OBAMA FOR USA

Donald Berwick, the new and controversial head of Medicare and Medicaid, has a bum knee.

The trouble started about 40 years ago when Berwick, playing soccer, suffered a painful partial dislocation of his kneecap. He underwent surgery, which was unsuccessful and followed by a second surgery, and he later developed a terrible case of osteoarthritis.

Beyond the pain, the whole incident troubled Berwick because the first knee surgery was later discredited for his injury. "In retrospect, a brace and some exercises would almost certainly have been enough," he wrote in a 2005 journal article describing the experience. "My first knee operation may well have been done not because my knee problem was there, but because the knee surgeon was there."

The story epitomizes the controversy surrounding Barack Obama's new top health care official, named to his job in July. His critics think he wants to ration all health care. His fans believe he understands better than anyone how hospitals and physicians operate inefficiently and profit from unnecessary procedures when less invasive, simpler and cheaper remedies can sometimes work as well - or even better.

It is hard to know for sure because Berwick has been all but invisible since Obama installed him via a recess appointment as the head of the Centers for Medicare and Medicaid Services (CMS). Still hoping to keep Berwick - and criticisms of health reform - out of the spotlight, the White House has declined to make him available for media interviews. "Apparently," quipped one health care policy expert, "they have him in a cave somewhere."

But not for long. Berwick will give the first public speech of his tenure on Sept. 13 at a Medicare and Medicaid conference in Washington, D.C.

Interest in his remarks will be high because Berwick is perhaps the single most powerful person in American health care, overseeing a 2011 budget of $759 billion - larger than the Pentagon's - and a bureaucracy that includes 4,500 employees providing health coverage for some 100 million Americans. As part of the new Affordable Care Act, Berwick will begin the process of cutting some $500 billion from Medicare - largely by eliminating subsidies for the private insurance program known as Medicare Advantage - and lay the groundwork for adding 16 million Americans to the Medicaid rolls. He will also head up an effort to reform Medicare through a series of pilot projects that hold perhaps the greatest hope for slowing the runaway health care spending that has the system - and the country - on a path toward financial ruin.

Before he became a lightning rod for Republican criticisms, Berwick was a pediatrician. He earned his medical degree from Harvard - picking up a master's degree in public policy at the same time - and went to work at several hospitals in Boston. While still a young doctor, in 1979, Berwick began working for a health-maintenance organization (HMO) where he was put in charge of quality assurance. Searching for ways to measure doctor and hospital performance - the U.S. health care system does shockingly little of this even today - Berwick got interested in the ways large companies measured their production processes to become more efficient. He met with executives at Toyota, Bell Labs, GE and even NASA, eventually launching a nationwide demonstration project to teach health systems how to adopt some of the efficiency and quality practices common in non–health care sectors.

By 1991, Berwick had left the HMO to start the Institute for Healthcare Improvement (IHI), a nonprofit research firm dedicated to improving health care quality. He partnered with health systems in the U.S. and abroad to measure outcomes and institute systems to save money and reduce patient injuries and unnecessary deaths; along the way, he became a cult figure in the health-policy world with a reputation as an innovator.

He also became the country's leading proponent of patient-centered care. This notion may sound abstract, but Berwick has gained a following - even among doctors - for urging medical professionals to pay closer attention to what patients want. Ending limits on hospital visiting hours is a Berwick hallmark, as is open-access scheduling, which allows patients to get same-day appointments in doctors' offices.

Critics say he will bring a heartless, bottom-line sensibility to CMS, but the vast majority of Berwick's writings, speeches and policy work suggest exactly the opposite. In a May 2009 journal article titled "What Patient-Centered Should Mean: Confessions of an Extremist," Berwick wrote that the way hospitals currently treat patients makes him fear being a patient himself. "What chills my bones is indignity. It is the loss of influence on what happens to me. It is the image of myself in a hospital gown, homogenized, anonymous, powerless, no longer myself."

