Former Head of CMS Berwick Says, 'Things Will Never Go Back'

Leigh Page


October 07, 2015

Editor's Note:
Don Berwick, MD, a pediatrician by training, has been at the very center of US healthcare policymaking for many years. He served as president and CEO of the Institute for Healthcare Improvement (IHI) before heading the Centers for Medicare & Medicaid Services (CMS). Then he entered politics, running for governor of Massachusetts in 2014. In this Medscape interview, Dr Berwick discusses these roles and his take on a variety of pressing issues in healthcare.

Medscape: What do you think you accomplished as CMS administrator?

Don Berwick, MD. Source: Associated Press

Dr Berwick: Devoting myself to the CMS was an amazing experience. I loved it. It was very hard work; there were 18-hour days, and I had to learn new things I didn't know. I had to learn the procedures for writing regulations, interact with the Office of Management and Budget, and comply with the Administrative Procedures Act. [Dr Berwick arrived at CMS in July 2010, 4 months after the Affordable Care Act (ACA) was signed into law. He ran the agency for the next 17 months, overseeing a staff of 5000 and beginning the process of converting the massive law into regulations.]

I basically had three different jobs. The first was to run the agency—the normal work that needed to be done by CMS even while major changes were underway. The second job was carrying out the provisions in the ACA. CMS was responsible for implementing about 70% of the law's components. And the third was to bring about a culture change at the agency—to make it a force for improvement and not just an insurance mechanism. I look back on all of that—especially trying to change the self-image of the agency—with a great deal of satisfaction. I hope that legacy is still there. One of the things I'm most proud of is bringing the Triple Aim to CMS and to our national agenda. [The Triple Aim, a concept developed by the IHI in 2007, when Dr Berwick was in charge, aims to improve the experience of care and the health of populations while reducing the per capita cost of healthcare through improvement.]

In terms of implementing the ACA, one of my proudest achievements was creating the Center for Medicare & Medicaid Innovation (CMMI). It was very high on my list of priorities, and I had to get it going from a standing start. I worked hard to set the initial framework for creating accountable care organizations (ACOs) and establishing bundled payment demonstrations. [The CMMI tests ways to change the healthcare payment system by funding pilot projects through $10 billion in funds designated by the ACA over 10 years. Its work includes such initiatives as ACOs, bundled payments, and primary care transformation.]

I also got to implement a number of terrific new programs at CMS, such as the Community-based Care Transitions Program and the Partnership for Patients initiative. [The transitions program tests models for improving the transfer of patients from hospitals to other settings and reducing readmissions for high-risk Medicare beneficiaries. The partnership initiative works with hospitals to help make hospital care safer, more reliable, and less costly.]

Medscape: Do you think the ACA is here to stay?

Dr Berwick: A lot of people have vowed to tear it down. If the Republicans win the 2016 presidential election, they might try to do that. But if they do, I don't think the American people would go along with it. If the American people were told that the ACA was going to be taken away, I think they would wake up and realize that they'd lose a whole lot of benefits. [The percentage of Americans in favor of the ACA has begun to edge out the percentage of those who oppose it in recent Kaiser Health Tracking Polls,[1] but the majority still don't support the law.]

My view is that the ACA has already benefitted millions of people. There are some really obvious benefits, such as the right of people with preexisting conditions to buy healthcare coverage. How could that right be taken away? Another popular provision is allowing people under 26 to be covered under their parents' insurance policies. Also under the ACA, most insurance policies must waive out-of-pocket charges to patients for preventive care such as colonoscopies and mammograms. [The ACA makes this provision for preventive services that are given an A or B rating by the US Preventive Services Task Force, of which Dr Berwick was vice-chair for many years before becoming CMS administrator.]

If the ACA were suddenly taken away in its entirety, what would take its place? There would be a return to the status quo: to a healthcare system that costs too much, leaves tens of millions of people without coverage, and provides fragmented care. In my opinion, one of the most important aspects of the law is the progress it has made toward enshrining healthcare as a human right in this country. While many Americans are still not covered, millions more have been added to the rolls. The Supreme Court upheld the mandate to buy health insurance, but it is regrettable that it did not uphold the law's Medicaid expansion. [The June 2012 Supreme Court decision upholding the mandate also held that states could not be compelled to expand their Medicaid programs; at this point, 21 states still refuse to do so.[2]]

Federal oversight to establish the health insurance exchanges and improve the benefit structures for commercial insurers was not originally assigned to CMS. This work is handled largely by the Center for Consumer Information & Insurance Oversight, which was originally a separate Office in the Department of Health and Human Services. But then CMS was assigned this function in order to simplify the management and increase policy coordination.

