The Right Prescription

A Triple Threat to Patients

Courtesy of Obamacare's unconfirmed czar, Donald Berwick -- a first order business from the next Congress.

By 10.25.10

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If and when a new Congress comes in, the fastest way to eliminate Obamacare will be by shutting down its "operating system" the Centers for Medicare and Medicare Services and investigating its unconfirmed director, Donald Berwick. And it should start by pulling the plug on Berwick's Triple Aim Program and the billions of dollars he has for implementing it.

The Triple Aim Program (TAP) focuses on "improving the patient experience, improving population health and lowering per capita health care costs." Berwick claims that all three are achievable not through consumer driven healthcare. In various speeches and slide presentations, Berwick claims there are isolated examples of private health plans delivering quality care at a lower cost through something he calls an "integrator." Berwick believes that America provides far less health for too few people at twice the cost as Europe and Canada. The Triple Aim is Berwick's master plan to remake American healthcare into Britain's National Health Service.

In advancing TAP Berwick often invokes Garrett Hardin's Tragedy of the Commons, which held that people seeking their own self-interest will deplete limited resources. As Hardin wrote: "Freedom in a commons brings ruin to all." In his grand scheme the "integrator" in TAP will save us from ourselves.

The Triple Aim is the organizing principle of Berwick's work at CMS. Indeed, it is rumored he was hard at work with CMS and other administration officials before the President rammed through his recess appointment without any confirmation hearing. Absent a congressional hearing where records, emails, pay stubs, etc., are made available, the extent of Berwick's involvement -- if any at all -- is unknown.

What is evident is that Berwick arrived at CMS with the resources and individuals needed to rapidly implement TAP already allocated according to plan. Over $1 billion was allocated for comparative effectiveness research. The money is intended to compare high cost to low cost treatments and identify geographic differences in spending. The Dartmouth Atlas claims that nearly one third of all health care treatments are unnecessary. That's TAP's underlying assumption even though the Dartmouth map fails to control for differences in patient needs or degree of illness. Indeed, one specific TAP goal is to eliminate regional variations in per capita healthcare spending by bringing spending down to what it is in Dartmouth's lowest spending region.

While there is great debate about the validity of the Dartmouth approach, there is no CER money for such discussion. Rather, as is the way of Washington, 90 percent of the $1.1 billion in CER funding will go to confirming the Dartmouth-TAP ideology. And 90 percent of the CER money -- controlled by Berwick and the Agency for Health Research and Quality (AHRQ) -- is going to individuals and organizations that have either received it in the past, help AHRQ decide who gets money, or were part of the Obama administration's "expert" panel that determined that CER money should be spent on, well, what the money is being spent on. Berwick knows, has worked with, or funded all these individuals and groups in the past. That is not just collusion requiring investigation of AHRQ and other agencies funding CER. It also reflects how Berwick, Team Obama, and various "stakeholders" use federal grants as patronage to reward "friends" and punish anyone who doesn't agree that CER can save the planet.

Initially Berwick and the Medicare bureaucracy will use CER to reinstate something called the "least costly alternative" (LCA) policy. This policy -- struck down by a federal appellate court -- allowed Medicare to pay for the cheapest version of a product it regarded just as effective as other products. The court said Medicare was denying necessary care as defined by the doctor. Now Medicare wants Congress to rewrite the law to reintroduce LCA based on CER and through decision-making guidelines developed by the Dartmouth group (for a huge profit).

Berwick once said: excellent health care is by definition redistributional. And ultimately, CER will be used to steer health spending into what Obamacare regards as valuable. Berwick's close Dartmouth associate Jonathan Skinner wrote CER can be used for "reallocating resources from cost-ineffective treatments for late-stage pancreatic cancer to cost-effective treatments for diabetes may improve health outcomes in the aggregate but not for patients with late-stage pancreatic cancer. "

Under TAP, late stage pancreatic cancer patients will just have to take one for the commons. That is, unless Congress pulls the plug on CER, TAP, and Berwick, in that order. Doing so will gut Obamacare while allowing the development of better approaches to bringing affordable coverage to those most in need.

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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.