The Fall of Berwick?

When President Obama named Dr. Donald Berwick to head the Centers for Medicare and Medicaid (CMS) last March, I wrote this:

“Most who know Berwick describe him a ‘visionary’ and a ‘healer,’ a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.”

To understand what I meant, view these clips from the film, Money-Driven Medicine, where Berwick speaks about the need for healthcare reform. Soft-spoken and charismatic, Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.

And now, it appears that we are going to lose him. Thursday, 42 Senators delivered a letter to President Obama demanding that he withdraw his support for Berwick to head CMS. The Boston pediatrician and co-founder of the Institute for Health Care Improvement (IHI) had received a temporary appointment in July while Congress was on vacation. President Obama re-nominated him in January. But Berwick still needs to be confirmed by the Senate, or he will have to leave his post at the end of this year.

With 42 out of 100 Senators firmly opposed to him, it appears that Berwick’s supporters won’t be able to muster the 60 votes needed to clear the Senate floor. Reportedly, Senate liberals already have given up. According to Politico.com’s Brett Coughlin: “At a meeting with Senate staffers Friday, health care lobbyists and advocates were told that there will be no confirmation hearing and that they’ll soon be discussing ‘next steps’ for CMS.”    If this is true, Berwick is now a lame-duck CMS director without power—as of today.

“Finance Committee Chairman Max Baucus has been mostly silent about the issue,” Coughlin added, “but he told Politico on Thursday that Berwick is Obama’s nominee and ‘it’s his choice.’” Assuming that Berwick is ousted, Congress will have succeeded in ripping the heart out of health care reform. Can it be replaced? I don’t know. I cannot think of a truly qualified candidate who would take the job.

By “qualified” I mean someone who possesses the knowledge of what needs to be done, the integrity and strength of character to battle the opposition, and the patience, compassion and powers of persuasion to overcome the vitriolic politics of hate that have taken over our government. I am not suggesting that no one could replace Berwick, just that I have a hard time imagining someone in Berwick’s league who would choose to go to Washington, knowing that he will become the conservative’s punching bag.

Today, The New York Times suggested that “Dr. Berwick’s principal deputy, Marilyn B. Tavenner, has emerged as a candidate to succeed him. Lawmakers of both parties said Monday that Ms. Tavenner, a former Virginia secretary of health and human resources with extensive management experience, could probably be confirmed.” While Tavenner is an excellent deputy, she does not possess the strength to quarterback health care reform. This is why conservatives might vote for her. (Never a fan of Berwick, the Times has consistently failed to understand who he is, or the role he would play in health care reform.)

Regular readers know that I am not quick to give up. I was convinced that the Patient Protection and Affordable Care Act would pass. I predicted that Berwick would be appointed, even when things were looking dicey. When you’re fighting a revolution, pessimism is not productive. Cynicism is fatal.

Yet, here is the truth:  Without a powerful, persuasive leader, Medicare will go broke in a matter of years. And if Medicare does not lead the way in breaking the curve of health care inflation, we can forget about affordable health care for everyone. Indeed, we can give up any hope of affordable health care for the middle class and much of the upper-middle class.

But first, is there any way that Berwick can hang on? Today, Reid Cherlin, a White House spokesman, told the New York Times that the president would not withdraw the nomination. “The president nominated Don Berwick because he’s far and away the best person for the job, and he’s already doing stellar work at C.M.S.”  But, the Times added, “It is not clear whether the White House will fight for the nomination or press the Finance Committee to hold a confirmation hearing, which could provide Republicans another opportunity to criticize the new health law.”

Is there a chance that the administration might be able to rescue Berwick by persuading two honest Republicans to break with a lynch mob led by U.S. Senators Orrin Hatch (R-Utah), Ranking Member of the Senate Finance Committee, and Mike Enzi (R-Wyo), Ranking Member of the Senate Health, Education, Labor and Pensions Committee?

After all, five Republicans refused to join the attack on Berwick: Senator Scott Brown, (who supposedly was elected from Massachusetts because of his opposition to the health care law), Maine’s Olympia Snowe and Susan Collins, and Republicans Lisa Murkowski of Alaska and Rob Portman of Ohio all declined to sign the letter. (For a list of those who signed, see the end of this post.)

