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The Right Prescription
Obama Performs a Bypass
The president’s recess appointment of socialist medicine advocate Donald Berwick to run Medicare and Medicaid raises huge questions — precisely those that would have come up in Senate confirmation hearings.
President Obama’s decision to bypass Senate confirmation hearing for Donald Berwick’s nomination as director of the Center for Medicare and Medicaid Services has less to do with Berwick’s romance with Britain’s healthcare system (first reported here) and support of rationing. The President’s other nominees handled questions about controversial statements with aplomb. No doubt Berwick, a charming man and gifted speaker, would have done the same.
Rather, the White House wants to avoid hearings for the following reasons, starting with his tenure as president and CEO of the nonprofit Institute of Healthcare Improvement (IHI):
1. For several years Berwick’s annual compensation at IHI averaged about $600,000. In 2008 his compensation jumped to $2.36 million while compensation for IHI’s executive vice president went from $520,000 to $1.25 million. Other senior executives received increases of similar magnitude. Yet in 2008, IHI revenues fell by $7 million and ran a deficit of approximately $616,000. According to IHI, this additional amount reflects the vesting of additional compensation necessary to maintain the talented team required to accomplish its mission of improving healthcare. By comparison the CEO of PartnersHealth, Massachusetts’ biggest HMO with revenues of $6.4 billion, made $2.6 million in 2008. According to Berwick, in America “each seeks to increase his share of the pie, at the expense of others.” Guess that applies to a nonprofits too, even if it means losing money.
2. At the same time, IHI receives nearly $ 2 million a year in federal grants. These grants appear to be awarded by the Department of Health and Human Services. Will Berwick recuse himself from grant-making decisions pertaining to IHI?
3. More troubling is the complex web of contracts, consultants, and grants that comprise IHI. The Institute receives about $40 million each year from a combination of grants, fees and consulting contracts from managed care companies, major academic medical centers, hospitals and health care foundations. Many of these organizations such as Kaiser Permanente, Blue Cross Blue Shield, and the Josiah Macy Foundation are already participating or seeking to influence boards and panels established by Obamacare to cut Medicare spending, ration new technologies, and only pay doctors when they meet the government’s definition of quality care.
Berwick has not only worked with these organizations, he has taken their money and funded projects of mutual interest, particularly those designed to reduce how much medical care patients use when they are critically ill.
All this may be to the good, but questions remain about the value of the IHI work product. These same organizations funded IHI’s “100,000 Lives Campaign” a program to reduce deaths in hospitals from preventable heart attacks, infections and adverse drug reactions by “deploying rapid response teams at the first sign of patient decline.” Berwick claimed the campaign saved 122,300 lives between 2004-2006.
Yet the estimate of lives saved was controversial. IHI took data from 33,000 patients and “adjusted” the number to arrive at 122,300. Robert Wachter, MD, a leading health quality researcher, noted: the difference between the unadjusted and adjusted number of “‘lives saved’ reflects a change in patient severity of illness and case mix during a short period of time that would be unprecedented in health services research…. An adjustment resulting in 89,000 additional saved lives continues to strain credibility.”
Finally, Berwick works closely with the Dartmouth Institute and the Foundation for Informed Medical Decisionmaking (FIMD). Why is this relevant? As CMS administrator, he will be developing guidelines for and spending millions of dollars on “Shared Decision-making Resource Centers.” The Disease Management Care Blog points out:
Google the term “Shared Decision Making” and guess what comes up: Dartmouth’s Hitchcock Center for Shared Medical Decisionmaking, which was founded by a grant from the FIMD and Health Dialog [a private company formed out of the Dartmouth Institute], which was built “in collaboration” with the same Foundation to sell programs that reduce the variation described in the Dartmouth Institute and in the Dartmouth Atlas….
Care to guess which institution(s) will be weighing in on the creation of federal standards on shared decision making, helping to promote their use and helping with the Centers?
