Letter Supporting CMS Nominee Donald Berwick Tries to Dispel Rationing Concerns

June 30, 2010

June 30, 2010 — In a sequel to the partisan healthcare reform debate, approximately 90 groups representing physicians, health plans, consumers, and businesses sent a letter to the Senate Finance Committee this week urging Congress to confirm patient-safety advocate Donald Berwick, MD, as administrator of the Centers for Medicare and Medicaid Services (CMS).

The letter represents the latest blue-chip endorsement of a physician who is dubbed "Dr. Death Panel" in the blogosphere and painted as an advocate of rationing by Congressional Republicans. Dr. Berwick, the president and chief executive officer of the respected Institute for Healthcare Improvement (IHI), was tapped for the CMS post by President Barack Obama in April. The Senate Finance Committee is expected to consider his nomination after July 4 — a prelude to a vote by the full Senate.

Since his nomination, Republicans have tried to portray Dr. Berwick — an admitted fan of the National Health Service (NHS) in the United Kingdom — as President Obama's point man for socialized medicine.

"Now we have this nominee who is applauding — applauding — a system where care is delayed, denied, or rationed," Senate Minority Leader Mitch McConnell (R-KY) said on the Senate floor last month. Sen. Pat Roberts (R-KS) chimed in, saying, "Dr. Berwick is the perfect nominee for a president whose aim has always been to save money by rationing healthcare. Dr. Berwick is the wrong man, wrong time, wrong job."

Yesterday's pro-Berwick letter to the Senate Finance Committee countered that Dr. Berwick and his beliefs have been misrepresented.

"Specifically, it has been suggested that Dr. Berwick is an advocate of health care rationing and that he in some way supports the government making health care decisions that should be made by patients and their doctors," the letter stated. "This misrepresentation does a disservice to Dr. Berwick, who has a long history of as a leader in promoting patient-centered care."

Signatories to the letter included the American Academy of Family Physicians, the American Osteopathic Association, the American College of Physicians, the National Business Coalition on Health, Wal-Mart Stores, Kaiser Foundation Health Plan, the AFL-CIO, Consumers Union, and the Alzheimer's Association.

Berwick's Group Has Fought for Quality Improvement in the Trenches

Dr. Berwick's supporters extend beyond the names on yesterday's letter to the Senate Finance Committee. Heavyweight groups such as the American Medical Association, the American Hospital Association, and the AARP are on the record applauding his nomination. Even former CMS chiefs from the administrations of George W. Bush and George H. W. Bush have reportedly given him the nod for the job.

Dr. Berwick's popularity may stem partly from his track record in actually improving the nation's healthcare system as opposed to merely theorizing about it. The IHI, the organization he heads, has worked with numerous hospitals and health systems to unclog emergency departments, reduce ventilator-associated pneumonia, prevent patient falls, and speed up treatment for heart attack victims.

On a grander scale, the IHI partnered with more than 3000 hospitals in the so-called 100,000 Lives Campaign to reduce preventable mortality. The letter sent to the Senate Finance Committee in support of Dr. Berwick noted that the campaign saved an estimated 122,300 lives in 18 months. The IHI followed up with a second campaign called Protecting 5 Million Lives From Harm to address surgical complications, methicillin-resistant Staphylococcus aureus infections, pressure ulcers, and other instances of treatment going awry.

"These groundbreaking initiatives are the hallmark of Dr. Berwick's work and the type of innovative leadership CMS needs," the letter to the Senate Finance Committee stated.

In addition, the IHI has gone global, collaborating with other groups to improve maternal and neonatal care in Malawi, treat patients with AIDS in South Africa, and battle multidrug-resistant tuberculosis in Peru.

"We've Got These Radioactive Words — One of Them Is 'Rationing' "

Dr. Berwick's medical career does not exactly square with the label of "death panel czar" that one blogger has pinned on the pediatrician. But opponents have seized on comments that Dr. Berwick has made in numerous speeches, articles, and books to cast him as a dangerous man.

Dr. Berwick, for example, once told a UK audience that he was "a romantic" about the NHS. "You cap your healthcare budget, and you make the political and economic choices you need to make it to keep affordability within reach," he said. "And you leave no one out." He even dared to say that a just healthcare funding plan must "redistribute wealth from the richer among us to the poorer and less fortunate."

Some critics have construed such remarks as signaling a Marxist plan to replicate the NHS here. Internist Nancy Nielsen, MD, the immediate past president of the American Medical Association, however, argues that such fears are not warranted.

"We're not going to go with [the NHS] system, and Berwick knows that," Dr. Nielsen told Medscape Medical News, adding that he criticizes the NHS just as she does. "It has a problem with access to care, and quality," Dr. Nielsen said.

Other controversial comments from Dr. Berwick come from an interview he gave to a magazine called Biotechnology Healthcare in 2009 on comparative effectiveness research (CER), which the federal government will conduct under the new healthcare reform law. A fixture in the NHS, CER aims to determine which medical tests, procedures, and medications do the best job of reducing morbidity and mortality. CER also needs to consider cost-effectiveness, Dr. Berwick said in the interview, adding that how a society applies such findings to its healthcare budget — whether in the form of mandatory rules or suggested guidelines — is a matter of choice.

"If a new drug or procedure is effective, and has some advantage over existing alternatives, then does the incremental benefit justify the likely additional cost?" he asked.

"The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open," Dr. Berwick went on to say. "And right now, we are doing it blindly."

The American Medical Association's Dr. Nielsen contends that critics have distorted Dr. Berwick's remarks, which she characterized as commonsensical.

"I think everybody wants to get the best value for their dollar," she said. "And doctors need better evidence to make the right decisions.

"We've got these radioactive words, and one of them is 'rationing.' I think we ought to give up that word. It conjures what insurance companies do."

Similar to Dr. Berwick, Dr. Nielsen said the United States already rations care — based on price. "People who don't have enough money can't get [needed] procedures and drugs."

Will Senate Put Aside Its "Political Knives"?

Dr. Nielsen said she views Dr. Berwick as a visionary leader who has unfortunately stepped into a "poisonous political atmosphere."

"I sincerely hope that the Senate will put aside its political knives and look at his entire record," she said.

Len Nichols, PhD, a health policy professor at George Mason University in Arlington, Virginia, told Medscape Medical News that the debate over Dr. Berwick — whom he supports — is not so much about the physician as it is about "our vision of government."

Republican opponents, Dr. Nichols said, have created a caricature of Dr. Berwick in an effort to force President Obama to withdraw his nomination. But if and when Dr. Berwick appears before the Senate Finance Committee, scorched-earth rhetoric could give way to a saner discussion of the issues, he said.

"The best defense against the claim that Berwick is Dr. Death is having him in front of a microphone talking to the committee about his commitment to patient care," said Dr. Nichols.

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