Why Berwick Matters

Two cover stories in this week’s Time magazine debate a provocative question: Is America in decline? Both the yes and no arguments are made persuasively, and I found myself on the fence after reading them, perhaps leaning ever-so-slightly toward the “no” side (optimist that I am). Sure, times are tough, but we’ve got the Right Stuff and we’ve bounced up from the mat before.

Then I considered the political fracas over Don Berwick’s appointment as director of the Centers for Medicare & Medicaid Services (CMS), and decided to change my vote, sadly. Yes, America is in decline, and this pitiful circus is Exhibit A.

Berwick, as you know, is a brilliant Harvard professor and founding head of the Institute for Healthcare Improvement. He is also the brains and vision behind most of the important healthcare initiatives of the past generation, from the IOM reports on quality and safety, to “bundles” of evidence-based practices to reduce harm, to the idea of a campaign to promote patient safety.

President Obama’s selection of Berwick to lead CMS last year was inspired. In the face of unassailable evidence of spotty quality and safety, unjustifiable variations in care, and impending insolvency, Medicare has no choice but to transform itself from a “dumb payer” into an organization that promotes excellence in quality, safety and efficiency. There is simply no other person with the deep knowledge of the system and the trust of so many key stakeholders as Don Berwick.

But Berwick’s nomination ran into the buzz saw of Red and Blue politics, with Republicans holding his nomination hostage to their larger concerns about the Affordable Care Act. In the ludicrous debate that ultimately culminated in Obama’s recess appointment of Berwick, the central argument against his nomination was that he had once – gasp – praised the UK’s National Health Service. Interestingly, without mentioning Berwick by name, Fareed Zakaria pointed to this very issue to bolster his “decline” argument in Time:

A crucial aspect of beginning to turn things around would be for the U.S. to make an honest accounting of where it stands and what it can learn from other countries. [But] any politician who dares suggest that the U.S. can learn from – let alone copy – other countries is likely to be denounced instantly. If someone points out that Europe gets better health care at half the cost, that’s dangerously socialist thinking.

I’ve argued that President Obama was right to use his recess appointment power to install Berwick as CMS director, and hoped – naively perhaps – that Don would win over his critics by the time his appointment expired in December 2011. And, in his eight months in the role, Berwick has done a terrific job. As always, his speeches on healthcare reform have been articulate and thought provoking (though one can see a heavy bureaucratic hand tamping down Don’s characteristic flair and penchant for provocativeness). He has appointed excellent people to key leadership positions, fleshed out some of the new CMS programs such as Value-based Purchasing and the Innovations Center, and will announce a major initiative in patient safety in the near future. Impressively, Berwick has accomplished all of this with at least one hand and several fingers of the other tied behind his back: doubt about his own future at CMS, uncertainty about the fate of the Affordable Care Act, and an unrelentingly hostile reception by the Republicans in Congress.

But my hopes were dashed by this week’s statement by Sen. Max Baucus (D-Montana) that Berwick’s is simply not confirmable by the Senate. This announcement followed a letter sent to the White House last week by 42 GOP senators, who argued – disingenuously – that Berwick’s “lack of experience in the areas of health plan operations and insurance regulation raise serious concerns about his qualifications for this position.” If the White House pulls the plug, he is likely to be replaced by his deputy, Marilyn Tavenner, a nurse administrator who ran two suburban hospitals for HCA and was Virginia’s Secretary of Health. The American Enterprise Institute blogger Joseph Antos praised her, sort of:

Tavenner has a reputation for making the trains run on time…. More importantly, [she] would not act as if she has a mandate to upend the health system, because she doesn’t.

In all likelihood, Tavenner would sail through her confirmation hearings, precisely because she won’t cause a stir.

But we need a stir!

From the moment of his nomination, Berwick’s plight has been a sad spectacle. I was particularly disheartened by the way he was treated during his testimony before the House Ways and Means Committee. It is too long and painful to watch the whole thing; if you’ve taken your Compazine, try a 5 minute stretch that begins precisely an hour into the testimony, as Representatives Davis and Reichert bait Berwick with a combination of hyperbole and rhetorical foolishness (“I’m not interested in an academic salon answer…”) that would make a middle school playground argument seem positively Shakespearean.

In the face of this kind of nonsense, I know of several superb physician-leaders who were offered positions in CMS – for roles that should have been once-in-a-lifetime opportunities to shape national policy – but turned them down. “Who needs this?” one told me. And they’re right.

The smart money is that the White House will fold on the Berwick appointment. The legendary Lucian Leape emailed many of Don’s colleagues yesterday, including me, asking that we sign on to a letter to the president in support of Berwick. Lucian wrote:

Watching the hearings and reading the statements being issued by the Republicans on this matter has been both disappointing and disgusting as we see our eminently qualified colleague disparaged by those who have no appreciation for what he has done and can do for our health care system.

