Berwick’s Bad Medicine

July 13th, 2010 at 2:09 am | 26 Comments |

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In the spring, the White House announced that Dr. Donald Berwick, a Harvard pediatrician and health-policy expert, would be the nominee to lead the Centers for Medicare and Medicaid Services.

It was then that I ordered a copy of Escape Fire – a collection of Dr. Berwick’s speeches. In the coming months, Dr. Berwick has sparked incredible controversy (a point I’ll return to in a moment). But in reading through his speeches, I can’t help but feel that he isn’t the “revolutionary” his many supporters suggest. Rather, he comes across as somewhat entertaining, somewhat clever, and – like most keynote speakers at health-policy conferences – somewhat light.

His lectures include clever stories about his kid’s baseball games, rockets, and explorer James Cook. As for the policy prescriptions, they tend to be sweeping if substance-less.

Here are his five recommendations from a 1994 speech:

  1. We must change our focus from integrating structures to integrating experiences.
  2. We must learn to use measurement for improvement, not for judgment.
  3. We must move beyond the naïve search for best practices to a much healthier mode of learning from one another.
  4. We must shift thinking from reduction of local cost to reduction of total cost.
  5. We must compete against disease, not one another.

Just so you know that I haven’t completely manipulated his hard-hitting analysis, here are “six ideas that represent for me appropriate foundations for design for the era of change that will be responsive to the new context of care” that he describes in a 1995 speech:

  1. Reduce waste in all its forms.
  2. Study and apply the principles of continuous flow.
  3. Reduce demand.
  4. Plot measurements related to aims over time.
  5. Match capacity to demand.
  6. Cooperate.

I never attended any of these speeches, but just can’t see the gasps from the audience when he announced that first point about waste – or the sort of challenging questions and comments that would have followed when, say, the executive from the Florida managed care company argued that hospitals and insurance companies should seek to reduce only some types of waste. Ditto on 3, 5, and 6.

Dr. Berwick’s work, of course, shouldn’t just be measured by his Anthony-Robbins-does-health-policy rhetoric. Rather, his work at the Institute for Healthcare Improvement can be weighed. There, he has spent decades championing causes like more hand-washing in hospitals and the use of check-lists.

Of course, Dr. Berwick’s work has created a stir in Washington. After being nominated, the President appointed him administrator of CMS as a “recess” appointment. Setting aside the issue around recess appointments, Republicans and conservatives have been harshly critical of the good doctor. Sen. John Cornyn, (R- TX) calls him “an extremist.” Conservative Mark Levin is even sharper: “We have another Marxist in our midst.” Pointing to his fondness for Britain’s National Health Service, critics have suggested that he would bring U.K.-style rationing to the United States.

Let’s be clear: Dr. Berwick isn’t an extremist and he isn’t a Marxist. And, no, your grandmother will not be euthanized under his watch. But he is an ideologue, one who looks fondly on government and government systems – he has, as has been widely quoted, professed his love for Britain’s National Health Service. And for a person charged with overseeing $800 billion a year in health spending, that is a big issue.

Ultimately, Dr. Berwick is impractical in his policy positions. In a piece that I’ve just co-authored with my colleague and friend Paul Howard, we note that he sees a consumer revolution rising out of careful government management – as if the iPhone and its competitors were the result of good central planning. Like too many in health policy circles, “he has fallen victim to the Harvard Disease: the idea that having experts peer through reams of data will lead to system wide improvements. Thus, he writes fondly of the ‘centralized stewardship” in the NHS.’”

And Dr. Berwick fails to appreciate the private sector. As we observe:

Here is the biggest irony: despite his hostility to profits and markets, many of the quality and process improvements Dr. Berwick champions were borrowed from the private sector – from hotel chains, 3M, and Proctor and Gamble. Let’s just state the obvious, yet again: these innovations arose from consumer choice and market competition.

Telegraph columnist Janet Daley, who is an American by birth but has lived in the United Kingdom for 45 years, makes another point: Dr. Berwick doesn’t really understand the British system either.

Dr Berwick professes a love (which he describes in ecstatic terms that will have a tragicomic ring to most British ears) of just those evils of a national health system with which we are exasperated: the calculated rationing of treatment, and the ruthless enforcement of uniform cost limits, which often puts the most advanced medication and procedures out of reach of patients whose lives might have been extended or transformed by them. Dr Berwick thinks that our own dear National Institute for Clinical Excellence (Nice) – which is scarcely ever out of the headlines for denying some poor suffering victim a remedy that is available in other countries – is simply wonderful.