Could the White House Save Berwick?  “You Know You Can’t Quote Me”

Yesterday, I talked to someone from the administration’s inner circle who knows Berwick and the opposition very well.  When I asked these questions, he laughed (not a happy laugh), and replied:  “You know you can’t quote me.”

This is what he went on to say:

“I don’t think he’s going to stay. The Congressional conservatives think they got screwed in the sense that he was a ‘recess appointment’ and they didn’t have a chance to vote on him. . . . I think the administration doesn’t want it to look as if they are abandoning him, but  . . .”  If Berwick’s backers in the Senate don’t have 60 votes, the White House may not have a choice.

As for my hope that President Obama could talk just two senators into splitting from the Gang of 42, my source—who knows beltway.gang politics far better than I—replied:

“What you don’t realize is that the retribution these guys exact is very high— especially against their own.” Far-right conservatives rely on fear as their weapon of choice—whether striking terror in the hearts of seniors or disciplining their own party members. “Look at Olympia Snowe and the health care bill,” said my source. “She voted for it in committee, but they brought all hell down on her to make sure she voted against it on the floor.”  (Given that experience, it is to Snowe’s great credit that she refused to sign the letter.  At the risk of appearing prejudiced in favor of my gender, I cannot help but note that three of the five who broke ranks with 42 of their colleagues were women. Maybe we need more women in the Senate?)

The law does provide one loophole that might let Berwick remain at CMS. “In reality, Berwick can stay on as acting administrator if he was once again a recess appointee — he just could not be paid for the position, thanks to a 2009 Omnibus Appropriations law,” points out Benjamin Domenech at “Don Berwick Online: Tracking the Controversy.”

But would an unpaid recess appointee have the power to do the job at the Centers for Medicare and Medicaid (CMS).  “He wouldn’t have any authority,” my source said flatly. “They’d skewer him.”

“The most worrisome part” of all of this, he continued, “is that we’re going have serious problems implementing reform through the Centers for Medicare and Medicaid. It’s a bureaucracy that doesn’t like big bold leaps. Housed in Baltimore, it’s not an innovative place. It is very, very cautious. And if you look at things that need to be done, they need to be bold.” This is why I very much doubt that Tavenner would be able to do the job that needs to be done.

The Back Story: Why Conservatives Want to Oust Berwick

When President Obama first put Berwick’s name forward shortly after passage of the Affordable Care Act last spring, conservatives were bitter over the passage of   reform legislation, and they poured their fury into blocking the appointment—postponing Berwick’s confirmation hearing, while simultaneously spreading lies about him. (For examples of how both conservatives and the media have cherry-picked what Berwick has said and written, grossly distorting his views, see this post.)

As I wrote at the time, Berwick was highly respected by virtually everyone who knew him—including Republicans:

“He 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.’” (For a profile of Berwick, see this post.)

As I noted, the American Association of Family Physicians, the American Medical Association, and the American Hospital Association” also offered warm endorsements. . . .  But I added, “The 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.” This is precisely what they did.

A hearing would have turned into a Kangaroo Court. Meanwhile, Medicare needed to begin the work of reform as quickly as possible. . President Obama had little choice but to do an end-run around Berwick’s opponents by making a temporary appointment in July while Congress was on vacation. Presumably the hope was that by 2011, the opposition’s anger over the passage of health care reform would have faded. But hell hath no fury like that of right wing extremists scorned. They believe that they represent what is Right and True, and thus, should always win.

Now, Senator Enzin, one of the leaders of the group that  sent a letter to President Obama last week, has  made it clear that they will not even consider Berwick as a nominee. In the past, skeptics claimed that they simply wanted Berwick to answer their questions. But at this point, they say that they will only entertain a candidate who agrees to “compromise” with them: “The President should start with a clean slate and send the Senate a nominee who is willing to answer our questions and seek our bipartisan support as he or she leads CMS in implementing the new health care law.”

Translation: President Obama should send us someone willing to reform Medicare Our Way.

Why Medicare Reform is Essential to Health Care Reform

The consensus among healthcare reformers is that one-third of Medicare dollars are squandered on procedures and products that provide little or no benefit for the  patient.  In our hospitals, preventable medical errors and accidents add to the waste.  And it doesn’t matter whether Medicare or a private insurers is paying the bills:  health care spending in the private sector is no more efficient. The cost of care has been spiraling at roughly the same rate, both in the public sector and in the private sector for the past twenty years. Medicare desperately needs to change how it pays for care and what it pays for. If CMS takes the lead, and provides political cover, private sector insurers have said that they will follow. This is the only way that we, as a nation, can hope to make health care affordable.