I gladly signed this letter, and I hope you’ll do what you can to turn this around. Please contact the White House, your senators and representatives, and the media, and tell them that Don Berwick is the best hope we have to improve our healthcare system. Tell them that the Senate should hold hearings on his appointment, letting the chips fall where they may. Tell them to start acting like grown-ups.

If this good and great man is thrown under the bus, you’ll have all the evidence you need that our society is, in fact, in decline. Let’s not let this happen without a fight.

15 Responses to “Why Berwick Matters”

  1. Troy Fiesinger MD March 12, 2011 at 10:44 am #

    I agree wholeheartedly. After hearing Dr. Berwick speak at the 2005 IHI meeting and reading a collection of his speeches, I was ecstatic when I learned of his appointment to lead CMS. Clearly his Republican opponents do not want radical changes at CMS even though we who toil in the trenches know such change is needed. My fellow family physicians and I have been at our state capital fighting to save our healthcare system and will continue.

  2. Freddo Frog March 12, 2011 at 1:07 pm #

    Slight digression from the Berwick story but his support for the NHS as you mentioned above forced my hand…why is the U.K. model always the one that is used by Republicans to “educate” (and I use that term loosely) the American public about options for socialized Medicine, rather than systems which seem to work well and don’t force a nation into huge debt, like the Australian Medicare? There are several other good models out there in developed countries, yet it seems the public is being hoodwinked into only (partly) understanding one that is under financial strain believing that they have two options- fixing the US system, or becoming the U.K.’s. Surely American ingenuity allows us to steal the best ideas from those models that work into a new Medicare that works, rather than use it as political ammunition to fire in the direction of whatever purpose they see fit, in this case, trying to oust Berwick

  3. Brad Stephan March 12, 2011 at 10:57 pm #

    Maybe . . . a blessing in disguise, in that – sometimes things must get worse before they get better. Berwick may be just the first domino to fall that eventually leads to the downfall of the entire ACA. Then, when swing voters see the return of pre-existing conditions, escalating deductibles and premium contributions, etc. – they may just come to appreciate and demand the only real solution – a single payer system.

  4. Jack Percelay March 13, 2011 at 4:29 am #

    My personal opinions below

    I’m not sure that Don Berwick is the one I’d allow to fall on the sword in the spirit of things getting worse before they get better.  It’s a perfectly legitimate criticism that he’s not an experienced administrator, but what we need now are ideas and vision.

    I appeal to colleagues from states with Republican Senators.  Write your Senators.  Ask for the dignity of a hearing.  Ecclesiastes may have been wrong.  There may not be a time for everything under the sun when it’s playing games instead of doing the work we expect of our politicians.

    Note the careful choice of words–”politicians”, not “leaders.”   I am reminded of JFK’s book “Profiles in Courage” in which the quintessential quality of courage was the willingness to act according to one’s moral compass independent of the actions of one’s peer group or the likelihood of being re-elected.  Unfortunately, as a child of the 60′s I was indelibly influenced by this optimism and lack the Machiavellian traits to respond to this BS.

    What are our next steps?  As individuals, and for SHM as an organization?*

    *Please note that these comments aremy own individual, personal viewpoints.  The only comment I will make as an SHM Board Member is that we encourage involvement of all SHM members in the ongoing  healthcare reform discussions and welcome civil discussion about the issues in this forum and others.  SHM’s official policy stances are available here.

  5. jb March 13, 2011 at 3:33 pm #

    Dr Wachter-

    You can be dismissive of the hostility to Dr Berman’s leadership of CMS, but it cannot be disputed that a substantial segment, and likely a majority, of Americans do not want a British style healthcare system.  Americans like to have choices, even (especially?) in health care.  Dr. Berwick is an unabashed admirer of the British system*, and that is not a system that would play well in the USA.  It’s true that our system is more expensive, and that ~15% do not have health insurance**. It’s also true that we could do a lot more with a lot fewer dollars spent better.  The British system is not the way that most Americans would want to go.  We complain about long waits to see a doctor.  The British system is worse than ours, especially for high tech or specialty care.  Americans want lots of resources used to preserve life.  The British system lets people die if their care is judged too expensive.  I agree that we can’t go on with current trends, but please consider that that solution to every problem in healthcare may not be yet more government intervention, yet more taxpayer-supported bureaucrats telling us how to take care of people, yet another few thousand pages of rules to follow and regulations to be enforced.

    *see here for example.

    **>80% of Americans do have health insurance and are more-or-less happy with the care they get, although they would prefer it were less expensive.  

