While everyone in Washington is chatting about a different nominee, President Barack Obama’s choice of Donald Berwick to head the Centers for Medicare and Medicaid Services (CMS) is an equally unique one and in some ways the more surprising choice. Berwick is known as a leading academic and technocrat and is generally respected for his work as a Harvard University professor and as the founder of a Cambridge-based think tank, the Institute for Health Care Improvement.
But running CMS is hardly the same as running a small think tank or talking in broad terms about the nature of health care. CMS is essentially the world’s second-largest insurance company after the United Kingdom’s National Health Service (NHS), covering more than 98 million people and overseeing roughly $800 billion annually in taxpayer-funded health care spending. Berwick previously had a significant role in shaping the NHS under Tony Blair, consulting for them for many years, in appreciation for which he was granted an honorary knighthood. But he is not an administrator or a manager.
As with many of Obama’s nominees, running CMS will involve applying the ideas Berwick’s developed for the first time; his decisions will no longer be just in the theoretical realm of a think tank but will hold massive ramifications for Medicare and Medicaid recipients, hospitals and doctors, and, under Obama’s law, all Americans. This makes it all the more important that we understand policy views and, in this case, understand how radical they truly are.
The documents cited below provide more information about David Berwick’s ideas and experience.
Berwick: Health Care Must Redistribute Wealth
Key to understanding Berwick’s views on the NHS is a speech he gave as part of a presentation offered two years ago, in which Berwick shared his thoughts on the NHS and health care in general. This video clip shows several notable lines from Berwick, including: “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 derides private-sector solutions to health care problems, dismissing the “invisible hand of the market” as an “unaccountable system.” And then we get to the heart of the matter, around the 3:50 mark, where Berwick states: “Any health care funding plan that is just, equitable, civilized, and humane must, must redistribute wealth from the richer among us to the poorer and the less fortunate. Excellent health care is by definition redistributional.”
The Fix Is In
Robert Goldberg, vice president of the Center for Medicine in the Public Interest, writes on Berwick’s views expressed in 2008: “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.'” Goldberg points out, “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.”
UK Has Terrible Record on Heart Attacks, Cancer
A recent piece in the Telegraph considers the OECD numbers on Britain’s actual outcomes from the system Berwick supports so strongly: “Britain also languishes near the bottom of the breast cancer league table, with a survival rate of 78.5 per cent. The OECD-wide average is 81.2 per cent. Heart attack victims in Britain are also more likely to die after entering hospital than in most other developed nations. Around 6.3 per cent of patients who have suffered a heart attack have passed away within 30 days of entering a British hospital—significantly higher than the 4.3 per cent average. The figures also show that British life expectancy is much lower than our nearest neighbours. Men in this country can expect to live to 79 years and six months, against 81 years in France. While the report’s authors identified some successes in British healthcare—we have among the best records in Europe for screening women for breast and cervical cancer—the survey indicates that Labour’s much-trumpeted NHS investment has failed to raise standards in key areas.”
The Triple Aim: Care, Health, and Cost
In a recent piece in Health Affairs, written with two colleagues, Berwick details his position on the ideal nature of health care, arguing the best system is single-payer: “If we could ever find the political nerve, we strongly suspect that financing and competitive dynamics such as the following, purveyed by governments and payers, would accelerate interest in [our policy ideal] and progress toward it: (1) global budget caps on total health care spending for designated populations, (2) measurement of and fixed accountability for the health status and health needs of designated populations, (3) improved standardized measures of care and per capita costs across sites and through time that are transparent, (4) changes in payment such that the financial gains from reduction of per capita costs are shared among those who pay for care and those who can and should invest in further improvements, and (5) changes in professional education accreditation to ensure that clinicians are capable of changing and improving their processes of care. With some risk, we note that the simplest way to establish many of these environmental conditions is a single-payer system, hiring integrators with prospective, global budgets to take care of the health needs of a defined population, without permission to exclude any member of the population.” Berwick is not particularly ideological in his endorsement: He expresses true belief that the single-payer model is the most efficient and most-easily managed approach to health care.
Rethinking Comparative Effectiveness Research: An Interview with Dr. Donald Berwick
In an interview on comparative effectiveness research, Berwick endorsed creation of an agency for rationing health care. He focused particularly on what he perceives as the benefits of the UK’s National Institute for Clinical Health and Excellence: “NICE is extremely effective and a conscientious, valuable, and—importantly—knowledge-building system [which has] developed very good and very disciplined, scientifically grounded, policy-connected models for the evaluation of medical treatments from which we ought to learn.” The interviewer pointed out: “Critics of CER have said that it will lead to the rationing of health care.” Berwick replied: “The decision is not whether or not we will ration care. The decision is whether we will ration with our eyes open.”
Berwick in Health Affairs
Greg Scandlen, founder of Consumers for Health Care Choices and a senior fellow for The Heartland Institute, in May 2009 highlighted an article by Berwick in Health Affairs. Scandlen noted, Berwick “has been moving in the right direction for a while and now has published an article in Health Affairs on the need for ‘patient centered care.’ While I don’t care for the term, the phenomenon he is after is just right.”
Berwick in the New England Journal of Medicine
Just a week after praising Berwick for his article in Health Affairs, Scandlen reports feeling “profoundly disappointed by an article he co-authored with Elliott Fisher and Karen Davis in the New England Journal of Medicine.” While the NEJM article “sprinkles the term ‘patient centered’ throughout,” Scandlen notes, “it is nothing more than a throw-away adjective with no meaning or substance.” And so, he asks, “which is the real Dr. Berwick? Was the Health Affairs article just window dressing to disguise his embrace of bureaucracy? Or was he suckered into co-authoring this NEJM article by the cynical and meaningless use of the term patient centered?”
Articles on UK National Institute for Clinical Health and Excellence
Here are just a few of the many horror stories about the UK’s National Institute for Clinical Health and Excellence over the past several years:
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