get the wrath from those of us who knew better than to participate in these November charades.
    Wow, what an opportunity come November, return the equally incompetent idiots who did so much damage from 2000-2006. Republocrats. Well, enjoy what you champion for, people. Obama is as failed a leader as was Bush. And you, the public, have only yourselves to look in the mirror to point the fingers of blame when that moment of clarity finally hits you.
    Hopefully in the middle of your temples!!!

  40. The administration let itself get blindsided with Daschle, and as a result played from behind on health policy. Still passage of the reform bill was a major achievment, with an inevitable price. Any frustration with the healthcare system now becomes an opposition talking point – and its easy to be a critic, hard to be a reformer when the system is truely broken.
    The misfortune is it took so long to get someone of Don Berwick’s potential in place at the helm of the operations arm of healthcare policy. Now, how the team performs determines whether we are playing the second quarter or the second half!

  41. Alas, even after a high school marching band career, I still don’t really get football (I’d just cheer when everyone else did). Regardless, I like your analogy Margalit. Now I’ll just have to reserach the terms to fully understand your and bev’s discussion. 😉
    And thank you for the compliment, Maggie, I appreciate your thorough responce. I agree with your statement that most people won’t care; in fact, I’m sure the majority of Americans aren’t even aware this recess appointment has occured or will remember it come November, any more than they’re aware of the many other presidents who’ve used this privilege (dating back to good ol’ Washington). In some ways it gets back to the tree falling in the woods paradigm: if no one’s there, doesn’t it still make a sound?
    I’m reasonably confident that no matter what is done between now and Nov, certain members of the population and in Congress would not have changed their minds. That’s a given regardless of who’s in charge. But for me, personally, the difference in the fallout from a confirmation hearing and the fallout that will surround this appointment is that in the latter case, the moral high ground is given up. I also wonder how combative Congress may be toward Dr. Berwick and his staff when they first appear before them in the course of their duties, especially after the dust of this year’s election settles.
    To fall back on my favorite analogy (scifi), the whole situation reminds of Babylon 5’s Season 4 finale, when Captain Sheridan is dealing with the aftermath of his successful revolt of a repressive regime: even though he’s now a hero for freeing his home world, his command is stripped because of disobeying his military orders and fellow officers. As the interim president informs him, “You probably did the right thing, but you did it in the wrong way, in the inconvenient way. Now we have to pay the penalty for that.”
    I appreciate that you may disagree with that statement, and respect that. I could be quite wrong; time will have to pass before we can accurately judge the event. Meanwhile, I look forward to the leadership Dr. Berwick will give CMS at a very crucial moment in its history. My prayers are with him.

  42. Margalit;
    At last – another woman who thinks in football analogies! I love it! (me, too!) (:
    The ironic part of your analogy is how often the flag is thrown for illegal blocks in the back on returns. Some of them are real; some not.

  43. obama is really leading usa and his decisions are correct. one of his decision was not to kill Muslims. so, don’t make ware with them. i strongly support that.

  44. Shall we just call a spade a spade?
    The President did what he had to do and blocked the inevitable tackle, and no it was not a block in the back. It is perfectly legal and it is enjoyable if you are on the scoring team. Much less so, if you are rooting for the opponent.
    Same thing with arguments for/against the “nuclear option”, if you recall. The righteous argument always comes from the loosing team. Unfortunately that’s how politics works and it worked like this 200 years ago too.
    Fortunately, no team wins forever and odds are pretty even on any given Sunday. Next game is in November and the next big one is only 2 years away. Good luck everybody and may the best party win!
    To paraphrase a great President from long ago, when things were probably as bad as they are today, we are all republicans–we are all democrats. Just another day at the office… in Washington, DC.

  45. The head of the Central Committee for Medical Services is a political head. Berwick will fail in this role. But I am glad he is on board. The sooner the train leaves the station the sooner we have the train wreck.

  46. To me it should be non-partisan. It should be about helping the most people possible. Sadly, this just isn’t the case these days. As to what the solution is, I’m not sure. I know there are some countries (smaller) that are doing okay. We need to do something.

