OP-ED

The Awful Dichotomy Between Health Care Politics and Policy

Amy Goldstein has an important article in today’s Washington Post detailing the place Don Berwick, the Medicare and Medicaid administrator finds himself in.

It is all but certain he will have to leave his post at year’s end, when his recess appointment expires, because the Senate will not confirm him for a lack of Republican support.

Berwick is one of the most respected health care experts in the country—his career has been dedicated to improving quality first and with that the cost of care. With the new law giving his agency more opportunities to experiment with new approaches and the ability to more quickly implement the things that work, he was the ideal choice.

But with the Democrats ramming the law through without a political consensus to support it, Berwick also became the political whipping boy for opponents to pile on. That he has been willing to point to the things that work in places like Britain only gave the political opportunists plenty of red meat to throw into an already red hot ideological debate.

In my mind, the great frustration in health care is that we really aren’t so far away from being able to make the system far better than it is—in both its quality and its cost. To test and perfect the best ideas we really need to be willing to try new things—many of which won’t work but can form the basis of finding out what does work.

His proposed Accountable Care Organization (ACO) rules were a disaster and he should have known better. But there is also no reason why that failure can’t lead to a better outcome—if finding the right answer is what we are all ultimately interested in.

But, particularly in this red hot political environment made more red hot by one side always more willing to jam their ideas down the other side’s throat—whether that be a new health care law or a debt ceiling solution—people like Berwick get caught up in the bigger political fight.

My sense is that a Republican President, as much as a Democratic one, could have as easily appointed Don Berwick CMS administrator.

People say Don Berwick’s failing is that he is a “political neophyte.” It is the reality that once you get to Washington having the right answer isn’t enough—you have to be able to get it through the system. What does it say about Washington when a first class expert speaking what he sees in good faith as “truth” is seen to be naïve and can be quickly dismissed for “having a record on rationing care?”

But Don Berwick never had a chance in an environment where trying to find the right answers takes a back seat to scoring political points.

With health care costs and the nation’s debt crisis now coming to a place that must finally be changed, we can’t afford this toxic take no prisoners political environment much longer.

In fact, August 2nd might be the day it all comes home to roost.

Robert Laszewski currently serves as the president of Health Policy and Strategy Associates of Alexandria, Virginia. Before forming HPSA in 1992, Robert served as the COO, Group Markets, for the Liberty Mutual Insurance Company. You can read more of his thoughtful analysis of healthcare industry trends at The Health Policy and Marketplace Blog, where this post first appeared.

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Maggie MaharMD as HELLJamesMargalit Gur-ArieBill Recent comment authors
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Maggie Mahar
Guest

Nate–

I wrote, at length, about risk in Bull! A History of Boom and Bust.

Warren Buffet recommended Bull! in Berkshire Hathaway’s annual report.

But I guess Buffett doesn’t understand risk.

And Leon Levy didn’t understand why Long Term Capital Management went down.

Maggie Mahar
Guest

Nate– You write: “sounds like they are afraid of unknown risk” Risk is, by definition, unknown or incalculable. Dictionary defintion: “a chance of injury or loss.” Chance. . .. A legal dictionary defines risk as “uncertainty as to chance of loss.” As it happens, I’ve written quite a bit about risk in the financial world. The notion that one can calculate or measure risk with any certainty is what brought Long Term Capital Management Down. (See Leon Levy’s brilliant The Mind of Wall Street” Levy ran Odyssey Partners, a famous hedge fund.” See Nassim Taleb’s “Fooled by Randomness” and Peter… Read more »

Nate Ogden
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Nate Ogden

“Risk is, by definition, unknown or incalculable.” LOL sometimes I think you say this stuff trying to be funny and know your not right, I don’t want to imagine any otehr scenerio that you actually beleive what you just said. The entire insurance industry is predicated on defining and predicting risk. You might not know who will get cancer but you know out of a representiitve population of X you will have 5 cases. You might not know when Matt will pass away but you know the average life expectancy of a 35 year old is 42 years. A chance… Read more »

Nate Ogden
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Nate Ogden

http://www.beckershospitalreview.com/hospital-physician-relationships/developing-an-aco-how-to-manage-risks.html

http://www.physicianspractice.com/blog/content/article/1462168/1847448

Erickson. He anticipates between 75 and 125 applications at the onset, with many waiting for best practices to emerge first. ACOs must, however, wait until Jan. 1 of each year to register, although the proposed rule by CMS indicates that there is a “possible” additional July 1 start date to come next year.