Berwick calls the institute’s Dartmouth Atlas, showing regional variations in Medicare spending, “the most important health-service research of this century.” He invokes Dartmouth data when claiming half of health care spending in America could be cut without harming people, an assertion that is now largely discredited. Yet Berwick thinks shared decision-making, because it discourages about 15 percent of people from seeking additional care, should be mandatory. And now he is in a position to directly fund his friends and fondest dreams.
If a Republican president nominated a managed care executive to run CMS and rammed him through in a recess appointment, allegations about conflicts of interests would abound. Berwick made millions working with for-profit firms that will make money off Obamacare. But because he believes in central planning he gets a recess appointment. That’s why elections, including the upcoming mid-term elections, matter.
About the Author
Robert M. Goldberg is vice president of the Center for Medicine in the Public Interest and founder of Hands Off My H ealth, a grass roots health care empowerment network. His is new book, Tabloid Medicine: How the Internet is Being Used To Hijack Medical Science For Fear and Profit, was published last month by Kaplan.
Letter to the Editor View all comments (34) | Leave a comment
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Emma| 7.8.10 @ 7:19AM
Our family acknowledges that the hussein train coming down the track (the track that DH and I are presently tied to) has its light on us, won't be stopping in time and will likely cause our premature deaths.
Neither of us has any serious health issues, but recognize that when we do, we should not expect timely, effective medical care. It simply won't be available because of the policies and priorities forced on Americans by the obaMadministration.
Galen| 7.8.10 @ 8:30AM
As someone who has been at death's door twice,(my heart stopped)I'm suspicious of "rationing" The claim is that certain procedures are mere palliatives;e.g. angioplasty.As all medicine is is paliative (we're all going to die) think what could be saved by refusing all treatment!
Louis Jenkins| 7.8.10 @ 9:00AM
Galen, that's exactly what the Pretender n Chief wants us to do. Refuse it all. Think of the $$ saved. Let's face it folks, the Health Care Rationing package is bearing down on us full force, and there isn't a thing we can do about it except refuse it.
Dan Hirsch| 7.8.10 @ 9:38AM
Louis;
"..and there isn't a thing we can do about it except refuse it." Come on.
You can tell everyone you know that it's coming. Most people are either oblivious or disbelieving. If the uninformed hear it from ten people, they'll start to understand.
You can politely, yet firmly, call, write, e-mail, text your Representative and Senators telling them that you thoroughly disapprove of the health care program and that it should be repealed.
You can find candidates for those offices who agree with you and donate some of your money, time, and effort to support their election.
You can find out what is going on with election regulation in your own state and city and work to let the officials know that you are keeping an eye on them and you can try to get the news out that there are problems.
OR you can sit home and whine and moan about how bad it's going to be. And if enough do just that, it'll be worse than you think.
Me? I'm moving into Paul Ryan's district so I can vote for him....
C'mon! Man up. We ain't dead, yet!
Louis Jenkins| 7.8.10 @ 1:49PM
Dear Dan:
I do the first three. As far as moving to Paul Ryan's district, well, that's out of the picture. The problem I have is that none of my elected representation seem to be listening.
Oldefarte| 7.8.10 @ 10:09AM
I share the MANAGED CARE philosophy of medical care, and think that it appropriately reduces the unnecessary visits by patients to medical practicioners and thus reduces the cost of medical care and related health insurance costs. People today sometimes go to physicians needlessly for every little ache and pain they encounter, especially concerning their young children. In previous times, when employment group health insurance was provided as an employment benefit at exceptionally low cost [no deductibles/premiums], people ran to doctors when experiencing cold sniffles, when taking an asperin would have cured their ills. If people would simply only go to their doctors if/when absolutely necessary, medical costs and health insurance would not now be so expensive. That said, I do not agree with the recess appointment of this Doctor Berwick, and Obama's sneeky, underhanded, back door appointment of him has to involve some politically nefarious intent, no doubt. Along with everything else that he's doing and has done already, I think that the American voters are onto Obama's unhanded methods, since his survey poll numbers are sinking like a rock in a pond. November cannot simply get here soon enough for some of us!!!!!