Government now covers well over 50 percent of all doctors’ bills, hospital charges, prescription drugs and other health care expenses in this country. As a result, only the Centers for Medicare and Medicaid (CMS) enjoy the market clout to insist on value for our health care dollars. Even the largest private insurer does not possess comparable power.

No hospital could stay open without Medicare patients. No drug company could turn a profit without reimbursements from CMS. A relatively small number of doctors might be able to refuse Medicare and thrive by offering concierge medicine to  affluent younger patients.  But what would happen when their patients needed to be admitted to the hospital?

Without reform, a concierge doctor’s patients would be exposed to the same high rates of errors, infections and accidents that threaten all hospital patients today. As one specialist who cares for the very wealthy (and does not accept insurance), said to me not too long ago: “It doesn’t matter who you are—or how much money you have—you don’t want to be in any of Manhattan’s hospitals.”

Nevertheless, conservatives are dead set against reining in health care inflation by excising waste and errors from our health care system because that would mean cutting into the incomes of the many industry lobbyists who feed at the trough of over-treatment. They argue that “more care is always better care. We can’t spend too much on health care. If we trim spending, we’ll stifle innovation.”

Rather than cutting Medicare spending, conservatives would prefer to shift the cost of Medicare to seniors, raising their co-pays and deductibles, while continuing to over-pay for diagnostic tests,  surgeries and treatments that put patients at risk without benefit. This would means that many middle-class Medicare patients who live on roughly $20,000 a year (median income for seniors, including Social Security and all other sources of income), wouldn’t be able to use Medicare: they couldn’t afford to cover the out-of-pocket payments.

In the end, many of Berwick’s opponents would like to simply privatize Medicare, turning it over to private-sector insurers who would offer “bait and switch policies” as they have in the past. Then, for-profit insurance companies  would decide how much care seniors deserve and how much they should pay, while they  made their own side deals with drug-makers, device-makers, medical equipment makers, and brand-name hospitals, agreeing to pay many of them lavishly, without regard to quality, just as they do today.

Looking Ahead

I may be discouraged, but of course, I am not giving up.

There is still a slim possibility that the administration might figure out a way to keep Berwick. And I hold out some hope that another extraordinarily talented and committed reformer will step forward to fill the slot.

But no one who believes in reform wants to “compromise” with conservatives when, by their lights, “bipartisan co-operation” means folding on everything that counts. And few would choose to preside over the demise of Medicare. Yet, without thoroughgoing reform, I am quite certain that Medicare is heading for a wall.

I don’t think most people recognize what the loss of Berwick would mean. They aren’t familiar with the details of the Affordable Care Act and so don’t realize how much of it pivots on Medicare changing the way it does business. As I have argued, Medicare reform is the only engine with the power to drive health care reform.  (For evidence, see this HealthBeat post.)

Without fierce leadership at CMS, I see only one alternative: Perhaps our last, best hope is that Berwick leaves the Beltway, returns to the Institute for Health Care Improvement, and helps lead reform from within the medical community, as he has in the past. He would not be alone.

On the ground, an amazing number of health care providers possess what Berwick has described as the “will to excellence,” and they have been turning health care around in communities across the nation, lowering costs, without impairing the quality of care. Often, patient outcomes are better. (See this Healthbeat post.)

Admittedly, reform from within will be a slow and patchy process. If we rely on a revolution that enjoys little support from Washington, it will not happen nationwide, certainly not anytime soon. Nevertheless, I believe Berwick when he argues that that there are enough like-minded people within the health care professions to eventually transform our health care system:

“The will to excellence is present everywhere in Health care,” Berwick told an audience at the National Forum on Quality Improvement in Health Care— these are natural capital, human traits. Not of all human nature, not all of the time, but enough, plenty enough. We can waste them and deplete them,” he adds, referring to low morale in many parts of our health care system. “But the will to have pride in work is not scarce; it is everywhere abundant.”

