Don Berwick’s Exit Interview

Today’s Managing Health Care Costs Indicator is 5

Don Berwick ended his 17 month run as Center of Medicare and Medicaid Services Administrator –and it’s too bad that we won’t have his willingness to be disruptive and his vision to lead CMS through these critical next few years.

Kaiser Health Networks praises Berwick for his top 5 accomplishments:

1. Made CMS less bureaucratic and more responsive
2. Made CMS a force for U.S. health improvement.

3. Pushed hospitals to improve patient safety. 

4. Started to move Medicare from paying by the procedure to paying based on outcomes. 

5. Encouraged "innovative" health care delivery models

Perhaps to be symmetrical, Berwick gave an interview to the New York Times as he was packing his bags, and noted that “20 percent to 30 percent of health spending is “waste” that yields no benefit to patients.”  He cited five key areas of waste in health care.

Berwick’s top five list, with my annotation.

1. Overtreatment of patients

There is certainly plenty of overtreatment – especially in Medicare patients at the end of life.  Much of the underlying reason is cultural –and cultural changes take a long time.

2. Failure to coordinate care

The sickest  1% of our population represents 20% of costs –and patients are on polypharmacy (more than 8-10 medications a day), and it’s hard to find a hospital discharge that includes appropriate discharge instructions. 

3. Administrative complexity

By definition a system that has multiple payers will be complex- and the Affordable Care Act increases that complexity further through a series of regulations to protect patients – but which require compliance efforts that some will find burdensome. 

4. Burdensome rules

One person’s burdensome rules are another’s critical protection.   Some rules can simplify choices (like Massachusetts’ requirement that plans offered by the health care exchange are easily comparable), while others just make for higher cost (like requiring an RN or MD license to give injections, even though medical assistants are well trained for this).  We’ll have to take a surgical scalpel to rules, not a bulldozer.  

5. Fraud

Fraud is certainly rampant in health care, and health plans and Medicare are doing a better job of ferreting it out.  Fraud settlements are the highest they’ve ever been in the last two years.  Building fraud detection into payment systems, rather than waiting for someone to complain, is critical.  There are tradeoffs in combating fraud, too.  Some systems to interdict fraud might delay payment to legitimate providers, and could increase the cost of providing care. 

This is a good list, but it’s not exhaustive.  I was surprised and a bit happy not to see variation on the list.  It’s pretty hard to get to rural Minnesota levels of utilization in urban Boston or New York – but that type of variation is usually included in estimates of health care waste.   Just because there’s waste, doesn’t mean that it will be easy to remove that waste.    I was also surprised not to see medical errors and health care acquired complications and infections.   Berwick, as the CEO of the Institute for Healthcare Improvement and as CMS Administrator, has worked tirelessly to reduce health care complications, and there is still plenty of work left to do.   

Don Berwick, I’m sure, will still be working to improve health care in his next role.

Don Berwick’s Impossible Job

Today’s Managing Health Care Costs Indicator is $509 billion

The General Accounting Office offered testimony today to Congress about why Medicare is a government program at “High Risk.”  They’re right – Medicare costs the government (us)  $509 billion annually, and doesn’t have the infrastructure or the regulatory latitude to do a superb job of improving health care.  CMS Administrator Don Berwick doesn’t have the tools to change this.

The GAO observed

·        10.5% rate of improper payment on the fee for service business (and 14.1% rate of improper payment to Medicare Advantage plans)

·        Large-scale fraud in home health care

·        Overspending on oxygen therapy

·        Inadequately vigorous oversight of nursing homes

Here are the GAO’s recommendations:

1. Implement an effective physician profiling system
2. Better manage payment for imaging (such as radiology)
3. Reduce fees when appropriate as technology lowers provider resource costs
4. Readjust the GPCIs – the geographic payment adjustments for rural providers
5. Improve contract oversight (including better review of claims at high risk of fraud and better nursing home oversight)

This is all sensible.  Fraud is certainly a problem in Medicare, and the feds have been late to move to predictive modeling and automated approaches to ascertain potential fraud. There is huge variability of care.  Imaging costs too much.   Payment differentials among areas don’t make economic or clinical sense, and while specialty societies go to the RUC (Relative Value Scale Update Committee) to complain about under-reimbursed procedures, but no external party keeps eyes out for over-reimbursed procedures.