Unfortunately, Dr Berwick is quite right to draw these particular conclusions about the inevitable consequences of state-sponsored health care. Which brings us back to [Health Secretary] Lansley and his not-really-all-that-radical reform of the NHS. At a time when both the demand for care and the scope of medical innovation are virtually infinite, a tax-funded health system must involve rationing and often the outright denial of advanced, cutting-edge treatments. There may be no theoretical limit to what miracles medical science can deliver, but there is certainly a limit to what taxpayers can subsidise, or to what governments can spend if they are not to starve every other public service to the point of death. The Government’s refusal to cut NHS funding – at whatever cost to other departments – is rightly condemned as wrong-headed and politically cowardly.

So why the inevitability of those aspects of our system which we most dislike? Why is Dr Berwick correct when he says that the NHS way of doing things is basically sensible, given the principles on which it rests? Because we have – and America is apparently about to embrace – an approach to health funding which is inherently self-limiting. Rationing is what happens when you do not have enough of something to go around. And health care that is paid for entirely by taxation creates shortages where they need not exist.

Dr. Berwick takes over CMS at an interesting and important time – at the point that America is beginning to really feel the weight of health-care spending on both the public and private sector. But like many in the White House, just when sober analysis is needed, we have Dr. Berwick arrive with his ideological inclination: that more government will save the day.

He’s wrong, as is the White House. And that is reason to fret his appointment, all partisan rhetoric aside.

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26 Comments so far ↓

  • jorae

    “… he is an ideologue, one who looks fondly on government and government systems…” Seems he is perfect. Probably was even in the Peace Corp….Exactly the type one should pick. I would think a Beverly Hills plastic surgeon might not see the same set of problems as someone who looks fondly on the government.

    The hand picked ideas you first points are from over a decade ago, and were not spoken knowing that one day be taking on American Health Care. The list hits me as something from the point of view of a Hospital Administrators or Teaching Hospitals.

    His current job does not include a “National Health Plan” although 77% of Americans wanted such a plan. There seems to be very few hands on responsibilities at this time since the only way to cover more people was to give states more money to run their own Medicaid program.

    If any of the rules laid out for the Insurance companies need to be addressed, I am sure Jon Q. Public will be loud and clear. And that is who he works for. I must admit it is nice Congress is out of the way so the party of NO can’t removed another National Health Plan next time Jon speaks.

    I do want to mention that the Medical field has always been structured to “what the market will bear” and this is why the costs have gotten out of control. It Blue Cross paid $10.00 on a lab test, the medical field would move the price to $10.50 to make sure they always got every cent. There was always one Insurance company that started to pay more, so the facility would change their computers to bill everyone this new price, so up and up the costs went. With Medicare, the facility knew what they would get, billed that amount, and never changed the price because it was a set price, with scheduled increases. One of the major mistakes that the Republicans have made, was not letting a national plan be included in the Health Reform.

  • hormelmeatco

    “he has … professed his love for Britain’s National Health Service. And for a person charged with overseeing $800 billion a year in health spending, that is a big issue.”

    How so?

  • End run denies public a debate on health care – Arizona Republic :Health Care Systems

    [...] and MedicaidBoston GlobeDon't let witch-hunt politics take down qualified doctorThe TennesseanFrumForum -Daily Star – Lebanon -ModernHealthcare.comall 105 news articles » [...]

  • SFTor1

    Rationing of treatment is a reality anywhere.

    And what is so damn great about the private system we are about to abandon? Nothing.

  • Rabiner

    Not sure why conservatives continue to prefer private insurance companies determining who gets rationing of care over government officials who are appointed by elected representatives? It isn’t that private companies are more efficient at it, it’s that their rationing tends to be focused on the poor.

  • jorae

    “According to a White House spokesman, the president anticipated Republican obstructionism, and so performed the end run. That explanation is debatable. There was no discernable “impasse” on the Berwick appointment.”…The quote is from the link above called “End run denies public debate”

    “…Democratic leaders in the Senate also were perplexed at the recess appointment. Senate Finance Committee Chairman Max Baucus of Montana said he was “troubled” by the move.”

    Right, no discernible “impasse”….everyone President Obama appoints gets unanimous approval. And how about that old Blue Dog Baucus being “troubled.”…what a surprise.

    Note: “no discernable impasse” The OP is a pretty good indication of what was to come.

    Seems like President Obama is a quick study when he has an option of using the End Run.

  • rbottoms

    President Obama has the power of recess appointment and he used it.

    End of story.

  • drdredel

    Also… why should the British system give us any cause for alarm? I just spent a week in London and everyone I spoke to on the subject, was extremely satisfied with their health care. Sure that’s entirely anecdotal, but the point is that the opponents of the new changes seem to suggest that any deviation from our (totally horrible) system can only go towards Haitian voodoo. Every civilized nation in the world has a better system than ours… we would do well to pick one at random and go with that rather than keep paying for nothing, as we do now.