Time and again, Berwick has seen IHI’s pilot projects work –without any financial incentives for the medical professionals involved. Hospital workers want change. Many are horribly frustrated to find themselves laboring in a system where the left hand and the right hand often fail to communicate, making much of their work seem redundant or even pointless. Berwick recognizes that these professionals would like nothing more than to turn their hospitals into efficient workplaces. Such an opportunity might well be worth more than a 2 percent raise.

At the same time, Berwick is not naïve. He understands, all too well, the role that money plays in our highly-competitive for-profit system. At one of IHI’s National Forums, Berwick recalled phoning a hospital in Houston to learn about its reportedly successful innovations in pneumonia care. He was told that “the gains are enormous but the methods cannot be reported to the public—excellent pneumonia care offered the hospital local competitive advantage.”

Berwick was stunned. “The enemy is disease,” he told his audience. The competition that matters is against disease, not one another. The purpose is healing.” Yet “in the storm of the health care crisis,” Berwick acknowledged “it is so easy to forget why we trouble ourselves in the first place. It is so easy—frighteningly easy—to become trapped in the sterile thesis  . . . that our true, deep purpose is to gain and preserve market share in a vacant terrain of others whose purpose is precisely the same.” In other words, it is so easy to forget the patients.

If Berwick leaves Washington, I hope he will continue to lead the vanguard for meaningful reform.

In the meantime, what can the rest of us do? If the Senator who represents you signed the letter to President Obama, you might want to drop him or her an e-mail, indicating that voters also can “exact retribution.” Here’s the list: Lamar Alexander (R-Tenn.), Kelly Ayotte (R-N.H.), John Barrasso (R-Wyo.), Roy Blunt (R-Mo.), John Boozman (R-Ark.), Richard Burr (R-N.C.), Saxby Chambliss (R-Ga.), Dan Coats (R-Ind.), Tom Coburn (R-Okla.), Thad Cochran (R-Miss.), Bob Corker (R-Tenn.), John Cornyn (R-Texas), Mike Crapo (R-Idaho), Jim DeMint (R-S.C.), John Ensign (R-Nev.), Lindsey Graham (R-S.C.), Chuck Grassley (R-Iowa), John Hoeven (R-N.D.), Kay Bailey Hutchison (R-Texas), Jim Inhofe (R-Okla.), Johnny Isakson (R-Ga), Mike Johanns (R-Neb.), Ron Johnson (R-Wis.), Mark Kirk (R-Ill.), Jon Kyl (R-Ariz.), Mike Lee (R-Utah), Dick Lugar (R-Ind.), John McCain (R-Ariz.), Mitch McConnell (R-Ky.), Jim Moran (R-Kan.), Ron Paul (R-Ky), John Risch (R-Idaho), Pat Roberts (R-Kan.), Marco Rubio (R-Fla.), Jeff Sessions (R-Ala.), Richard Shelby (R-Ala.), John Thune (R-S.D.), Pat Toomey (R-Pa.), David Vitter (R-La.), and Roger Wicker (R-Miss.).

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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26 replies »

  1. Dr. Berwick has had a long and distinguished academic career with a medical institution that is notorious for negociating highway robbery fee schedules with insurers without any demonstrable quality advantages. He is either aware of this, or not aware of this .Each scenario brings into question his ability to guide CMS.

  2. Peter – I have the highest regard for Warren Buffett as an investor and I own some shares of Berkshire Hathaway, the company he leads. That said, he’s a master of minimizing personal taxes. Berkshire has NEVER paid a cash dividend since Buffett took it over more than 40 years ago. Buffett grew his wealth by shrewdly reinvesting Berkshire’s free cash flow and never paying any taxes on the inside buildup of value. Meanwhile, he pays himself a very low salary. In the end, most of his wealth will go to the Bill and Melinda Gates Foundation. While that’s laudable, neither income nor estate taxes will ever be paid.