The ACA also boosts primary care. [In 2013 and 2014, Medicaid paid primary care physicians at Medicare rates for evaluation and management codes. And from 2011 through 2015, Medicare awarded these physicians a 10% increase in reimbursements for primary care service codes.]

The law also introduces new forms of financial transparency. [Hospitals will be required to release a standard list of prices, and insurers have to provide a uniform summary of benefits and coverage, and report a wide variety of data about coverage and claims.]

Medscape: What are your goals for healthcare in the United States?

Dr Berwick: My goals are to help create a healthcare system that is just, safe, infinitely humane, and that takes only its fair share of our wealth—that engages only in work that actually improves the lives of patients, families, and communities. Our nation is at a crossroads. The healthcare system we have simply cannot be sustained. What we spend on healthcare takes away precious resources for other parts of the economy and the national infrastructure. Instead of healthcare taking up 18% of our gross national product, I think we could get it down to 15% without any rationing and no harm to patients. That could happen by cutting the waste—and not vital healthcare needs—and by faithfully meeting the real needs of patients and families.

I deeply believe that healthcare is a human right. We are the only Western democracy that hasn't made it a human right. We need to have a system that focuses on patient-centered care. Patients need to be able to experience transparency, individualization, recognition, respect, dignity, and choice in all matters. I also believe in the benefits of data. All philosophies of improvement depend on having information. Without transparency of data, improvement is really stymied. Improvement requires this transparency—turning the lights on—to support learning and to usher in productive changes.

Medscape: Can the US political process support the healthcare changes you envision?

Dr Berwick: The past 7 years have been a very tumultuous time. I always wished that the ACA could have been implemented faster, but because of the political logjam in Washington, it was hard to move as fast as we might have.

The polarized politics in Washington have prevented us from having a true national dialogue on healthcare, which we need in order to design a better system of care. As administrator, I became embroiled in the political process, and there was tremendous confusion. [Dr Berwick was nominated as CMS administrator in April 2010, but his nomination was held up by Republican senators who accused him of advocating healthcare rationing. President Obama finally installed him as a recess appointment in July of that year, but without Senate approval he could serve only temporarily. Under the Constitution, his recess appointment had to end in December 2011.]

I was a recess appointee. I would have stayed if I could, but I couldn't do that under the terms of the Constitution. The accusations that I advocated rationing were distorted, demagogic, and false. I am not in favor of holding back effective, scientifically proven healthcare from anybody. The real rationers were and are the politicians who stand in the way of the Medicaid expansion under the ACA and withhold healthcare from millions of Americans. We saw the same kind of distortion with the so-called "death panels" controversy. That was a travesty in our public debate, and the press enabled it by stoking it without setting the record straight. [The "death panel" debate involved a draft version of the ACA that proposed to reimburse physicians who counsel Medicare patients about end-of-life care. Opponents said this would lead to "death panels" of bureaucrats deciding whether medical care was appropriate for certain patients. The provision was removed from the final bill.]

A year after leaving the agency, I decided to enter politics. Being CMS administrator was my first experience in government, and I was awed and moved by the ability of government to enact change to benefit the people. I ran for governor of my home state, Massachusetts. [In 2013, Dr Berwick announced that he was running for the Democratic nomination for governor of Massachusetts. He was considered to be the most left-leaning candidate in the race—and for the first time, he endorsed a single-payer healthcare system.]

During the campaign, I became even more familiar than I had been with the obstacles that people—especially the poor and disadvantaged—face in education, housing, and employment, as well as in getting healthcare. Solutions for these problems require public investment, but our expensive healthcare system takes money away from this. I believe that a single-payer system could substantially reduce costs while improving care, outcomes, responsiveness, and community health status.

As a politician, it was thrilling to be able to sit and talk with people. I found that the public cares tremendously about the need for humanitarian policies, and they had a sense of caring for each other and for their communities. [Although Dr Berwick lost the 2014 Democratic primary, he outperformed nearly all projections, gaining 21% of the vote.]

Medscape: Do doctors have too many data-reporting requirements?

