Don Berwick, MD, may no longer be the administrator for the Centers for Medicare & Medicaid Services, but he's still very much involved in the business of healthcare reform.
Berwick, now a lecturer at Harvard Medical School's department of healthcare policy, spoke at a recent Health Affairs briefing on the Patient Protection and Affordable Care Act. He has long championed changes in healthcare delivery, and says that with the Supreme Court decision to uphold the PPACA now behind us, healthcare stakeholders need to be vigilant in making sure that real healthcare reform continues.
With much of the national focus now on the November elections, Berwick explained that no matter which party wins the White House, he has seven worries about the continued implementation of healthcare reform.
1. Will healthcare change? Berwick offered a story about the auto industry's reactions in Japan and the US after the passage of auto emissions legislation. In Japan the industry responded by mobilizing to reduce emissions. In the US, the industry mobilized to change the law. "This is the strategy choice that we're going to face" in healthcare, Berwick explained.
2. Will we actually reduce cost? Berwick says we are in a rhetorical phase of cost reduction; we're talking about it, but not yet accomplishing it. He points to Massachusetts, which is now grappling with the costs of implementing near-universal coverage. Berwick's concern is that "as you watch the rhetoric play out, it's a playing field in which the authenticity of reducing costs remains in question."
He says he has considered promoting a national project that he calls the "15% projection" to keep healthcare spending at 15% of the GDP. "That would solve the problem, but is the authenticity there to reduce costs?"
3. Mechanics of coverage. Berwick believes health insurance exchanges are among the most difficult aspects of the PPACA. States are struggling with the mechanics of setting up this new "creative and agile element" of the healthcare coverage system. "It's a serious challenge. We can do it, but we have to be serious about it." The difficulty of the task is "compounded by political polarization."
4. The safety net. Berwick says "we must preserve the commitment and mechanics to make healthcare a human right." He notes that there are "real people really at risk" living at the poverty line. Unfortunately, he says, middle class politics are at the foreground and the political will to maintain the commitment to healthcare for the most disadvantaged is vulnerable.
5. Commitment to science. Healthcare should be science-based, Berwick says. Patients should get what works and they shouldn't be subjected to what doesn't work. "All the rhetoric about death panels and rationing has distorted the important issue of whether we will commit to healthcare that works." Berwick says that will require a "reconnection of the healthcare agenda to the scientific agenda."
6. Prevention. If the US is going to pursue the storied triple aim (better care, better health, and lower costs) then it needs to invest in the causes of illness, says Berwick. "This is always vulnerable. It's the easy target, the budget you can cut." It's time, he says, to get very serious about reducing risk factors in healthcare. "This is a huge challenge to grapple with. Will our country prevent illness?"
7. Communication. "Somewhere at the beginning of healthcare reform we lost the opportunity to make the case for healthcare as a human right," Berwick said. While he contends that it's an easy case to make, he says work needs to be done to "build a bridge to public sensibility and a dialog about the healthcare we really want."
Berwick wrapped up his comments by calling for fewer pilots and a "more wholesale change" in the delivery of healthcare. He also alluded to state demands to have more say in healthcare reform and more independence in developing their own programs.
He described the states as "true laboratories of democracy. If we're smart and keep our wits about us we will learn a ton." Berwick also seemed to endorse the idea of more state independence. "If we have the wisdom to give states the license to move ahead…I think we're going to see an era of great learning."
Margaret Dick Tocknell is a reporter/editor with HealthLeaders Media.