JF| 7.8.10 @ 12:51PM
Hi Olde
The problems with health care that you cite are easily solved with Health Savings Accounts and Flex accounts. I've participated in both, have been in a situation in which I've negotiated a price for treatment of a health issue that became serious, and discovered that when you actually discuss treatment options with medical practitioners and take responsibility for weighing costs vs. benefits, you make better informed and more economical medical decisions. I agree that health insurance with no limits and no cost to the individual (such as the coverage offered to union members) does encourage overuse of the medical system; more importantly, the meager remunerations and 90+ day payment terms offered by government-sponsored insurance (Medicare, Medicaid) demands costs be inflated to ensure medical practice overhead costs are covered. I will be interested to see which demographic is the first to have their care rationed - will it be the elderly, who have contributed to our country's economic well-being already, or will it be the chronically unemployed welfare recipients who have leeched off society all of their lives and who increase costs to taxpayers for education, law enforcement, and social services? From a purely cost-benefit analysis, I know who SHOULD be eliminated, but we're talking about this administration, which has imposed a policy of get-evenism on the productive members of society. You're right, November can't come soon enough!
AMENBRO| 7.8.10 @ 10:52AM
HAIL YEAH MAN.
That Sarah Palin's a fear monger-er for mentioning the now clear as wino washed windshield at a stop light in NY FACT, that rationing care was the scheme,, I mean plan all along.
Course the real aim behind it all is for all of us to pay for the promises of the UNIONs to their pensioners LIFETIME FULL FAMILY HEALTH BENEFITS. This sheet has been hoisted up the flag pole since FDR. Now we got a bought & paid for LIFETIME, CARD CARRYING, YOUR FIGHT IS MY FIGHT, UNION PRESIDENT.
What the Hail was the fantasy that is CAMELOT thinking when the UNIONIZATION of Gov employees was codified into law at JFK's behest?
The UNION musta had some really good 8MM on him cavorting,,, as is the KENNEDY way. For all you ed-U-kated youngsters, that's film.
Dthomas| 7.8.10 @ 11:08AM
Nearly every unexpected death within my social circles was followed with the words: "he wasn't feeling good lately, but said it was probably nothing", or "I told her to go to the doctor, but no, she wouldn't go".
Conversly most succesfull recoveries from serious and often fatal illnesses were explained by "thank God I went to see a doctor" or "I'm glad I listened to my wife and got it checked out early".
It seems that early detection is the key. Therefore I have real problem with Oldefart's opinion that "only go to their doctors if/when absolutely necessary". How the hell are you supposed to know and who decides? You, me, or some accountant?
I'm covered under the TRICARE managed care plan similar to Medicare. They encourage us to get our "little aches and pains" checked out so as to actually save the plan money. It seems early detection and treatment saves a great deal of money over costly and drastic medical heroics.
Tom| 7.8.10 @ 2:36PM
The problem is early detection does not save money in the aggregate. There are far too many negative results, which cost money.
Of course, this does not mean there is no individual costs for early detection. I know I like the option of getting suspicious symptoms examined.
Oldefarte| 7.8.10 @ 3:30PM
Dthomas, You misinterpreted my point. At 64, I [and most seniors,etc] have everyday aches and pains that OTC medications can remedy. To the extreme, I've know individuals who were lonely and needed someone to converse with, resulting in a office visit to their doctor. I'm NOT REFERING to minor chest pains that may be preceding a upcoming heart attack!!!!!
Doctor Right| 7.8.10 @ 11:28AM
So a socialist radical has appointed another socialist radical to a position of power in D.C..?
...Yawn...
Too late. The time to stop this nonsense...peacefully...was November '08.
Doctor Right| 7.8.10 @ 11:28AM
So a socialist radical has appointed another socialist radical to a position of power in D.C..?