Berwick also served on a panel that published an influential 1999 Institute of Medicine report that found that up to 98,000 Americans die unnecessarily every year due to preventable medical errors. In the report's wake, hospitals across the country contracted with Berwick's firm to figure out ways to improve their own statistics. Eventually, more than 3,000 hospitals joined an IHI campaign to share data about what worked and what didn't, as well as strategies to reduce infections and errors. The result, according to IHI, was 122,300 lives (and countless dollars) saved in just 18 months.

That's a lot, but there is still much room for improvement. A June study commissioned by the Society of Actuaries found that 1.5 million injuries caused by medical errors in 2008 led to $19.5 billion in wasteful spending.

Berwick has some Republican fans. The notion that a rogue Berwick plans to enact a rationing agenda is "ridiculous," says Gail Wilensky, who served as a CMS administrator under George H.W. Bush and who has advised Berwick on how to approach his new job. Elsewhere, Berwick has been endorsed nearly across the board, with the list of medical associations, hospitals and patient-advocacy groups that want him to lead CMS running to seven single-spaced pages. Three former CMS administrators who served under Republican administrations back him, including Mark McClellan, who held the job from 2004 to 2006. McClellan has also counseled Berwick. Among his advice: Don't take anything personally. "A lot of people talk about health care reform as being just about expanding coverage and that's important," says McClellan. "But if we really want to do something about cost and quality, we've got to find better ways to deliver care. That's where Don can have the most extensive and direct role."

Notably, Berwick has never said health care decisions should be based on cost - i.e., explicitly rationed - but he contends that there are billions of dollars of waste in the U.S. health care system that could be eliminated without any effect - except possibly fewer unnecessary knee surgeries. "There are a lot of tests done, a lot of procedures, a lot of hospital admissions which we really know scientifically cannot help the patient," he told a PBS interviewer in 2009. "I think working hard on the overuse of ineffective practices is a very good way for us to save money and not harm a hair on a patient's head."

Critics might say that while this might be true, government shouldn't be the one choosing which procedures and practices are worth doing. Yet Medicare, the world's largest health care payer, already does this, deciding which medical care it will reimburse. Private insurers, taking their cues from Medicare, do it too.

Medicare is such a driver of the overall U.S. health care system that the Affordable Care Act in fact targets most of its real reform within the program itself. The law calls for a series of Medicare payment-demonstration projects - familiar territory for Berwick - that will allow hospitals and health systems to experiment with changing systems and payment structures to reward quality and save money in the process.

The success of these demonstration projects could determine if the Affordable Care Act changes the practice of medicine and saves money or whether it simply cuts one entitlement program (Medicare) while expanding another (Medicaid) and creating a whole new one (federal subsidies to help Americans buy private insurance).

Berwick will have the final say on which Medicare pilot projects get funding and he will choose the head of the Center for Medicare and Medicaid Innovation, a newly created division where "all our hopes and fears lie," according to Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University. Wilensky, the former CMS administrator, agrees. "Ninety percent of what might be regarded as health care reform is tied up in that innovation center," she says.

Lofty efficiency goals notwithstanding, the first job of any CMS administrator is "just managing the fire hose," says McClellan. And whether Berwick has the management chops to run a massive federal agency is less clear. "I don't feel like a leader - inattention to detail is my biggest defect," Berwick told U.S. News & World Report in 2006. "I want everyone to like me, and yet I'm aware that when you're pushing for change, that isn't always going to happen. To be more effective as a leader, I would probably want to thicken my skin."

And though under the terms of a recess appointment he only has his job until January 2012, Berwick will be called to testify on Capitol Hill in the coming months. "Right now, he's in there as damaged goods and he can only hide so long," says Republican Senator John Barrasso, a leading Berwick critic. "We're going to smoke him out."

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Monday, 13 September 2010

Donald Berwick: Obama's Health Care Czar Takes the Stage

OBAMA FOR USA

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