But how realistic is this? Can CMS Administrator Don Berwick effectively follow the GAOs gameplan to make Medicare more effective?

Medicare can profile physicians, and has a large enough penetration of most adult practices that the profiling would be better than most.   BUT – legislation requires that Medicare offer participation to any willing provider. Physicians can be removed for the program for fraud – but not for inefficient resource use.  There is no ability to change benefit design to encourage Medicare members to go to higher value providers.  So it’s not clear that Medicare has the leverage to make profiling meaningful.   It’s also a huge job that ideally requires substantial engagement of practicing physicians – and Medicare isn’t resourced for this.

Medicare has lowered radiology professional fees substantially – but of course radiologists and hospitals oppose any fee concessions.   Reducing fees to account for efficiencies in technology means there will be losers. Those who get a financial haircut are almost always vocal. 

The GPCIs, and even local fee schedules, have long been micromanaged by members of Congress.  I’ve noted before that Ted Stevens obtained a permanent 35% rate increase for Alaska Medicare providersbo just before he left the Senate.     

CMS has been improving the oversight of contracts, but doesn’t have the staff to do more nursing home site visits. Separately, the GAO noted that bundled payments (such as for transplants) are administered by private health plans, but CMS doesn’t have the case management infrastructure to do this for Medicare beneficiaries.

A few ideas:

·        We should acknowledge that as much as we hate to see dollars spent on administration, Medicare’s administrative budget is too small for a program of its size. 

·        Congress needs to back off – and leave determination of prices to bureaucrats who can implement rules

·        We need to resource the RUC to do independent evaluations, as opposed to relying on testimony from specialty societies.

We need to be patient.  For its size, Medicare is remarkably effective at procuring care for our elderly and disabled. Its inflation rate has been consistently lower than the overall market (although to some extent this represents cost shifting to the private market).   Medicare has been run by able folks – both in Republican and Democratic administrations.  But they need a little more leeway, and some time to get the Medicare house in order. 

Don Berwick

The Boston Globe reported today that Republicans will oppose Don Berwick’s nomination as the head of the Centers for Medicare and Medicaid Services (CMS) by accusing him of being “an advocate for rationing care.”

Nothing could be further from the truth.  

In most industries, it is well accepted that the highest quality requires minimizing waste.   However, in health care there has been a real divide between those who devote their careers to improving quality, and those who devote their careers to minimizing waste.    That’s starting to change, and the Institute of Medicine defined quality as Safe, Timely, Effective, Efficient, Equitable and Patient Centered.  That’s a good sign indeed.   

Don Berwick is a pioneering prophet of quality who recognized early that controlling waste, and keeping health care affordable, is critical to quality.  He has written (eloquently) about the “triple aim” of improving the experience of care, improving the health of populations, and reducing per capita costs of health care.”   His organization, the Institute for Healthcare Improvement, has helped spread knowledge, best practices, and the gospel of reducing errors and complications to save lives (and money).

We clearly need a CMS Administrator who cares deeply about quality, and who also understands the centrality of reining in our out-of-control costs.  It won’t be an easy job, because unnecessary costs in one person’s eyes are income to someone else.   Don Berwick can do this job.  We’re lucky he’s willing to try.

We must all agree that to guard our country's future financial health (and decrease the future deficit) we must control health care costs. Demagoguery accusing anyone who cares about costs of rationing, or death panels won't help. 

Berwick was prescient in Health Affairs in 2008 when he wrote:

WHETHER OR NOT THE TRIPLE AIM is within reach for the United States has become less and less a question of technical barriers. From experiments in the United States and from examples of other countries, it is now possible to describe feasible, evidence-based care system designs that achieve gains on all three aims at once: care, health, and cost. The remaining barriers are not technical; they are political. 

6-9-10: Addendum. Doctors For America (offshoot of Obama's election committee) has a petition in favor of Senate confirmation at http://drsforamerica.org/petition/berwick_letter.php 

It's also worth reading his essay "My Right Knee," available free at the Annals of Internal Medicine web site.