...Yawn...
Too late. The time to stop this nonsense...peacefully...was November '08.
Jack Kinch(1uncle)| 7.8.10 @ 3:26PM
This is just one more reason to get rid of Nomobama. Folks lacking in good sense and common sense elected him cause he is one of them.
Pete| 7.8.10 @ 4:08PM
We have to appoint him so we can find out what he believes in?
Dr. Piper| 7.8.10 @ 6:06PM
I am a physician and many of the comments do represent the reality of the front lines of medicine where I slog daily. There are hypochondriac patients who attempt to see the physician for every ache and pain because there actually is no cost to them (due to lack of co-pays, no outlay from their flex account or HSA). Of course we will all want more of what we perceive as free. This is what is the perception of what Medicare is, it has no co-pay or other marked solutions to weed out those who need care from those who really have a medical issue that needs to be addressed, the demand has increased. As the demand has increased, the costs have exploded.
Medicare has responded by continually cutting what it pays physicians and limiting expensive procedures. I have had had my fees cut by 40 to 50% over the past 4 years. What this means for patients is shorter visits and as Berwick finds procedures to cut or pay the doctors less( the ones that are used the most, and thus cost the system the most, not related to medical efficacy), patients will find fewer doctors willing to take Medicare as we will be unable to keep our practices open as we will be paid less than our operating costs. This is already the case as it is my private insurance patients that subsidize my ability to see Medicare patients.
Now, it is certainly true that private insurance plans deny care, but they have a defined benefit plan to which you agree. They will deny expensive treatments that are not part of your plan. The Government, meanwhile, has no such defined benefits plan. You will be eligible for what they give you. They can take away any treatment and any procedure at any time and you will have no recourse, the unelected bureaucrats are unaccountable. You will not be able to sue as you can currently with private insurance companies.
Additionally, the way ObamaCare was set up, was to eventually result in the destruction of private insurance as the ability of insurance companies to increase premiums will be limited and people will be able to sign up for care when they are sick, as you will be unable to be denied insurance, then drop insurance when they are well and avoid paying premiums the rest of the time. Those of us with chronic health issues, will continue to pay our premiums and our premiums will rise. But since the insurance companies will not be able to increase their premiums enough to stay afloat, they will then go bankrupt. Then we all be in the public health care system which has been the design of Obama and the Democrats all along.
But sadly, this system will be just as poorly managed as the National Health System in Britain. Who will go into medicine to be a doctor at this point? Not the best and the brightest. They, being the best and the brightest, will figure out another career to enter. Meanwhile, as all of this is happening, physicians, the older physicians, will retire saying I have had enough. The rest of the mid-career physicians will hang in there just long enough until they can, and then they will retire. Not enough physicians any more? See an physician assistant with 2 years of additional training past college. Physicians 4 years of medical school and 3 to 7 year residency programs. You get what you pay for.
What was the solution? Expand Health Savings Accounts (ObamaCare is slashing them), do not tie health insurance to employment (pre-existing conditions would not be as subjected to dropping),give states the tools to create their own innovative reforms that lower health care costs, end junk lawsuits that contribute to higher health care costs by increasing the number of tests and procedures that physicians sometimes order not because they think it's good medicine, but because they are afraid of being sued, Federal or state assistance of health care premium payment when between jobs, allow individuals, small businesses, and trade associations to pool together and acquire health insurance at lower prices, the same way large corporations and labor unions do, and let individuals buy insurance across state lines to increase competitions. These measures would have gone a lot further in terms of improving the state of the US health care system, but instead, all of us are losing choice and freedom and my patients and all Americans will lose in the end.
dw| 7.8.10 @ 6:44PM
Thanks Doc,
Anyone with half a brain can see all the results you speak of once government intervenes in the private sector. The failures of all socialist programs has been proven every time they are instituted. The collectivist never understand the role free markets play in producing the best performance at the lowest cost. Therefore demotivated doctors will flee the industry leaving an inferior product in their places. The solutions you speak of, including competition between insurance companies across state lines, would do more to lower cost while maintaining quality than the socialist doctrine could ever dream of, but alas they must indulge their ideology at the cost of rationality or risk personal and political failure. Admitting that you've spent your whole life chasing a fairy tale can be psycholigically devasting.