Dr Berwick: I'm a strong proponent of the use of data to improve care, but I think that now we are overshooting with respect to data-reporting requirements. Meaningful use, ICD-10, and the Physician Quality Reporting System—these are administrative attempts to mold care. I can appreciate that all of this scrutiny and administrative demand make doctors feel very hassled. [These three programs were launched by CMS, and parts of them were planned or implemented during Dr Berwick's tenure, but they were mandated by laws such as the ACA and the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009.]

We are heading toward increasing misunderstanding between physicians and the people who are in charge of financing and regulating the healthcare system. In part, it's the result of an overwhelming burden of measurement and accountability, and very complex rules and procedures for payment. Some top-down requirements can be helpful, but it makes more sense to give physicians the data and let them use it in their own way to make care better. That's how you achieve real improvement.

That said, I don't think things will ever go back to the old way. The mismatch between care and need is too great. Doctors of my generation, who were trained in a different age, are not automatically comfortable with the new circumstances and models of healthcare, such as team-based care, transparency, and useful forms of standardization.

As physicians, we should take responsibility for reducing the cost of care. If we don't, the changes are going to come from outside of the profession, and they will be less wise than changes led by caregivers. Physicians and other health professionals have an opportunity to assume leadership for change. I'm working with the IHI again, and one of the initiatives I am involved in is the Leadership Alliance, which works with about 40 hospitals and healthcare systems that want to achieve the Triple Aim. Those that can do so will be an example of what I call inside-out change—as opposed to change enforced from outside—and that could be catalytic.

Medscape: Should doctors follow clinical guidelines for care?

Dr Berwick: I don't think most doctors are that upset about guidelines. They've been using them for years. When I was in training, my mentors and teachers taught me the guideline for taking care of diabetes patients, and we were expected to follow it—unless we had good reasons not to.

The problem for doctors, I think, is the way that guidelines can be used. When they are used as surveillance—in a punitive, blunt, disrespectful way—doctors are rightfully incensed. Every patient is unique. You have to be smart enough to use guidelines that apply to that one patient, and you should be given the latitude to do so.

As I've said already, I'm a strong proponent of using data to improve care. There is plenty of evidence showing substantial variation in healthcare from place to place around the country. We should be able to agree, in many cases, on what the evidence-based standards ought to be and stick with them. I'm a fan of the use of science and evidence in healthcare.

Many guidelines are still open to question, but when a guideline is not open to question, I have no objection to tying it to payment. That said, adherence to data shouldn't be absolute. Not everything important can be measured, and not everything that can be measured is important.

You can provide doctors with information on their performance, but a numerical scorecard is not enough. You need to interpret the data, and there are different ways of presenting it to doctors. You can set objectives and hold their feet to the fire if they don't meet them—the carrot-and-stick approach—or you can use data for learning. I prefer the learning approach—the doctor as the learning person—because I think it's more profound and respectful.

Medscape: What are your thoughts about Medicare and Medicaid turning 50 this year?

Dr Berwick: I think we should applaud both programs and take pride in what they've accomplished.When these programs started in 1965, they represented an enormous step forward toward healthcare as a human right. That was an incredibly exciting time for healthcare policy, and I think we're in a comparably important era right now. We're unfrozen again.

The Medicare program is doing OK right now, but its future is challenging, due largely to rising healthcare costs. So it isn't Medicare that needs to change; it's healthcare that needs to change. And Medicare could be a force for good in those changes.

Medicare should be a supporter of the new healthcare world. One way it can help is to change the reimbursement structure so that it's more supportive of new and better approaches to healthcare, such as team-based care. People with chronic illness need their caregivers to work together. If the payment is piecemeal—in fragments—then the care is also going to be fragmented.

I'm also extremely enthusiastic about telemedicine. In its best forms, telemedicine allows people to be on the phone or Internet instead of going into the hospital or practice. It could allow access to the world's greatest specialists literally anywhere. Medicare should be encouraging this much more than it has been. [Medicare has begun reimbursing, in some cases, for telemedicine for remote face-to-face services via live videoconferencing, some non–face-to-face services, and home telehealth services.]

Medscape: Should nurse practitioners and physician assistants get wider scope of practice?

Dr Berwick: I'm a supporter of expanded scope of practice. It's a mistake to say that nurse practitioners, physician assistants, and other healthcare professionals represent lower levels of function than doctors. They have complementary skills. We know different things. They can give better care in some areas than we as doctors can give, and they allow primary care physicians to see more patients and have more time to focus on issues most in need of their expertise.