  6. Evan Benjamin March 13, 2011 at 6:04 pm #

    Bob
    Thanks so much for blogging this week and encouraging all of us to support the necessary steps we need to take to reform our health system. Having worked closely with IHI and Don for years, I know how his work can help us all change how healthcare is delivered. We have so much to do, yet the rhetoric in Washington is about the next election and not about creating a health care system that is safe, effective and efficient.
    Evan Benjamin MD
    Baystate Health, Massachusetts

  7. AD March 14, 2011 at 3:58 am #

    Rejection of Dr. Berwick a good person is but a reflection of the society we live in politics trumps professionalism.

  8. Mark Neuenschwander March 16, 2011 at 5:47 am #

    Thanks Bob for articulating what so many of us believe about Dr. Berwick.

  9. rafmar March 18, 2011 at 5:15 am #

    I see no evidence that Dr. Berwick is particularly amazing. What works in Europe cannot necessarily work here. European countries with rationed single payer systems are less diverse, less unequal, and less dynamic. But that’s the tradeoff. The Jeffersonian premium on individual liberty, which the US has historically exemplified, comes at a price. A price which, incidentally, may be good value. The strength of a society cannot in fact be measured only by life expectancy and health coverage. I would invite US physicians who really think that single payer is superior to consider a sabbatical in the NHS. Having worked there, I suspect such an experience might change your mind. Yes, Europe is socially, economically, and medically more equitable than America. But it’s also less dynamic and less diverse. You can’t have it all. There are fundamental tradeoffs coded in the very warp and woof of society itself.

  10. BostonMD March 18, 2011 at 8:17 am #

    It’s a sad affair to see Dr. Berwick attacked by half-wits in the Senate. The whole confirmation process has turned in a mockery of that chamber–”I’ll put a hold on these 1,001 nominations because I’m pissed at not getting my pork included in that bill.”

    But the unjustified, shameful treatment of Dr. Berwick is consistent with the sad fact that a large number of American citizens still watch Fox News, listen to Limbaugh, and Glenn Beck and Sarah Palin.

    Call me elitist, but I think the slow decline of America is due to our failure to educate a big portion of our citizens on critical thinking. Just look at the state of affairs of public education over the past decades and you understand why politicians are willing to throw Berwick under the bus.

  11. Freddo Frog March 18, 2011 at 10:37 am #

    NHS, NHS, NHS.

  12. Megan March 19, 2011 at 4:26 pm #

    Yes, Don Berwick has pointed out positive aspects of the British system, but in the link provided by jb it also states that he recognizes ways that it is not perfect. I also find fault in the logic that because he praised the NHS in a speech (in London at an event commemorating the 60th anniversary of NHS), he believes that it would be advisable to copy that system in America. While I can not say for sure, I have faith that Dr. Berwick has the reasoning skills to know that creating an exact replica of any system would not work in the US. But does this mean we shouldn’t find aspects of those systems that would be worthwhile to implement?

    I encourage you all to read T.R. Reid’s book “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care” in which various different systems are looked at to see what we can learn from them. “Universal” coverage is not synonymous with “socialized” medicine, and there are many good ideas out there.

    I sincerely hope that Don Berwick can weather this storm and help move the US forward in improving healthcare quality for all Americans.

    • H. Butler M.D., FACS October 4, 2011 at 5:13 pm #

      T.R. Reid’s book states the choices clearly. We spend ~30% of our hospital budgets on administration; Canada spends 14%; England spends 5%: The MBA and the JD control the MD in the Land of the Free. We cannot continue this waste. As in the film: “It is a mathematical certainty. Titanic will founder.”

      No one has proposed a voluntary non-profit plan conducted state by state, to avoid the Constitutional issues: Call it VanguardCare in honor of the mutual fund company owned by its customrers. The only difference is that patients are not customers in the usual sense: We become distraught at once upon fearing the inevitable–no one likes to go to the doctor.

      I suspect we will continue on our litigious path, and that we will ignore chances to address the doctor-shortage:

      1. A tax-credit for charity-care;
      2. A contract by cities to pay for medical school in return for x years of care;
      3. Cost-shifting within Concierge Care, a kind of Robin-Hood Medicine currently
      forbidden by Medicare.

      For those who believe in ACA, please consider the following:

      1. http://www.youtube.com/watch?v=ULy5vjcGuDc
      2. http://www.youtube.com/watch?v=hV-05TLiiLU
      3. http://www.jpands.org/vol15no3/orient.pdf .

      “The only winning move is not to play.” — Matthew Broderick, 1983

      HButler@post.Harvard.edu

  13. Mainer March 22, 2011 at 11:19 pm #

    I am one of the 80% with “health insurance.”

    For $600 a month, I can rest easy knowing that my $30,000 annual family deductible means that if one of us is involved in a serious automobile accident or receives a diagnosis of cancer, I might not lose my house. That is literally all my premium buys.

    NHS? Bring it.

  14. ccyisouthey April 5, 2011 at 5:08 am #

    Interesting story

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