While much of Washington is focused on President Obama’s Supreme
Court pick, Republicans are gearing up for a confirmation battle
over another Obama nominee who promises to put health care back
in the spotlight.
At issue is Obama’s choice to head the Centers for Medicare and
Medicaid Services, Donald Berwick, a Harvard professor with a
self-professed love affair with Britain’s socialized health care
system. In his writings and speeches, Berwick has defended
government rationing and advocated centralized budget caps on
health care spending.
“Cynics beware, I am romantic about the (British) National Health
Service; I love it,” Berwick said
in a July 2008 speech at England’s Wembley stadium. “All I need
to do to rediscover the romance is to look at health care in my
own country.”
While Berwick would not have the authority to impose a British
health care system on the United States in one fell swoop, as
head of CMS, he would be running both Medicare and Medicaid.
Given that the two programs alone account for more than one out
of every three
dollars spent on health care in America (all government
programs combined account for 47 percent), private players tend
to follow CMS’s lead. Berwick himself has made this point.
“(G)overnment is an extraordinarily important player in the
American health care scene, and it has inescapable duties with
respect to improvement of care, or we’re not going to get
improved care,” he said in a January 2005
interview with Health Affairs. “Government remains a
major purchaser.… So as CMS goes and as Medicaid goes, so goes
the system.”
There are two basic visions for how to contain the growth of
health care spending. The free market approach would give
individuals control over their health care dollars, with the idea
that it would encourage more shopping that will drive down costs
and increase quality as has happened in every other aspect of the
consumer-based economy. But the other approach, employed by
nations such as Britain, is to have the government ration care to
meet a global budget.
President Obama rejected the market-based approach, and sought to
drastically expand insurance coverage while reducing health care
costs. But according to a
report by CMS’s chief actuary, the new law will actually
increase health care costs. That leaves rationing of care based
on a bureaucratic notion of the common good as the remaining
option for containing skyrocketing spending, and it’s an outcome
that Berwick himself once predicted would be necessary to achieve
universal coverage.
“(T)he Holy Grail of universal coverage in the United States may
remain out of reach unless, through rational collective action
overriding some individual self-interest, we can reduce per
capita costs,” Berwick
wrote in an article for Health Affairs he
co-authored in 2008.
He went on to write that, “The hallmarks of proper
financial management in a system… are government policies,
purchasing contracts, or market mechanisms that lead to a cap on
total spending, with strictly limited year-on-year growth
targets.”
On a number of occasions, Berwick has praised Britain’s
National Institute for Clinical Excellence (NICE), a body of
experts that advises the government-run health care system on how
to allocate medical spending based on cost-benefit analysis.
Among other decisions, they have ruled against the use of
cancer-treating drugs and
put a dollar value on the final six months
of human life.
“NICE is extremely effective and a conscientious, valuable,
and — importantly — knowledge-building system,” Berwick
said in an interview last June in
Biotechnology Healthcare. “The fact that
it’s a bogeyman in this country is a political fact, not a
technical one.”
The national health care law that President Obama signed in
March will greatly expand the role of CMS by adding an estimated
15 million beneficiaries to Medicaid. In addition, the law
contains a number of initiatives, to be spearheaded by the
Secretary of Health and Human Services in conjunction with the
head of CMS, to provide incentive-based pay to doctors and
hospitals based on performance. This builds on the comparative
effectiveness research provision of last year’s economic stimulus
package. While none of these measures will have the same sway as
NICE does in Britain, taken together, they will move America in a
NICE-like direction, especially with Berwick at the helm.