  • msmilack

    I actually think he sounds perfect for the job. He is not an idealogue. Being idealistic is not the same as being an idealogue. I am so glad Obama made the appointment during the recess so no more time would be wasted by Republican partisan objections simply because he was the choice of Obama. They’ve wasted enough of our time to last a lifetime.

  • JohnnyA

    I’m not a fan of the health plan and I may agree with you in principle, but this is another weak article. The best information you can offer up to support your points are 2 speeches from 15 years ago, some Republicans and conservatives think he’s an extremist (a surprise in the current climate…) and he’s said some nice things about Britain’s National Health Service?

    Therefore, “He’s wrong, as is the White House. And that is reason to fret his appointment, all partisan rhetoric aside.” Maybe I missed it, but was there any real substance beyond the “partisan rhetoric” kool aid?

    Perhaps I’m in the minority here, but I’m interested in real information and debate. Plenty of other places to get the kool aid.

  • Jeffry1

    The numbers don’t add up. Obamacare is unsustainable. Period.

  • LFC

    David Gratzer said… Instead, health care is in desperate need of more consumer-driven innovations like the iPhone that have the potential to change the way we think about health and health care.

    This point of view is either breathtakingly ignorant or intentionally misleading. It has been pointed out multiple times in so many forums that it is impossible to compare the health care industry to a standard consumer industry. Getting an iPhone is a choice between having a really fancy phone or having a basic one … or none at all. If you need surgery to save your life, I guess you could always pick the “none at all” selection due to cost, but then you would die. This, of course, may be exactly what’s being advocated.

    To put it simply, if my wife was seriously ill, I would give anything … ANYTHING … to keep her alive. Every dollar I’ve carefully saved and invested for retirement. Every thing of value I own. My house. Every dollar I could borrow. Every dollar. Do you understand that? EVERY! If you can’t grasp how incredibly that skews market forces, you have no business writing about them.

  • Jeffry1

    LFC…what if you don’t have enough to keep her alive but I do? Sounds like you would give everything I have to keep her alive too. At what point do you stop “wealth transfer”?

  • LFC

    Jeffry1, hence the reason that market forces don’t work, and hence the reason that Mr. Gratzer doesn’t seem to grasp reality on this topic. If you look at the ever increasing of medical care, the current system simply doesn’t work. How come market forces can’t keep health care cost rises somewhere remotely close to CPI? Because often the consumer is without choices. They are sick NOW. They are physically incapable of making a decision. The decision to forgo health care could mean death.

    On the flipside, I could advocate that every person in the country should have access to any care they request (doctor recommended or not) for as long as they want and it should be paid for by tax dollars. I wouldn’t because, as you noted, it would take everything everybody had too. So both systems, private insurance companies taking on only a segment that is profitable to insure and unlimited gov’t insurance, won’t reign in costs.

    The other problem we have with market driven health care is that we don’t have the ability or information to do a true cost-benefit analysis. Quick, tell me exactly how many complaints were filed against your local hospital, how many lawsuits, and what the details were of those complaints and any lawsuits that were settled? How many were against one particular doctor versus other doctors in the same specialty? Can’t be done. Much of the information is confidential so you really have no way to independently determine quality.

    Every sane person on this debate agrees that some form of rationing is required. In fact, that’s exactly what we have today in making insurance unattainable by tens of millions of people, but that form of rationing is still not keeping costs contained. The question is, how do we want to ration it? This is not a question Mr. Gratzer wants to approach.

  • easton

    Jeffry1, Jeez Jeffry, that is just nuts. You do understand the whole concept of insurance is a form of wealth transfer, the healthy pay for the treatment of the sick via their premiums, the reason people buy insurance is based on the realization that they too would likely need health care in the future.
    Or are you against insurance? Do you favor lifetime caps, that after a person goes over that they should be left to die even if standard treatment can keep them alive and healthy? Do you think ICU’s should run a meter over a bed and once someone goes over that the plug should be pulled?

    The US spends 16% of its income on health care with no better outcomes than the rest of the OECD which has a much lower average of around 9%, with these systems having far more Government intervention in health care, in addition our system leaves out tens of millions of people who then rely on hospital ER’s for their health care, with those costs then foisted onto the people who have insurance. I suppose Jeffry thinks we should revise the Hippocratic oath so doctors can say “I shall only help those that can pay, those that can’t should die.”

    I also love the backasswards reading of the bible from the knucklehead Republicans, Matthew 25:36 according to Jeffry: I was naked, and you clothed me. I was sick, and you took care of me. I was in prison, and you visited me now becomes bizarre : I was naked and you laughed at me, I was sick and you did not take care of me since that would require you transfer even a penny of wealth which is unthinkable, I was in prison and you sought to execute me since prisons cost money.