    While the wealthy aren’t clamoring to pay more taxes either, income taxes have gone up for them in many states including my home state of NJ and NY (where I work). The top state income tax rate in both states is currently 8.97%, which in New Jersey, kicks in at $500K of income. All income, including capital gains and dividends, are taxed as ordinary income here and in NY. Also, starting in 2007, Medicare eligible individuals with incomes above $85K and couples with income of over $170K pay more than the standard amount for their Medicare Part B benefits. For those who make over $428K, the premium is over $350 per month each as compared to the standard $115 for those turning 65 this year. Finally, people who earn their income mainly from wages and interest as opposed to capital gains and qualified dividends, are the only ones paying federal income tax rates higher than those that were in effect after the 1986 Tax Reform Act passed. Those with lots of capital gains and dividends are paying less but there are plenty of people in NY, NJ, CT, CA, and elsewhere who earn high incomes from salary, bonus, stock options, and restricted stock awards all of which are subject to taxation at ordinary income tax rates.

    Even the current fiscal debate in Congress which is focused on discretionary spending finds most members recommending cuts that affect someone else’s constituents but not their own. Think NYC Congressmen recommending cuts in farm subsidies and those from rural areas suggesting cutting subsidies for Amtrak. The name of the game is don’t cut you, don’t cut me, cut that fella behind the tree and that’s what voters reward.

    As for healthcare, I think we’re finally starting to see payment innovation happening in the private sector. We have BCBS of MA’s Alternative Quality Contract. We have value based insurance design, including tiered networks, gaining traction. And just today, Anthem BCBS of MO announced a bundled payment arrangement with the largest provider of knee replacements in the St. Louis metropolitan area. I think there is a lot more to come with or without Don Berwick heading CMS.

  3. As far as I am concerned, Barry and Peter are both right and wrong, they both miss the big picture, and that is America is a failing society. The rich are just addicts, and we just rationalize and minimize to their advantage while they destroy themselves while they destroy society. The middle class is just waiting for someone else to ride in, to save the day for them, when they do not realize nor want to expend the appropriate energy to do the work for themselves, and instead need to stop expecting this failed “representation” of politicians to work. And the poor are nearly out of hope and faith that they can get a fair chance to improve their odds, and are forced to accept full dependency for any shred of alleged opportunity. This, is the best we are these days. Ignorant, bloated, and sitting around just bitching for the good ol’ days. And technology really hasn’t saved the day, it just entrenches the mentality.

    Neither Democrats nor Republicans are going to save this country, as they stand now. Wisconsin is not an exception, it is the latest example. Think about it, Democrats did the bidding of special interests of unions, who while not as well off as corporate fat cats, have the same mentality of fleecing the public, and the Republicans, well, let’s be honest, they pretty much tell you to your face they are beholden to the rich special interests, and the results of 2010 just rode the usual pendulum behavior of the dumbed down public who saw the Democrats these past 2 years just embrace past Republican behaviors and thought punishing them would help the country. HA!!!

    So, bringing it back to Berwick and Mahar and why this legislative madness of PPACA is just another political failure for the masses, elites do not care about the common man, who is more often the middle class and true majority of America. You just have to pay attention to the deeds, and stop listening to words alone. Incumbent politicians are lost, and if you follow a lost soul, you go nowhere of substance. So, get lost in the projecting rhetoric of the failed two party system that is American politics, or, start thinking for yourselves and if you need representation, start with the mirror.

    Health care needs help, no doubt about it. It just won’t come from Washington alone!

  4. “They’re willing to soak a small group of high income people but they’re not willing to sacrifice anything themselves.”

    Sacrifice!? You’re kidding right Barry? Who’s sacrificed over the last 2-3 years, high income earners, corporations, Wall Street scammers? When Warren Buffet can say, If this is class warfare, my class is winning”, then you know it’s not greedy middle classers soaking the rich, it’s the other way around. I can link any number of articles on what it’s like to be “middle class” in America, but this one is pretty good, especially the raw wisdom of George Carlin at the end.


  5. Peter – I think the broader problem beyond just Medicare is that the American people simply want more and expect more from government than they are willing to pay for. They’re willing to soak a small group of high income people but they’re not willing to sacrifice anything themselves. When it’s time to vote, too many of us are too quick to reward pandering and demagoguery and penalize truth telling and tough calls. Until voters are ready to reward the latter and penalize the former, it will be hard, if not impossible, to make much progress toward reining in government spending, especially for programs that primarily benefit the elderly.

  6. “Hmmm, does anyone have the guts to say what are probably the 2 biggest expenditures for Medicare: prolonging lives beyond reasonable and fair quality of life, and, the push to medicate every complaint that is presented in the office?”

