Donald Berwick, CEO of the Institute for Healthcare Improvement, was nominated by President Obama last week to be administrator for the Center for Medicare and Medicaid Services (CMS). Under the Patient Protection and Affordable Care Act, the CMS administrator does more than make sure Medicare and Medicaid pay claims in a more or less accurately and timely fashion. The office defines the quality of health care for every insurance plan, sets reimbursement rates for physicians in Medicare and Medicaid, and decides what treatments are more “valuable” than others.
Berwick will get control of the practice of medicine. Can he or anyone be trusted with such power? Berwick, a former pediatrician, has made safer and patient-centered care his life’s mission. His institute sponsors a lot of pilot projects to promote quality, including one he pledged would save 100,000 lives. (The venture did not demonstrably hit the target.) In a Health Affairs article last year, he “argued “for a radical transfer of power and a bolder meaning of ‘patient-centered care,’ whether in a medical home or in the current cathedral of care, the hospital.”
Berwick also believes consumers are getting horrible care that costs more than it should. He insists, “[U]p to half of the more than $2 trillion that the U.S. spends on healthcare does nothing to relieve suffering.” In fact, “much of it adds to suffering.”
However, his “estimate” is based on the questionable Dartmouth Atlas of Healthcare that claims regional variations in Medicare hospital expenditures are mostly the result of differences in how much care greedy doctors supply and have nothing to do with how sick people are or how well they become. According to the atlas, eliminating that “wasteful care” by cutting Medicare spending to the lowest level and applying the percentage difference (28%) to all healthcare ($2.4 trillion) would “save” $700 billion annually. That’s how Berwick got to $1 trillion, I guess.
You would think a patient advocate would support consumers choosing the care they need through “medical homes” they build and own. Instead Berwick thinks a “commissioner of care” should limit health care spending nationally by dividing the country into health regions (exchanges?). “It could be a small state — or part of a large state… We could start with the current per capita cost,” which he contends could be 20 percent to 30 percent lower.
Berwick not only has a role model picked out for a role that sounds a lot like what he would be doing at CMS, he has a soulmate: For the past 15 years he has consulted for — or, in his words, been “starry-eyed” over — Britain’s National Health Service. In 2008, at a 60th anniversary celebration of the creation NHS, he told a UK crowd, “I am romantic about the NHS; I love it. All I need to do to rediscover the romance is to look at health care in my own country. “
Berwick complained the American health system runs in the “darkness of private enterprise,” unlike Britain’s “politically accountable system. ” The NHS is “universal, accessible, excellent, and free at the point of care — a health system that is, at its core, like the world we wish we had: generous, hopeful, confident, joyous, and just”; America’s health system is “toxic,” “fragmented,” because of its dependence on consumer choice. He told his UK audience: “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.”
It may not be joyous or just or configured correctly, but for nearly every disease, particularly cancer, stroke, and heart attacks, Americans live longer and healthier than the English because of better care. Americans spend less time in the hospital, have fewer doctors, and see doctor’s less often per capita than people in Great Britain.
In the past two years the number of people waiting over three months to see a doctor in the NHS has increased by 50 percent. Productivity of the NHS — which was Berwick’s principal mission — declined 2.5 % over the past five years. Last year it cut primary care services and wound up with a 2 billion pound surplus. The NHS spent the money not on patients but on equipment, bonuses, and consultants in an end of the year rush. Meanwhile hospital-acquired infections in the UK remain as high as ever while they decline in “toxic” America.
Berwick described how NHS rations care this way: “you plan the supply; you aim a bit low; historically, you prefer slightly too little of a technology or service to much too much; and then you search for care bottlenecks, and try to relieve them.” Relieve them? In 2008 the system Berwick believes is an example for healthcare worldwide denied cutting edge cancer drugs to 4,000 people, forcing thousands to remortgage their homes to pay for treatment. Love is blind. With regard to Dr. Berwick’s devotion to the NHS, it’s deaf and dumb as well.