  • easton

    LFC, here is a great program: http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/

    It presents facts about health care systems in major developed nations. Republicans seem to believe that England is the only other country that exists, funny how they never compare Japan to the US system, fundamentally it is because they are either duplicitous (they know they will lose the argument), racist (the Japanese are not the same kind of human as us whiteys) , or flat out ignorant (Japan, never heard of it). I am going with duplicitous.

  • LFC

    Or are you against insurance?

    Easton, I have the same question for Jeffry, but want to expand it to all forms of insurance. How about auto? That’s a shared risk pool. If you are a safe driver and never have an accident, you paid for somebody who did. Disability? Long term care? Life insurance? And as long as we’re talking about life insurance, we have to throw in annuities since my payout might be better or worse depending upon how long I live versus the others in the “pool”. If you have any one of these, you’re paying for other people … or they are paying for you.

  • sinz54

    rbottoms:
    President Obama has the power of recess appointment and he used it.
    End of story.
    So much for Obama’s promise to “changing the tone in Washington.” I always knew you were liars about that.

    But it’s not the end of the story.

    Should the Republicans take over the House of Representatives in the upcoming November election, you can expect at least one House committee to call Dr. Berwick to testify about his views before Congress–and before the news cameras.

    Reverend Wright will be next.

    What’s really motivating GOP activists to win the upcoming election, is all the opportunities it will give House Republicans to investigate the Obama Administration–and its friends.

    Unlike Obama, we never promised to “change the tone in Washington”!

  • sinz54

    LFC: How about auto? That’s a shared risk pool. If you are a safe driver and never have an accident, you paid for somebody who did. …. If you have any one of these, you’re paying for other people … or they are paying for you.
    But with auto insurance, you have a lot more skin in the game regardless.

    If you have many accidents, or if your car is stolen several times, your insurance company will raise your premium. You’ll be considered a high-risk driver. That’s how auto insurance companies stay in business.

    The obvious equivalent would be to raise the health insurance premiums of obese people, people who smoke (even LIFE insurance premiums are higher for smokers), heavy drinkers, etc. But Americans won’t tolerate that, so we end up with a situation where those who abuse their bodies get health care paid by those who tried wellness methods to stay healthy longer.

  • easton

    So much for Obama’s promise to “changing the tone in Washington.” I always knew you were liars about that.

    How is using recess apointment anything to do with “tone” did he scream the appointment?
    Republicans have been using anonymous holds, there are far more unfilled positions in Government than there ever was during Bush’s term. So when Republicans use parliamentary tactics that is fine, but when Democrats do the same it is an affront. Good lord, what a disgrace.

    Unlike Obama, we never promised to “change the tone in Washington” Ha ha ha ha hahaha. Funny one. No, Bush never said he was a uniter not a divider. Nope, never said it. I don’t care if there is video of him saying it (sinz then covers his hands and eyes so as to continue his supposed ability to deny)

    By the way sinz, they do charge more for smokers and overweight people under individual plans. What planet are you living on? Now as to group plans, um… companies negotiate with insurance companies, and even so families pay more than singles. You know this right?

  • LFC

    Funny one, Sinz. You blame Obama for not changing the tone of Washington while very casually ignoring the fact that Obama STILL has 189 nominees awaiting confirmation, including 49 who have been cooling their heels for more than 6 months. I’m very GOProud of you.

  • Rabiner

    Sinz54:

    “The obvious equivalent would be to raise the health insurance premiums of obese people, people who smoke (even LIFE insurance premiums are higher for smokers), heavy drinkers, etc. But Americans won’t tolerate that, so we end up with a situation where those who abuse their bodies get health care paid by those who tried wellness methods to stay healthy longer”

    They already do that and I believe are permitted still to have higher insurance premiums for smokers. However health insurance is fundamentally different than car insurance in that the risk of getting sick increases significantly with age whereas car accidents may or may not depending on the individuals eye sight and reflexes.

  • TerryF98

    Sinz54 another name for zero credibility.

  • jorae

    I have never had children, but some of my tax dollars seem to go to schools. Am I to complain about the transfer of wealth?

    If I am at the grocery store and something I like has tripled in cost, I don’t buy it. The maker of the product wants to see what the public is will to pay and increase profits. Some people will be able to buy it, most will just not. This is how health care is distributed in America. Both food and health are essential to life. But in the grocery store, I can skip buying it, I can’t skip an emergency appendectomy.

  • JohnnyA

    Rabiner:

    “They already do that and I believe are permitted still to have higher insurance premiums for smokers. ”

    True, but it’s mostly honor system at least at the companies I have worked for. Everybody just puts down “non-smoker” because the premium is lower, even if you are a 3 pack a day chain smoker…

  • Rabiner

    JohnnyA:

    Well that’s a different discussion entirely. People lying about habits to receive a lower insurance premium is different than saying they can’t get a higher insurance premium for unhealthy habits.