July 7, 2010
POSITION: ADMINISTRATOR, CENTER FOR MEDICARE AND MEDICAID SERVICES (CMS)
NOMINEE: Donald M. Berwick
BIRTHDATE: 1946 in New York City, NY
B.A., Harvard University
M.P.P., John F. Kennedy School of Government, Harvard University
M.D. 1972, Harvard Medical School, Harvard University
FAMILY: wife Ann (Greenberg) Berwick; father of four children (two sons and two daughters)
President and Chief Executive Officer, Institute for Healthcare Improvement (IHI)
Clinical Professor of Pediatrics and Health Care Policy, Harvard Medical School
Professor of Health Policy and Management, Harvard School of Public Health
Associate in Pediatrics at Bostons Childrens Hospital
Consultant in Pediatrics at Massachusetts General Hospital
Liaison to the Institutive of Medicines Global Health Board and serves on the governing council
1991-2001 Chair of the National Advisory Council of the Agency for Healthcare Research and
1995-1999 Chair of the Health Services Research Review Study Section of the Agency for Health
Care Policy and Research
1990-1996 Vice Chair of the U.S. Preventive Services Task Force
1987-1991, Co-founder and Co-Principal Investigator for the National Demonstration Project on
Quality Improvement in Health Care (NDP)
Member of the Institute of Medicine of the National Academy of Sciences
2005 Honorary Knight Commander of the Most Excellent Order of the British Empire
2004 Inducted as Fellow of the Royal College of Physicians in London
2002 Award of Honor from the American Hospital Association
2001 Alfred I. DuPont Award for excellence in childrens health care
1999 Ernest A. Codman Award
ON RATIONING AND SINGLE PAYER SYSTEMS
The decision is not whether or not we will ration care—the decision is whether we will ration with our eyes open.”
“You plan the supply; you aim a bit low; historically, you prefer slightly too little of a technology or service to much too much; and then you search for care bottlenecks, and try to relieve them.”
Limited resources require decisions about who will have access to care and the extent of their coverage. The complexity and cost of health care delivery systems may set up a tension between what is good for the society as a whole and what is best for an individual patient…Hence, those working in health care delivery may be faced with situations in which it seems that the best course is to manipulate the flawed system for the benefit of a specific patient…rather than to work to improve the delivery of care for all.
If we could ever find the political nerve, we strongly suspect that financing and competitive dynamics such as the following, purveyed by governments and payers, would accelerate interest in the Triple Aim and progress toward it: (1) global budget caps on total health care spending for designated populations, (2) measurement of and fixed accountability for the health status and health needs of designated populations, (3) improved standardized measures of care and per capita costs across sites and through time that are transparent, (4) changes in payment such that the financial gains from reduction of per capita costs are shared among those who pay for care and those who can and should invest in further improvements, and (5) changes in professional education accreditation to ensure that clinicians are capable of changing and improving their processes of care. With some risk, we note that the simplest way to establish many of these environmental conditions is a single-payer system, hiring integrators with prospective, global budgets to take care of the health needs of a defined population, without permission to exclude any member of the population.
Rational healthcare stakeholders are eroding a common good, simply doing what makes sense to them individually. In the short term everyone wins, but in the long term, everyone loses. … Healthcare is not entitled to everything it has, and it is surely not entitled to everything it can get.
If I could wave a magic wand…health care [would be] a common good—single payer…health care [would be] a human right—universality is a non-negotiable starting place…justice [would be] a prerequisite to health—equity is a primary quality goal.
ON THE FREE MARKET AND CAPITALISM
Fifth, please dont put your faith in market forces. Its a popular idea: that Adam Smiths invisible hand would do a better job of designing care than leaders with plans can. I do not agree. I find little evidence anywhere that market forces, bluntly used, that is, consumer choice among an array of products with competitors fighting it out, leads to the health care system you want and need. In the US, competition has become toxic; it is a major reason for our duplicative, supply-driven, fragmented care system. Trust transparency; trust the wisdom of the informed public; but, do not trust market forces to give you the system you need. I favor total transparency, strong managerial skills, and accountability for improvement. I favor expanding choices. But, I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.