Oldefarte| 7.11.10 @ 1:36PM
Beautifully stated, Dr. Piper, and great comments, DW! I concur and will only add that hopefully, this WELFARECARE can begin to be defeated/defunded if/when enough conservative Republicans [I think the Democrat Party is now nothing but extreme liberals] can be placed into office [hopefully starting in November]. My heart bleeds for this [and all physicians] who spend enumerable hours in educational training and thereafter in medical practive in order to care for us patients [some like myself have spent a lifetime in PAYING MEDICAL PREMIUMS for health insurance only to now see some radical politicians destroy health insurance and the practice of medicine by this moronic legislation]!!!!!
fwb| 7.8.10 @ 6:57PM
And of course the entire appointment is unconstitutional.
The Constitution allows the president to fill vacancies that may happen during the recess. This vacancy DID NOT HAPPEN DURING the recess so the appointment does not meet constitutional scrutiny on that point. The power granted requires someone to be in the position and to then leave the position during a Congressional recess thus causing a vacancy to happen during the recess. It does not allow for the president to stick someone in at will just because no one has been approved for the position.
If one allows the appointment based on the recess, the IF the Congress is in recess rather than just on a break, then the "next session" begins when Congress returns and ends when Congress takes its next break. Thus the appointment is good for a few months at best.
dw| 7.8.10 @ 6:57PM
As for "the ones" continued behavior in operating a "transparent" government, I believe he is confuse as to what that big word means. Maybe NASA can educate him. As of now I believe he thinks it has something to do with misleading and lying to the public.
John| 7.9.10 @ 12:11AM
Any "researcher" associated with the criminal "Kaiser Permanente" bunch isn't legitimate. Period. End of subject.
Yosemeti Sam| 7.9.10 @ 1:15AM
Berwick and his baby ass-kicking big bro BHO.
A match made in - no, not in heaven!
Rubysue| 7.9.10 @ 2:20PM
Wait - you're criticizing the guy for leading a campaign because it *only* saved 89,000 lives? Take a moment and look at that number. Perhaps the man has something to offer?!
survivor| 7.10.10 @ 1:59AM
On the other hand, there is always the danger of the tender mercies of "what the doctor ordered".
In September 2009 after an action-packed day of caring for grandson and dog-sitting a Queensland Heeler who wanted to herd him, I was restoring order and walking at a fast clip while folding a down comforter. Corner of comforter gets underfoot, I careen forward until stopped by kitchen table and slam into floor.
Struggle to phone - I live alone - and while that dog's smart, she can't dial 911 - call a son to say I need a ride to ER -as I may require an X-ray. He's a half hour away so I have time for a quick shower. Drag myself up flight of twelve steps. Shower, dress and gingerly make it back downstairs. You want to look your best at midnight on a Saturday night in an Emergency Room!
At hospital it is discovered I have fractured pelvis and must be admitted. There follow 6 days of bed-ridden immobility with IV pain-killer being pumped into me (against my will) the first 3 days.. That and half-hourly inquiries of "Do you have an Advance Directive"? was the extent of my care.
Why all the Advance Directive questions? I gave them my health history. My doctor was available for confirmation. I know they shoot horses, but I saw no immediate need to get out a lipstick and scrawl DO NOT RESUSCITATE on my chest.