In 2003, Berwick signed on to an
open letter in Health
Affairs, called “Paying for Performance: Medicare
Should Lead.” (Among his co-signers was Nancy-Ann DeParle, the
current White House health care czar.) “Our
recommendation-to the executive branch; to Congress; to employers
and health plans; and to hospitals, physicians, nurses, and other
health professionals — is that payment for performance should
become a top national priority and that Medicare payments should
lead in this effort, with an immediate priority for hospital
care,” the letter read. It went on to say that the CMS
administrator’s successors must continue to show “aggressiveness
and commitment” to the cause, noting that, “A major initiative by
Medicare to pay for performance can be expected to stimulate
similar efforts by private payers…”
The idea of paying doctors and hospitals for delivering
better quality health care and of offering guidance on best
practices seems benign enough. As the letter put it, “Quality is
not an issue for partisanship.” The problem arises when
government bureaucrats or expert panels are in the position of
judging quality, performance, and best practices which get
applied across a broad and diverse population.
As cardiologist Sandeep Jauhar argued in a September
2008 New York Times op-ed,
pay for performance initiatives can cause unintended consequences
such as doctors overprescribing certain medications that are
deemed effective and carry bonuses. He also recounted how an
initiative in the early 1990s to give report cards to doctors
performing coronary bypass surgery prompted doctors to cherry
pick patients to avoid the most severely ill cases that could
jeopardize their grades.
The problem with any uniform medical guidance is that
what’s good for the “average” patient may not be right for any
given patient.
The irony in all of this is that Berwick, at times, has
eloquently argued for what he called an “extremist”
patient-centered approach to health care, in which hospitals
wouldn’t restrict visiting hours or force patients to wear gowns.
As he said in a speech to the American Board of Internal Medicine
in 2008 of the experience of a patient at a hospital: “That’s
what scares me: to be made helpless before my time, to be made
ignorant when I want to know, to be made to sit when I wish to
stand, to be alone when I need to hold my wife’s hand, to eat
what I do not wish to eat, to be named what I do not wish to be
named, to be told when I wish to be asked, to be awoken when I
wish to sleep.”
Yet the term “patient-centered” is typically used by
supporters of a free market approach to health care who argue for
more individual choice and consumer empowerment. It’s hard to
think of a health care system in the world that dehumanizes
patients more than Berwick’s beloved British system.
In March 2009, a report found that up to 1,200 died as a
result of “appalling standards of care” at just one hospital in
Britain’s NHS. The Telegraph
reported that “patients
(were) left for hours in soiled bedclothes.…” In addition,
“Patients described one ward as a ‘war zone’ and said people were
often left in Stafford’s A&E (Accident and Emergency) for
hours covered in blood and without pain relief, even though they
had serious injuries. Others were left without food or drink,
leading some to reportedly drink from vases when thirsty.”
In November, another report estimated that up to 400
patients a year died at two other hospitals, with similar
conditions that included,
according to the
Telegraph, “lack of basic nursing skills,
curtains spattered with blood on wards, mould in vital equipment
and patients being left in A&E for up to ten hours.”
During the health care debate, Obama dismissed any attempt
by Republicans to liken his vision to the British system. But
Berwick’s nomination, which will have to be approved by the
Senate, provides Republicans with ample fodder to make the
connection.
On Wednesday night, Sen. Minority Leader Mitch McConnell
took to the floor for a half-hour along with fellow Republican
Sens. Pat Roberts and John Barrasso to rip into Berwick’s
positions, in what could be seen as the opening salvo in the
nomination battle.
“Many of us are alarmed by the nominee’s focus on the
British health care system,” McConnell said, and criticized
Berwick for “applauding a system where care is denied, delayed,
or rationed.”
McConnell also suggested that Obama intentionally delayed
the Berwick appointment until after the passage of the health
care law, because announcing his CMS pick during the debate would
have confirmed Republican charges that Democrats were intent on
rationing care.
Berwick will have to first pass muster with the Finance
Committee, which oversees Medicare and Medicaid. A hearing has
yet to be scheduled.
Though the nomination of Elena Kagan to the Supreme
Court is likely to garner more attention, the Berwick pick could
produce more fireworks. In Berwick’s case, there’s a long
paper trail detailing his disturbing views on a wide range of
matters relevant to the position he’s seeking.