  47. Bob W, bev M.D. and Michelle W.
    Let me echo Bev M.D.’s thank you.
    I’d add that Michelle W’s comment is well worth reading even though ultimately, I don’t agree. She got the thread off to a good start–I hope others follow her lead.
    Michaelle W.–
    I understand your concerns.
    You write: “I’m still not sure this decision was the best one to follow, if only because it offers free fuel to the opposition to make accusations this fall. Wouldn’t it have been better to at least schedule the hearings, or let the Finance Committee finish their vetting, before deciding to bypass the process (as there’s another oppotunity to make a recess appointment during the Labor Day break)?”
    The problem is that the confrimation hearings also would have offered free fuel to the opposition who would have made headlines quoting Berwick out of context, putting “death panels,” “rationing” etc. back in the headlines.
    Most Americans are not going to get terribly upset that the president made a “recess appointment.” Most don’t know what the phrase means–they’re just not interested in that level of technical detail about how things work in Washington. But they would be upset by weeks of headlines telling them that Berwick wants to cut Medicare benefits, and let govt’ “bureaucrats” ration care.
    And most of the people who are very angry about a recess appointment already hate the president and the administration.
    As for waiting until Labor Day– that means losing two full months. Berwick and Medicare face an enormous task: lifting the quality of Medicare while reducing costs. Medicare is charged with paving the way for healthcare reform. I think Berwick and CMS can do this. But time is of the essence. Two months is just too much time to waste.
    And the whole debate over reform legislation demonstrated that no matter how how hard the administration tries, the hard-line conservatives are just not interested in listening . . .
    Finally, the reason to point to Bush’s use of recess appointments is not to justify Obama’s action by saying “Bush did it too!” but rather to point out that this is perfectly legal, something that that presidents often do when concerned that partisan politics are going to slow important appointments.
    In terms of transparency, after naming Berwick as teh president’s nominee, the administration gave the public and the media nearly 3 months to investigate anything that people should know about Berwick. He has been a very public figure for many years–speaking candidly, writing voluminously.
    He wasn’t rushed into office under cover of night.
    That said, yes, conservatives will use this as ammunition. But,by and large, they already have made up their minds and the people who will believe them also have made up their minds. Their followers are not terribly open-minded.
    I think the November elections will come down to this:
    Has Washington begun to create jobs? And, who comes out to vote? Will Democrats manage to bring out the voters who elected Obama? On the margin, many of the voters who tipped the scale were new voters. The Democrats need to bring them out–along with their relatives and friends–again.

  48. Heck, Clinton did it too.
    How can we know if the Obama administration’s policies are any good if his managers don’t get out the door?
    What kind of leadership doesn’t make use of the tools and tricks at their disposal to get their guys out there leading this important organization?
    The President is in charge and I for one am happy that he took some action and got his show on the road.

  49. I know Dr. Wachter is smart enough not to read comments on his own posts on this blog – however, I would like to say, thank you.

  50. Let me see if I have it:
    CMS has “extraordinary new powers”. But the first leader with these new powers is appointed during recess, to avoid those mean Republicans. But he’s “nimble”. But they don’t play fair, so it’s ok to just skip the hearings.
    (I assume when the Republicans gleefully follow this precedent, the Left will go back to being grieved about the death of the republic.)
    ((By the way, yesterday we told you that the Republicans were holding the nomination, to “defer” the confirmation as long as possible. Uh, forget that. It’s no longer operative.))
    But back to Berwick! He’s so smart he would have made them look stupid! But he needs to get busy “facilitating new levels of transparency”! Skip the hearings and get right to the transparency!

  51. WaPo LIBERALS LAUGH @ BERWICK APPOINTMENT
    http://bit.ly/9S3e5J
    As a matter of politics, the president’s choice of Berwick was, well, the polite word would be bold. The less polite word: boneheaded. Administration officials argue that Republicans would have seized on any nominee as an opportunity to re-litigate the health-care debate. But Berwick offered opponents a loaded gun with his talk about rationing, his discussion of health reform as a matter of redistributing wealth, and his effusive praise for the British system. If the president wanted to buy a fight like this, he ought to have been better prepared to wage it.
    Yeah, yeah — Bush’s fault. Racism. Sexism. Got it, the first goog-illion times.
    Nov. 2 — a reckoning, for reckless, incompetent acts. Can’t wait.

  52. Exactly how long was it that Republicans held this confirmation up before Obama was forced to resort to recess appointment? Ah that’s right it ever even got that far. Republicans don’t even need to oppose someone, just the thougth they might is now enough to justify such appointments.
    His lack of experience running anything of meaningful size will doom him just like it has Obama. Text books just don’t prepare you for the reality of running a business or nation.

  53. I’ve tried to wear my best nonpartisan, look-at-all-sides hat on this one, and I’m very torn. I totally understand the desire by President Obama to avoid a backyard brawl, and unfortunately the Republicans have certainly been quite vocal in their plans for this confirmation hearing. I make no defense for the minority party in this matter, as their plans are a matter of public record.
    But even though I too am glad CMS has such a qualified leader after a four year drought, I’m still not sure this decision was the best one to follow, if only because it offers free fuel to the opposition to make accusations this fall. Wouldn’t it have been better to at least schedule the hearings, or let the Finance Committee finish their vetting, before deciding to bypass the process (as there’s another oppotunity to make a recess appointment during the Labor Day break)?
    Also, while I fully understand that President Bush and the GOP were certainly eager to use this perogative during the past eight years, I’m a bit confused by the desire to justify an Obama action with the Bush record: that seems a double-edged sword at best, and at worst a sound bite for this fall’s election.

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