So that means, said Erickson, that those jumping in for 2012 — the “sophisticated players” — will likely elect for Track 2, having established their ACOs and partnerships well in advance and willing to take on risk for greater rewards.

http://www.hfma.org/Templates/Print.aspx?id=23532

Maggie Mahar
Guest

Nate:

“Since publicatoin of the government’s rules for forming ACOs in April, hospitals and doctors have balked, objecting that the provisions are too complex and subject them to substantial risk of financial loss rather than gain.” http://www.markpine.us/?p=3783

Nate Ogden
Guest
Nate Ogden

“Organizations of providers, however, have objected that the potential savings are uncertain, and the rules create too great a risk of loss.” “It was predictable that hospitals and some doctors would balk at the idea of taking financial risk.” These are not the same statements. Balking at the idea of taking risk is not the same as taking on a known loss. If you don’t understand this difference I wonder how you ever reported business. Insurance carriers take on risk, they will not insure a high risk pool without government subsidy or something to offset the known loss they will… Read more »

Nate Ogden
Guest
Nate Ogden

http://www.beckershospitalreview.com/hospital-physician-relationships/premier-offers-aco-recommendations-to-cms.html Premier healthcare alliance has written a letter to CMS with recommendations for ACOs, including the immediate allowance of multiple payment models, according to a Premier news release. The letter mentions the following recommendations: • CMS should allow multiple payment models within the ACO model from the start, such as shared savings, bundled payments, capitation or a combination of these. • Existing legal exceptions regarding one provider entity funding the infrastructure costs of another need to be broadened, particularly for small physician practices. • CMS should allow ACOs to participate in the medical home demonstration programs. • The program should… Read more »

Maggie Mahar
Guest

Regarding the notion that Democrats rammed the legislation through without a consensus . . . Consensus was impossible. Republicans have made it clear that their primary goal is to make sure that Obama is not re-elected. Thus they were committed to opposing any major piece of legislation that he supported–particularly one this big. The PPACA is t he major achievement of his first term. As for Berwick and the ACO rules– It was predictable that hospitals and some doctors would balk at the idea of taking financial risk. Medicine is perhaps the only sector where you are almost always paid… Read more »

Nate Ogden
Guest
Nate Ogden

“Consensus was impossible. Republicans have made it clear that their primary goal is to make sure that Obama is not re-elected. ” Prior to that Obama made it clear he was going to pass his version of healthcare without any input from Republcians. Nice job starting half way through the story Maggie. Republicans tried to meet with Obama and he wouldn’t allow it. It was his actions on healthcare reform that caused them to so strongly advocate for his defeat. “Medicine is perhaps the only sector where you are almost always paid even if you do a bad job. In… Read more »

MD as HELL
Guest
MD as HELL

” With the new law giving his agency more opportunities to experiment with new approaches and the ability to more quickly implement the things that work, he was the ideal choice.”

Problem is here.

If we were ALL free from JCAHO and CMS and runaway consumerism and litigation, we could all “experiment”.

The central committee canot possibly have all the answers, no matter who is at the top. Just ask Stalin.

Nate Ogden
Guest
Nate Ogden

“and what does”written by a politician or academic” mean, Nate?” It means written by someone that doesn’t have any idea what they are doing and thus are prone to write bills with obvious but unintended consiquences. For example PPACA in an effort to increase insurance coverage for kids actually eliminated the entire market for child only insurance policies. Instead of increasing coverage it greatly decreased it. Forthcomming is the maximum deductible provisions meant to limit the deductible is going to actually increase more people’s deductibles then it will lower. people that work in the industry saw these comming as soon… Read more »

Margalit Gur-Arie
Guest

Nate, can you explain why it is necessary, or beneficial, to have a child only insurance market? Since all adults should be insured anyway, isn’t adding a child to adult policies cheaper than buying separate policies? If I was selling insurance, I would offer a discount for family purchase, and I think they do….