Six days' in-patient for a fractured pelvis is apparently the limit, which was fine with me. I didn't want to be there, as I was tiring of the solicitous "Do you have an Advance Directive"? question. Told I would be transferred to a "skilled nursing facility", I said, "No, I am going home." Brief discussion, "You can't go home. Your doctor says you live alone." Finally, I ended it with ,"This is not a jail. I can leave when I please and go to where I please.. I am going home. Are you familiar with AMA (against medical advice)? I am going home." Well, you will have to demonstrate you can walk".(This, after 6 days of advising me not to attempt to leave my bed) I did and I left.
Medicare and my insurance would have paid for me to languish in a skilled nursing facility, where I would have gotten questionable therapy, probably a virus - and maybe pneumonia from inactivity.
I came home with two walkers and my determination and the help of a daughter-in-law, who came every morning to fix my breakfast and assure herself I was OK.Over-achiever that I am I was always showered and dressed when she got here. In short order I was fixing my own breakfast. One cannot claim to be independent and rely on others - there's a disconnect there. I made it up the stairs 15 minutes after I broke everything, I could do it again.
A week later, out of nowhere appears a Home Health Aide - apparently ordered by the hospital or my doctor. "My name is ___, I will be your occupational therapist. Do you have an Advance Directive?" Yes I do. May I see it? No, you may not. I told them I did not require their services, "We have someone who can assist you with a bath twice a week." I said " Thank you, but sometimes I shower twice a day." She left.
My primary physician, who was my husband's rheumatologist, had benignly assured me that the "cure" for a fractured pelvis (this one in three places!) was "tincture of time". Not for me, I made an appointment with my orthopedist and underwent 3 months of intensive therapy. I did not use a walker after 3 weeks - I used a cane less than a month. I returned to swimming and I walk as well as I did at twenty.
I think a good percentage of old folks you see shuffling behind a walker are doing it because of lack of interest by doctor in pushing re-hab and lack of initiative in bucking the "tincture of time" prescription..
I have an friend who had a lesser fracture in December who caved to the skilled nursing detour and she isn't walking unassisted, yet.
I will be 83 in August and I in good health. I feel sorry for the elderly who frequent doctor's office and never leave without a new prescription. I never broke anything before and I never will again. That was a fluke.
I tolerated a lot of tsk-tsking about "Well when you are older these things happen. . ." Two weeks before my "event", my dermatologist fell on a squash court and broke his arm. He is 15 years younger than I am. My grandson fell off monkey bars at school and broke his arm. My daughter-in-law's 55 year old sister fell UP the stairs carrying books and broke two somethings in her spine. Five years ago my daughter-in law tripped on a sidewalk fell against a brick wall and broke her a-c joint. Four years ago another grandson broke his arm snow-boarding. But it's old ladies that get a bad rap! I didn't break my hip, Obama!
So, Berwick, give me your best shot. I may be your match.
Connie Bailey| 7.14.10 @ 1:35AM
After reading the above comments I have to say I'm glad there are so many informed people. As a proud Tea Partier and Insurance Acct Mgr for an insurance agent I try to keep our clients informed. What I know is people are tired of rate increases, rightly so, but what they don't look at is we are paying for the uninsured. Since Medi-care and Medi-cal don't pay their share the hospitals and doctors have to make up for it by charging the insurance companies more. University of CA Davis (they get most of the gunshot victims here in Sacramento) did a study several years ago, they lost $750,000 on uninsured gunshot victims but amazingly they made $780,000 on uninsured gunshot victims. There is also the problem of lawsuits, who among is God, no one and we should not expect our doctors to be God either. As human beings we make mistakes, maybe an I'm sorry would help but also there is also to much greed. Our liberal policies in CA are killing this state and we are sue happy, Tort reform should have been a major componet of health care but as the doctor above said he wants to bankrupt insurance companies. This will fuel the unemployment rate and add more employees (union of course) to the federal tax dole. Britain has 24,000 employees and would love to get out of the healthcare business but don't know how. Sad looking at other countries going down because of this issue and here we are trying to do the same system that is failing in Canada, Britain, France, Greece and even Oregon and Massachusetts. God help our country before it's too late!