At the individual level, I dont trust incentives at all. I do not think its true that the way to get better doctoring and better nursing is to put money on the table in front of doctors and nurses. I think thats a fundamental misunderstanding of human motivation. I think people respond to joy and work and love and achievement and learning and appreciation and gratitude-and a sense of a job well done. I think that it feels good to be a good doctor and better to be a better doctor. When we begin to attach dollar amounts to throughputs and to individual pay, we are playing with fire.
Berwick complained the American health system runs in the “darkness of private enterprise,” unlike Britain’s “politically accountable system.” The NHS is “universal, accessible, excellent, and free at the point of care — a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just”; America’s health system is “toxic,” “fragmented,” because of its dependence on consumer choice.
In the United States, those hundreds of insurance companies have a strong interest in not selling health insurance to people who are likely to need health care. Our insurance companies try to predict who will need care, and to find ways to exclude them from coverage through underwriting and selective marketing. That increases their profits. Here, you know that that isnt just crazy; it is immoral.
ON REDISTRIBUTION OF WEALTH
You could have protected the wealthy and the well, instead of recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just, equitable, civilized, and humane must must redistribute wealth from the richer among us to the poorer and less fortunate.
ON BRITAINS NATIONAL HEALTH SERVICE (NHS) AND NATIONAL INSTITUTE FOR HEALTH AND CLINICAL EXCELLENCE (NICE)
There is less progress in some areas…such as in specialty access, cancer outcomes, patient-centeredness, life expectancy and infant mortality for socially deprived populations.
I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country.
The National Health Service is one of the truly astounding human endeavors of modern times.
We think nationalized health care was a wise choice in 1948 and that it remains so now.
NICE is not just a national treasure, he says, it is a global treasure.
NICE is extremely effective and a conscientious, valuable, and importantly knowledge-building system. The fact that its a bogeyman in this country is a political fact, not a technical one.
“I hope you will never, ever give up what you have begun,” said Berwick. “I hope you realize and affirm how badly you need — how badly the world needs — an example at scale of a health system that is universal, accessible, excellent and free at the point of care — a health system that, at its core is like the world we wish we had: generous, hopeful, confident, joyous and just. [Source]
Some background on Britains system…
Michael Tanner notes that, NICE, however, is not simply a government agency that helps bureaucrats decide if one treatment is better than another. With the creation of NICE, the U.K. government has effectively put a dollar amount to how much a citizens life is worth. To be exact, each year of added life is worth approximately $44,305 (30,000). Of course, this is a general rule and, as NICE chairman Michael Rawlins points out, the agency has sometimes approved treatments costing as much as $70,887 (48,000) per year of extended life. [Source]
Dr. Milton R. Wolf notes that, Britain’s higher cancer mortality rate results in 25,000 more cancer deaths per year compared to a similar population size in the United States. But because the U.S. population is roughly five times larger than the United Kingdom’s, that would translate into 125,000 unnecessary American cancer deaths every year. This is more than all the mothers and fathers, aunts and uncles, cousins and children in Topeka, Kan. And keep in mind, these numbers are for cancer alone. America also has better survival rates for other major killers, such as heart attacks and strokes. [Source]
Robert M. Goldberg writes, It may not be joyous or just or configured correctly, but for nearly every disease, particularly cancer, stroke, and heart attacks, Americans live longer and healthier than the English because of better care. Americans spend less time in the hospital, have fewer doctors, and see doctor’s less often per capita than people in Great Britain. In the past two years the number of people waiting over three months to see a doctor in the NHS has increased by 50 percent. Productivity of the NHS — which was Berwick’s principal mission — declined 2.5 % over the past five years. Last year it cut primary care services and wound up with a 2 billion pound surplus. The NHS spent the money not on patients but on equipment, bonuses, and consultants in an end of the year rush. Meanwhile hospital-acquired infections in the UK remain as high as ever while they decline in “toxic” America. [Source]