    The guts will be taking on AARP members. If you were running for office DMD would you expect to win on that platform? Who has the guts to tackle any entitlements, no one so far, they’re just happy looking brave cutting 12% of expenditures.

  7. Hmmm, does anyone have the guts to say what are probably the 2 biggest expenditures for Medicare: prolonging lives beyond reasonable and fair quality of life, and, the push to medicate every complaint that is presented in the office? The latter includes the push to consider brand name drugs, which if the pharmaceutical industry is supporting this legislation as is, must be granted consideration, when in fact that is contraindicated if cost cutting measures are to be factored in at the beginning of the legislative impact.

    So, where is the incongruency here? Looking to bring in a hatchet man to contain costs, does he/she lie to big pharma and then cut out new brand name drugs, or, does he nickel and dime providers with threats of punitive action if they write for brand name drugs? Either way, pharma will find out they were played, not that I care that they were, because they were playing Democrats in the first place anyway.

    I will not touch the former matter of cutting costs, because who wants to renew that discussion of alleged “death panels”, not that this topic can be ignored for years to come. Just how objective and unbiased are the baby boomers in this conversation, that will be interesting to ascertain!

    Devil is in the details, eh. But, hey, you gotta pass the legislation to find out what is in it, eh? It just won’t be Nancy Pelosi reading to you all!

  8. Yeah CMSinsider! Dr. Mark McClellan, the consummate “split-the-difference” approach that had been his hallmark of his tenure. In regards to the $300 million nationwide demonstration project in 2005, to gauge how patients feel during treatment. In return for $130 a patient per day, oncologists collected information about three conditions: pain, nausea and vomiting, and fatigue.

    The oncologists got much of the money they had demanded for care they give to improve patients’ quality of life, but if they collect data about how well their efforts are working. It wasn’t about developing better evidence, it was about just giving oncologists more money.

    The Senate Finance Committee Chairman found that the value of the Medicare demonstration project to report on a patient’s level of nausea, vomiting, pain and fatigue was for nothing. CMS paid chemotherapy providers $130 per report, per infusional-chemotherapy recipient, on a patient’s level of nausea, vomiting, pain and fatigue, but HHS’ inspector general’s office found these providers were being paid an extra $130 to simply forward the data that was already collected.

    McClellan was more economist/businessman than he was physician. A continuance of the Medicare demonstration project would have exacerbated existing economic and clinical problems instead of resolving them by increasing the temptations for physicians to overuse injectable drugs and promise to aggravate the economic problems Congress was attempted to fix. Yeah, an individual who understands the “business” side of healthcare alright. Business first, patients last.

  9. “You can’t do health reform without support/leadership at CMS.”

    Precisely why the Republicans don’t want effective leadership there.

  10. The sad fact is that CMS has been functioning on inertia for five years. You can’t do health reform without support/leadership at CMS. Health care has drifted far too long and the result is costs go up and coverage declines. Boy it is increasingly obvious that in the US we don’t want to deal with health care its the national ostrich, with our collective heads in the sand.

  11. I think tcoyote is right this time. The Senate “Democrats” (and I use the term loosely) and the White House didn’t dare appoint Berwick for the first year of the Administration and we’re never going to try post Scott Brown’s win. Berwick is clearly a great leader in health care, but I never thought he was going to be there long.

    On the other hand, I’m unclear as to whether the actual leadership of CMS makes that much difference so long as someone there enforces what’s in the law. And whether they enforce all the pieces of the law depends on who’s backing them (or opposing them) from the White House and Congress 2012 and especially 2014 onwards.

  12. Earlier this week I wrote several articles on HealthTrain about Don Berwick, MD. Dr Berwick is a political appointee chosen because of his alignment with Obama’s mantra about redistributing wealth and health. Dr. Berwick unknowingly fell on his sword when he gave his infamous speech before the NHS in the U.K. literally dissing our health system and telling those in the UK what a superior health system they had, while ridiculing our own system, which has grown out of the work of many individual people and not the product of a mindless bureaucratic system. While our system is flawed it has the capacity to change and adapt. Witness that the NHS is now trying to unravel it’s leaden responses to it’s own needs. They are privatizing their health system while we are told to nationalize our own.

  13. Thank you CMSinsider for your comment. And I hope every reader pays attention to what was said in this comment above, because it sums up succinctly and accurately what I have been saying is the agenda of this legislation.

