Rationing Care? Death Panels?
Dr. Topol: In the background, you were dealing with people saying that you're trying to ration care and set up a death panel. Did all these ridiculous things upset you at all?
Dr. Berwick: It was ridiculous. Rationed care? I'm a pediatrician, for Pete's sake. I've gone to the mat over and over again for my patients.
We've built this kind of volume-based, do-more-and-more-stuff healthcare industry, and I've very systematically looked for years at the levels of overuse and the administrative hassles in healthcare, as well as the failures of coordination and the problems of reliability, and these add up to the total. We now have the data that 30%-40% of care is just wasted.
Dr. Topol: You've written about this in different pieces, but there is a particular JAMA article I reference quite a bit and which I think is extraordinary. You estimated that healthcare waste was about 20% but could be as much as 40%. How can we get that on track?
Dr. Berwick: It's not going to be easy. After all, we have a legacy of a century built on the current payment system; the current training systems; and the current inherited structures, capital structures, and labor structures. But to me, the key is to focus on the patient. We just go back to the question, "What will help the patient?" And if there is something we're doing that doesn't help the patient that means we can stop doing it. It's the intellectual route out. We're going to have to change the business models.
Dr. Topol: You can't disagree with that kind of patient-centered logic. But you have physicians -- and most physicians are extraordinary, but some are doing procedures at very high rates that are considered potentially inappropriate or just not the ideal way to practice medicine, and we aren't able to rein that in. Are the ACA and Accountable Care Organizations (ACOs) going to help fix this?
Dr. Berwick: They're a step. Look, this is an expedition we're on here. It's not one step. We're going to have to learn our way to integrated care -- care that meets the triple aim of better care, better health, and lower cost. We kind of built this care system for technocracy, and for miracles, which is great. We can cure leukemias. We can transplant organs. We should never ever, ever give that up.
But those arguments about rationing drove me nuts, because I want to preserve what helps. I understand that it's going to be tough, but we need to change training. We have to help doctors and nurses, and others in healthcare, to really understand more about the ways to focus on a patient's well-being and needs. We need to wean ourselves from fee-for-service, volume-based payments.
Dr. Topol: Can't you just hit a switch and get that fixed? Is there a way to do that?
Dr. Berwick: Frankly, the people who manage our care systems -- CEOs, executives -- they're really smart, and if we change the pitch they'll hit the new pitch. Right now, we still pitch them a financing system that says, "You make your money by staying full. You make your money by being busy. You want the MRI machine on. You want specialists seeing more patients." That's what they do. They're not bad people. They're just playing the game of doing more because we built it that way. All of us did together. It's no conspiracy.
But suppose we change the game. Suppose we say that what we're really after here is staying healthy as long as possible -- prevention, so that patients don't get sick.
We want journeys. I don't know if people understand what I mean by that, but any doctor or nurse, and anybody with a relative who has chronic illness, ought to. Chronic illness is where most of the care is, and for that you need a journey. You need to know that wherever you are, someone's got your back.
The handouts are proper. The medication plan makes sense. You're being taught the proper kinds of self-care. You know the early warning signals. Someone's reaching out to you instead of waiting for the trouble [to come to them]. The last place you want to be is at a hospital. The idea that we get you in the hospital to fix you up is backward. But as long as we pay for volume, we're not going to buy journeys.
When we start paying for journeys, we're saying, "Hey, wait a minute; you're in charge of Ms. Jones over time and space. You've got her back. Here are the resources to take care of her. Do what you know she needs." Then you don't have to keep the wheels spinning. I think that will make a big difference.