Friday, September 24, 2010


We live in a time when optimism is in short supply. Large majorities of voters believe the country is on the wrong track. We don't trust insurance companies, Wall Street, or the news media, and we especially don't trust the government. The Pew Research Center characterizes it as "a perfect storm of conditions associated with distrust of government - a dismal economy, an unhappy public, bitter partisan-based backlash, and epic discontent with Congress and elected officials." But ratings "are just as low for the impact of large corporations (25% positive) and banks and other financial institutions (22%). And the marks are only slightly more positive for the national news media (31%) labor unions (32%) and the entertainment industry (33%)."

It was refreshing, then, for me to hear a committed public servant today tell the ACP's Board of Governors that "optimism is the crucial resource" in improving the American health care system. The public servant is Dr. Don Berwick, the administrator of the agency (CMS) that runs Medicare and Medicaid and that is responsible for much of the implementation of the Affordable Care Act.

Dr. Berwick described his vision of CMS as an agency that supports innovation by the private sector - "we have to do this together." He spoke of "partnerships" with physicians, nurses, hospitals, pharmacists and patients to design systems to achieve the "triple aim" of better care, better health, and lower per capita costs. (To learn more about Berwick's triple aim, see this Health Affairs blog from April 20.)

He said that top-down mandates from the federal government won't work. Instead, he spoke of an unparalleled opportunity for physicians to be leaders in designing systems to improve care and the heath of the population, and to reduce health care costs. Cost reductions, he argued, can be achieved "without ever harming a single hair on the patient’s head," if we commit to eliminating treatments that have no benefit to the patient. He sees the government playing a supporting role by providing funding and re-aligning incentives to support innovation at the community-level. His optimism is ground in the many examples where physicians have been leaders in building better systems to reduce fragmentation, improve patient safety, and reduce costs.

But Dr. Berwick also suggested that there needs to be an authentic commitment by all involved to creating a better health care system and that those who instead want to repackage the status quo will not serve the public interest. He praised ACP for its leadership in proposing ways to reduce ineffective care while improving the care of patients and the overall health of the population. ACP's Board of Governors reacted very positively to Dr. Berwick's remarks, with many of the governors offering ideas on how to achieve his triple aim.

Now, I anticipate that given the intense levels of distrust of government, some who read this blog will react to my description of Dr. Berwick's remarks dismissively. You'll probably tell me that ACP is being taken in by yet another "bureaucrat" who heads an agency that, in the minds of many physicians, exemplifies big and unresponsive government - even though this goes against the grain of everything that Dr. Berwick has said and written about how change must come from the bottom-up.

The question in my mind really isn't whether we can or should "trust" the government to do the right thing, even when led by good people like Dr. Berwick, but whether we have confidence in ourselves. Confidence that the can-do spirit that has made America such a great country still lives. Confidence in our own capacity to build a health care system that achieves Dr. Berwick's triple aim of better care, better health, and lower costs. If we can regain such confidence in ourselves, then there is every reason to be optimistic about the future of American health care.

Today's question: How optimistic are you that we can build a better health care system that achieves Dr. Berwick's triple aim?


Arvind said...

Unfortunately, this is simply hollow talk from Dr. Berwick. If he truly wishes cooperative effort with physicians, then why send bounty hunters after them? Why consider every physician a fraud unless proven otherwise? Why not interact with physicians in the trenches before creating rules for CMS? Why create top-down measures such as PQRI (which is an ineffective way of measuring quality)?

If Dr. Berwick truly wishes a cooperative relationship with physicians, CMS must first establish durable trust with physicians - the first act would be to dismantle RAC's. Then stop enforcing price-fixing; and let Medicare beneficiaries decide who they want to receive their care from, i.e. make value-based decisions at a personal level. Third, stop the establishment of cook-book medicine via establishment of artificial processes like Comparative Effectiveness, etc. Finally, if government can determine "ineffective care", they should also determine "ineffective lawsuits" and set up alternate methods of addressing patient complaints, i.e. stop the lawsuit factory that is currently in full force.

Actions, I'm afraid, speak louder than words. So far no such actions from Dr. Berwick.

ryanjo said...

Thomas Scully, CMS Administrator (Feb 2002): "My personal view, what's going to happen increasingly, is that we're going to economically shift toward higher copayments, higher deductibles, and having people be more sensitive. They're still going to get everything they need, but they're going to start paying more and so they're going to start making more reasonable choices." (Two years later, resigned after lying to Congress about the cost of Medicare D)
Kerry Weems, CMS Administrator (September 2008): "A new era of transparency and accountability must begin." (Shortly afterwards, Weems abruptly cancelled the Medicare Health Support program for chronic disease management.)
Dr. Berwick, CMS Administrator (September 2010): "We have to do this together." (A few weeks after his recess appointment, to avoid Congressional oversight).

Hearing these statements, how could one not be optimistic?

Okay Dr. Berwick, we've heard the talk. Now it remains for you to walk the walk. Let's see you immediately reverse several oppressive CMS policies that punish your physician "partners-to-be" and their patients:
-25 day waiting period to pay clean claims (what right do you have to hold my payments?)
-non-coverage for Zostavax and several other inexpensive preventive measures
-stopping payment to physicians for simply changes of address, often as long as 2 months
-allowing private Medicare D intermediaries to harass patients with "preauthorization" requirements for drugs they have taken for years
-physicians participating in Quality Improvement initiatives are subjected to byzantine requirements, payments are delayed for years, and denials are never explained. Not to mention that the data collected is never found again, no less available to improve medical care
As the Chief of CMS, why not change this today?

"If you pretend to be good, the world takes you very seriously. If you pretend to be bad, it doesn't. Such is the astounding stupidity of optimism." - Oscar Wilde

Jay Larson MD said...

I am 0.009% optimistic that the U.S. can build a better health care system that achieves Dr. Berwick's triple aim of better care, better health, and lower costs. "Better care" and "better health" are subjective and therefore can not be defined in a way that all agree on. Only "lower costs" is objective and can be measured reliably.

The big probable I see is that Dr. Berwick talks about populations and those of us involved with front line medicine are involved with individuals. Individuals can have a favorable response to treatments that have "no benefit" based on "group" studies. Placebo controlled studies have shown that placebos have a positive response in some patients of the study.

Arvind and Ryanjo point out some of the difficulties that have been pushed onto physicians by CMS. For physicians to apply their "can do spirit" to work towards a better health care system, they first have to be dug out of the rubble and be resuscitated.

Then there are the current incentives of our health care system. These definately need to be changed. Move the carrot towards spending time with patients so that their needs can be met. Don't keep using the rod so that people are treated like livestock being run through the chutes.

If Dr. Berwick wants some ideas on how to improve our system, he should sit down and talk to small office general internists who still are practicing. This group of physicians are still able to survive, even though the system is stacked against them. They must be doing something right.

Steve Lucas said...

While I agree that the negative attitude, and partisan politicking, have reached a level that should embarrass all of those involved. I am also surprised at the generous positive comments directed at Dr. Berwick, given that the ACP will soon be in a position of effectively negotiating with him on behalf of its members.

Steve Lucas