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Don Berwick left CMS last week. When he was appointed, he was vilified  because he used the word “rationing” in polite company. So vilified, in fact, that he was never able to gain the needed 60 votes in the Senate or confirmation and was appointed via the recess route. As a consequence, his appointment expired after a calendar year and it was for this reason that he stepped down.

Dr Berwick was never known for his shy, retiring demeanor and now that he is no longer in government service he is once again “telling it like it is.” He was awarded the Picker award at the Institute or Healthcare Improvement annual meeting and in his address he seemingly called out his opponents:

The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry ‘foul’ about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people — elders, the poor, the disabled –who are least able to bear them,” he said, according to a copy of his remarks.

Dr Berwick points out that the country is at a crossroads. If we attempt to reduce our country’s health care responsibilities through indiscriminate cutting, his concern (as is mine) is that the cutting will begin at the “voiceless and the poor” but won’t stop there. Soon, as a consequence of lower benefits, less access, increased payment burden for necessary services, and delays in care delivery, our country’s health care quality will further decay and the cost will remain high. Dr Berwick identifies six domains that our health care system has failed us:

  • Overtreatment – the waste that comes from subjecting people to care that cannot possibly help them – care rooted in outmoded habits, supply-driven behaviors, and ignoring science.
  • Failures of Coordination- the waste that comes when people – especially people with chronic illness – fall through the slats. They get lost, forgotten, confused. The result: complications, decays in functional status, hospital readmissions, and dependency.
  • Failures of Reliability – the waste that comes with poor execution of what we know to do. The result: safety hazards and worse outcomes.
  • Administrative Complexity – the waste that comes when we create our own rules that force people to do things that make no sense – that converts valuable nursing time into meaningless charting rituals or limited physician time into nonsensical and complex billing procedures.
  • Pricing Failures – the waste that comes as prices migrate far from the actual costs of production plus fair profits.
  • Fraud and Abuse – the waste that comes as thieves steal what is not theirs, and also from the blunt procedures of inspection and regulation that infect everyone because of the misbehaviors of a very few.

How do we avoid this undesirable fate? Dr Berwick refers to the Affordable Care Act as a “majestic law” and feels that if we work effectively we can save $1,000,000,000 in health care costs. He outlines 5 prinicples all of us in healthcare should follow:

  • Put the patient first. Every single deed – every single change – should protect, preserve, and enhance the well-being of the people who need us. That way – and only that way – we will know waste when we see it.
  • Among patients, put the poor and disadvantaged first – those in the beginning, the end, and the shadows of life. Let us meet the moral test.
  • Start at scale. There is no more time left for timidity. Pilots will not suffice.
  • Return the money. This is the hardest principle of them all. Success will not be in our hands unless and until the parties burdened by health care costs feel that burden to be lighter. It is crucial that the employers and wage-earners and unions and states and taxpayers – those who actually pay the health care bill – see that bill fall.
  • Act locally. The moment has arrived for every state, community, organization, and profession to act. We need mobilization – nothing less.

It is not going to be easy work. As Dr Berwick points out, the “pace of change is majestic.” We now have the framework for health care improvement. Leadership will now not come from the top but will come from those of us in the trenches. Let’s get to work!

In February 2009 President Obama made electronic health information a part of the American Recovery and Re-investment Act. Our Family Medicine group had been pushing the larger University Practice to purchase such a system for a little while (oh, about 15 years) so we have been anticipating this. Yesterday, we used the system in actual patient care for the first time. My observations are as follows:

1) Why is “go live” a noun, verb, and adjective?

2) Why do computer tech folks and donuts go so well together?

3) Who knows how many steps it takes to write a prescription? I do now and it is a lot.

4) When given a choice between the doctor-patient relationship and the doctor-computer relationship which will we choose?

5) You ever notice how when you rent a car, the clerk stares intently at the screen wondering how to ask you one of the more stupid questions imaginable just because it’s on a computer screen? I now know how those clerks feel…

6) Why not let the doctors decide if medical terms are misspelled instead of Mr Gates?

7) How many different ways can you tell someone “I’m sorry but we’re learning this new system and…”?

As you might be able to determine from reading my entries regarding the new health reform law,  I am excited about the possibilities and am looking forward to seeing how the regulations are written that implement the law. There are many agencies who will have a hand in regulation, but none more important than CMS. This agency sets the tempo and tone for the entire health care enterprise in this country. They dictate payment rules for Medicare. They dictate eligibility requirements for Medicaid. They set rules regarding the training of resident physicians. In short, although we may have believed we have a “market-based” health care system, in reality I worked in a system whose rules were dictated by some faceless bureaucrat that ran the Center for Medicare and Medicaid Services. This has been brought home to me at intervals when I am told that I have to turn my training program upside down to satisfy “CMS.”

This is why I am very excited about the news that Don Berwick will be named to head up CMS. I have been a huge fan of his organization, the Institute for Health Care Improvement, for the last 10 years. I first became aware of this organization when I decided that there must be a better way to see patients in a primary care setting than the way we were doing it. I began looking for others who believed in primary care and ran across IHI and their “Idealized design of Clinical Office Practice” project. Although we were unable to participate in these programs, I eagerly read about their efforts to incorporate:

  • Access: Care is available when patients want and need it. 
  • Interaction: Every patient is the only patient.
  • Reliability: “All and only” effective and helpful care is given.
  • Vitality: The practice is sustainable and continually innovating.

into clinical practice and we have been striving to make our changes in our clinical practice leading to enhanced care as a consequence. Much of the work of the Patient Centered Primary Care Collaborative is built on IDCOP principles.

Don Berwick’s organization has as its goals:

 No needless deaths
 No needless pain or suffering
 No helplessness in those served or serving
 No unwanted waiting
 No waste
 No one left out

and the strategy to accomplish this is to build will and optimism for change, drive broad scale adoption of sound changes, invent new solutions, build the future healthcare workforce, and to stay vital for the long haul by achieving excellence in loyalty, financial stability, and worklife for IHI.
Although I doubt he knows who I am, my interactions with Don have been rewarding and we practice better medicine because of my interactions with him and his organization. I look forward to watching him (should he be confirmed) change the culture at CMS. These are interesting times…