    “What is needed is an individual who understands the business side of healthcare and can articulate effectively a business case as to what changes need to occur in order to make Medicare and Medicaid run more efficiently, how to eradicate the redundancy and waste in the system, and how to integrate quality of care into that umbric.”

    That is what the agenda of PPACA is, which is to emulate and to eventually incorporate health care for the country into the Medicare/Medicaid model. And if this spokesperson is a legitimate source and speaker for CMS, this should define the defenders and the detractors of this legislaton very clearly hereon.

    So, wake up and smell the coffee, commenters. I read this to basically say the government needs a stooge who has no soul as a provider, which is what Ms Mahar has been almost openly advocating for in her posts for the past year or more. But, how ironic you kept pushing your agenda, and now hopefully have had someone open the box and reveal the true intent.

    You figure it out, objective and unbiased readers!

  14. As someone who has worked in a senior position at CMS for nearly 12 years, I have to respectfully disagree with your assessment of Dr. Berwick’s leadership and that he is the only one who can fill the role. Dr. Berwick as a person is a very warm, charismatic and passionate individual who is clearly a proponent of the quality and clinical sides of reform. However, that is not what CMS’ primary focus is nor is it what a CMS Administrator needs to be able to “sell” to the public and Congress. What is needed is an individual who understands the business side of healthcare and can articulate effectively a business case as to what changes need to occur in order to make Medicare and Medicaid run more efficiently, how to eradicate the redundancy and waste in the system, and how to integrate quality of care into that umbric.

    CMS has been without a confirmed Administrator since Mark McClellan left in October 2006. Since then, the agency has been in the hands of several talented, but hamstrung, leaders by virtue of their lack of authority to effect real agency wide change since they were not confirmed. CMS is first and foremost a business, the largest health insurance business in the world to be precise, with over $800 billion in expenditures (soon to be over $1 trillion), over 1.2 billion claims a year, and nearly 4500 employees to be overseen. Dr. Berwick does not have any concept of how to manage this massive bureaucracy and in meetings with senior staff is repeatedly unable to converse on the payment methodologies, delivery systems and operational infrastructure necessary to ensure CMS is working effectively. Health care reform from a quality perspective is his primary focus and he is indeed passionate about it, even giving teaching sessions on quality to all CMS staff. If CMS was a care delivery agency first and foremost then he would be the man for the job. As it is, the Republican senators have the right of it. Dr. Berwick is ill equipped to handle heading up the largest healthcare business in the world, one that is consistently expanding with each turn of the health reform wheel (including the recent transfer of the insurance exchange office into the CMS fold). He may be a great person, academic and physician, but he is not the man to step in to lead CMS through these turbulent times. Hopefully at some point Congress and the White House will finally understand what CMS does well enough to nominate a person who actually can handle the breadth and scope of the job. Dr. McClellan was such a person — an economist and physician who understood that care integration and quality were important, but that came second to ensuring the operations and payment side of CMS worked efficiently. For the sake of those of us who actually do the work to ensure those operations continue seamlessly I can only hope that day is coming sooner rather than later.

  15. “Maggie’s narrative about “conservatives’ blocking Berwick’s appointment is rubbish. The Dems had 59 votes in the Senate until January. All they needed was one Republican to break the filibuster, assuming the Republicans decided to filibuster, to get him confirmed last year.”

    Exactly. You need 60. No one breaks ranks for fear of losing their next primary.


  16. Well, cogent response. Thanks.

    I followed the various drafts of the bills that eventually resulted in the PPACA. I was not happy with the outcome either.

  17. Go back and look at the polling data on this issue. The January Scott Brown victory in Massachusetts convinced the White House political operation that the health reform debate was an increasing political liability for the Democrats. They could see the wave that hit them in November was already building. They wanted to pull back and enact something less ambitious than ACA and were stopped cold by Nancy Pelosi, who insisted in pressing on to enact a comprehensive bill. The longer the debate went on, the more it cost the Democrats. By the time the bill passed in mid March, Democratic leadership in both houses were sick of this issue and wanted to move on to other pressing items, like financial reform.

