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.