Nate Ogden
Guest
Nate Ogden

What if you parent is over 65 and on Medicare, it doesn’t cover children. A stand alone child policy is $60 to $100 for very good coverage, To add a dependent to a group policy usually cost hundreds per month. Your parent could be on Medicare or Medicaid due to disability and the kid would not be eligibile All adults should be insured but 30 million+ aren’t, isn’t the responsible thing to do to make sure your kid is covered though? We also see a lot of cases where non birth parents take care of kids but are not custodial… Read more »

James
Guest
James

Had Mr. Berwick had a confirmation hearing, I maintain he would have been approved. The recess appointment doomed him.

Margalit Gur-Arie
Guest

…which is exactly the point….

Passing legislation is “ramming through”
Legislation itself is critiqued for style (poorly written, too long), and what does”written by a politician or academic” mean, Nate? Is this statement supposed to appeal to anti-Harvard sentiments in the, so called, plain folks population? Did you expect a broker to write the regulations, or maybe the entire legislation?

Margalit Gur-Arie
Guest

So when we say that the “(ACO) rules were a disaster and he should have known better”, what exactly do we mean? Where they a disaster because they encourage creation of corporate medicine (i.e. consolidation + vertical integration), in the form of multiple privately owned, profit-driven NHS-like entities, which anyway you want to look at it, cannot be good for patients (or costs)? Or were the ACO rules a disaster because they had too many quality measures, including patient opinions, too much patient freedom of choice, and too much corporate risk, ergo too little certainty that profits will be as… Read more »

Nate Ogden
Guest
Nate Ogden

or as everyone has said when they called them a disaster they were so poorly written and onerous that people took one read and dropped any plans to be an ACO. They were such a bureaucratic mess it looked like they were written by a politician or academic that never actually had to work in the field, sort of like the appeal procedures comming down the pipeline that are going to blow up into a huge disaster. lofty goals are fine as long as they aren’t so poluted with wishful thinking they are inpraticle or downright impossible. The 1099 rule… Read more »

DeterminedMD
Guest
DeterminedMD

Amen!

pcp
Guest

all of the above.

Bill
Guest
Bill

Government and politics have always been about power and the ability to control and influence others. Don Berwick has had a great influence on many of us in the health care field due largely to his work and accomplishments. That makes him a threat to others who have a financial and political stake in seeing the dysfunctional status quo maintained so that they can use it as an argument for their party to accumulate even more clout. That being said, Berwick shot himself in the foot a few times as well, most recently with the ACO regulations. Perhaps CMS is… Read more »

DeterminedMD
Guest
DeterminedMD

How much would you bet the people who champion this partisan bs legislation by the Democrats were the loudest ones howling for Republican scalps when the Iraq War was started? And, even that had some Democrat support! Hypocrisy should never be tolerated much less approved. That is why as much as I detest the Republican Party as the party of Self, the Democrats are now the party of “do as I say, not as I do.” I never have respected anyone who claims as a defense of committing a wrong that “well that is what the other guy did”. Hope… Read more »

steve
Guest
steve

“Silly me. I thought they voted on and passed it.”

Silly you. They only spent 13 months getting it passed. They only got 60 votes in the Senate. This now constitutes “ramming through.” Catch up on your memes.

Steve

Richard L . Reece, MD
Guest

Winston Churchill said, “If you’re not a liberal at twenty you have no heart, if you’re not a conservative at forty you have no brain.” Berwick’s cardinal sin may have been he tried to be both a liberal and conservative at 65, It’s a combination that does not work well in American partisan politics. Hearts and brains don’t always mix, as I point out in my new book The Health Reform Maze, due out in a month or so (Greenbranch Publishing).

Nate Ogden
Guest
Nate Ogden

Wouldn’t the ACO mess be a perfect example of why he CLEARLY was not the right person for the job? His supports decalre endlessly how ideal he was and when he clearly blows it just ignore it. He would be great for a department inside CMS that advocated quality or efficency, he has zero qualification for running the whole thing.

Appointments like this are another example of the partisian problem you want to address, appointing him was just as political as the healthcare bill and debt ceiling debate.