    Re-igniting the debate at Berwick’s confirmation hearings would have continued the downward pressure on Democratic poll numbers and enabled Republicans to capitalize on the bill’s unpopularity. Look at the Kaiser Foundation tracking polls and you’ll get an idea of why. The real mistake was not to put someone up for CMS at the normal time- in December of 2008 or January in 2009. They couldn’t get the people they wanted and elected, fatally, to wait until health reform passed.

  18. “The reality is the President’s “friends” in the Senate did not want Berwick’s confirmation hearings to highlight ACA’s unpopularity.”

    Something about that doesn’t wash.

    The PPACA was signed into law in March 2010. Berwick was nominated in April.

    Would you care to expand? Are you arguing that the Democrats threw him under the bus forthwith, because, uh, why?

  19. Maggie’s narrative about “conservatives’ blocking Berwick’s appointment is rubbish. The Dems had 59 votes in the Senate until January. All they needed was one Republican to break the filibuster, assuming the Republicans decided to filibuster, to get him confirmed last year.

    It was the President’s Democratic colleagues who killed Berwick’s nomination by being unwilling to schedule hearings and move this process along. And instead of ratcheting up the pressure on Congress last summer, the White House pulled the plug on the regular confirmation process, and basically sacrificed him by making a recess appointment LESS THAN NINETY DAYS AFTER NOMINATING HIM.

    The reality is the President’s “friends” in the Senate did not want Berwick’s confirmation hearings to highlight ACA’s unpopularity. To blame conservatives for this is simply nonsense. This was Baucus passive aggression and a trigger happy White House working together to tarnish a good man. Maggie’s right about the limited options for replacing him; no one in his right mind would want to endure the abuse of a CMS confirmation process.

  20. “Perhaps it’s time for Obama to play hardball with Congress and hold some of the Republican agenda hostage”

    What! Obama showing backbone and commitment to his core values – whatever they are now. It’s too late for that.

  21. Dr. Berwick is a fine man and a fine physician. He is eloquent and is a true believer in government-led care and a disbeliever in any form of market-based reform. To his credit, he has made his position clear on multiple occasions. But he is not a saint in the eyes of most practicing physicians. His qualities, admired so much on the left, make him a less than desirable person, in our view, to lead CMS. The November elections have consequences and casualties. Medicare will survive without him.

  22. Obama made a difficult choice to make Dr Berwick a recess appointment given the consequences of not having a strong physician leader at CMS to manage the health care reform process and align Medicare and Medicaid with this direction.

    I fully agree with Maggie’s view that CMS needs this type of leader to both sell and implement health care reform using these two government health insurance programs as the poster children for how the system needs to change to achieve sustainability.

    Perhaps it’s time for Obama to play hardball with Congress and hold some of the Republican agenda hostage until the two sides have a meeting of the minds. Let’s see how far the Republicans are willing to go if they are facing the prospect of going back at the next election without any tangible results to show to their constituents.

  23. The Senate Bullies will probably succeed and health reform will pay the price. Dr. Berwick can return to the real world and some sense of sanity as a casualty of the health reform war. And like Ted Kennedy admitting, late in his career, the worst mistake he made was not compromising on health care with Richard Nixon, a Republican (to be named at a later date) will admit their worst mistake was chasing Don Berwick out of Washington. A perfect example of winning the battle but perhaps losing the war for health reform. Yep be careful what you wish for you just might get it.

  24. Those politicians who are determined to obstruct Berwick as a way of payback to Obama for circumventing them, will have their way – but, as often in this country, they are cutting off their noses to spite their (and our) face. So be it.

    I am aware of Dr. Berwick’s good works elsewhere, and he has plenty of good left to do. My personal wish for him is that he not be reconfirmed so that he may escape Washington and go back to doing something constructive.

  25. We need not worry that Determined-MD-As-Hell will ever be invited to write a blog post here. Either of him.

  26. Ms Mahar, can’t you just make your point in a few paragraphs and save the pontificating for whatever journals you write for who enjoy your verbage? I will say this, at least you finally document that you wrap yourself around this man as I knew you do. He is not the best person to lead an organization of the magnitude that is Medicare.

    I would say sorry or tough break, but I do not lie. The proponents of this legislative assault on health care and the professionals who work hard at maintaining the correct standards and principles better be ready for more disappointment if truth and appropriateness prevail.

    Hopefully it may motivate you to move on to find your choir somewhere else!