There will always be some things that only physicians can do, but I don't think laws that widen the scope of practice are permitting nonphysicians to do things they aren't qualified to do. It's not just a matter of filling in the gaps; there is a great deal of evidence to show that including other clinical professionals leads to better outcomes, as well as physician and staff satisfaction.

It's hard for a lot of doctors in small practices to accommodate other professionals into their work, but if we put our minds to it, we can find ways to do this through ACOs and other relationships. Healthcare professionals are an integral part of team-based medicine. Moreover, there may be a role for entirely new forms of caregivers. For example, some systems are experimenting very successfully with "resilience counselors," who deal with children and adults who have been abused, and "community paramedics," who help people in their homes.

Medscape: Should coverage be reduced for patients who do unhealthy things, such as not taking their medications?

Dr Berwick: Heavens, no. As I see it, we are guests in the lives of our patients. When patients are not adhering to their medications, that should be information for us. As caregivers, we need to find out why that is. Maybe it's because they cannot afford the prescription, or because taking the drug produces uncomfortable side effects. We should be finding these things out and helping patients do something about them.

Let me say here that I'm an advocate of patient-centered care. To me, that means that the patient is the boss and we are the servants. They should be directing their own care, and we the caregivers should understand and honor what the patient wants. An ideal medical practice would give patients not just what they need but also what they want—within reason. As my IHI colleague Maureen Bisognano puts it, when we try to help people, we ought to be asking not only "What's the matter with you?" but also "What matters to you?" [Bisognano has been CEO of the IHI since Dr Berwick stepped down.]

Medscape: Is the quality of healthcare improving?

Dr Berwick: I feel that we've made significant improvement in certain areas. It's very clear that outcomes are much better for certain complications, such as pressure ulcers, infections in ICUs, and central venous line complications, for example.

We know how to achieve much better coordinated care for people with chronic illness, but we haven't brought this to a systemic level. We need a healthcare system that is more efficient and more equitable. We have to think about total systemic improvement, and that's just not getting done yet.

Medscape: How is it that improving care is linked to reducing waste?

Dr Berwick: In very large measure, improving care and reducing waste are one and the same. This is a fundamental principle about every production system. Poor quality—not meeting people's needs—raises costs. Of course, there are instances when you can add a feature that improves quality and does add to cost, such as adding a sunroof to a car. But in the long run, a car that's a lemon is going to cost more than a car that works right. It's the same in healthcare.

Just six categories of waste—overtreatment, failures of care coordination, failures in execution of care processes, administrative complexity, pricing failures, and fraud and abuse—represent at least 35% of total healthcare expenditures. [These categories of waste were identified in a 2012 article co-written by Dr Berwick in the Journal of the American Medical Association.[3] It estimated that this waste, unabated, would represent a potential $11 trillion of costs in the US healthcare system from 2011 to 2019.]

Eliminating waste does not mean rationing. Quite the opposite. It involves making improvements in the way that care is delivered—making it seamless and coordinated. Better care, better health, and lower cost are all achievable at the same time. I would never, ever want to put us in the position where we're withholding care that would work. If we focus on waste—the non–value-added activities—we'll find that margins for savings without harming a person at all are very, very large.

But if we don't make these changes and just keep with the status quo, then I believe that we are going to get to the point where healthcare spending is no longer tenable. We cannot continue spending 18%, 19%, 20% of the country's income on healthcare. If we get to that point, the temptation is to take services away—first and foremost, cutting back on the safety net, but also reducing access for everyone else. We would save money, but it would be at the cost of our health and our moral compass. That in itself would be a form of rationing. It would be a totally needless tragedy, when instead we could implement a strategy of continual improvement.

Medscape: What is your vision for healthcare in the United States?

Dr Berwick: The Triple Aim—better care, better health, at lower cost—could improve healthcare by a full order of magnitude. The "better care" part is only one element of it. Better health—which includes what we eat, where we live, and how we conduct our lives—is, in fact, a much more significant factor in our health, and we don't pay enough attention to it. This involves issues of social justice. People with low incomes and chronic illness have to carry an extra burden that is not fair or just. To improve care, I believe we need to spend money to upgrade our communities. I know we can get there, as long as we have the will to do so.

At the IHI, I am helping in the 100 Million Healthier Lives campaign, which brings together the best ideas from communities around the world. This involves creating a healthcare system that is both good at health and good at care. It involves building bridges between healthcare, community, public health, and social service systems. And it means addressing the social determinants of health head-on across all sectors of society. I think we can do it.


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