Former acting head of the Centers for Medicare & Medicaid Services, Don Berwick, MD, acknowledges healthcare providers have come a long way in the last few decades, but it's "by no means enough."
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"And the wild things roared their terrible roars and gnashed their terrible teeth and rolled their terrible eyes and showed their terrible claws."
– Where the Wild Things Are by Maurice Sendak
Like this line from Maurice Sendak's celebrated children's book, America's hospitals face some terrible monsters, 11 of them to be exact, said Don Berwick, MD, former acting administrator of the Centers for Medicare & Medicaid Services.
"We're scared of the truth, the next wave of what we have to do to transform healthcare. And it crosses some scary landscape. It's stuff we don't want to think about and don't want to talk about," he told some 1,400 executives assembled for the American Hospital Association's Leadership Summit in San Diego last week.
That "stuff" involves grasping the extent of the industry's greed, ignorance, excess, overutilization, and waste, Berwick admonished.
Now a senior fellow of the Institute for Healthcare Improvement, which he founded in the late 1980s, and a candidate for Massachusetts governor, Berwick said he's seen a lot of changes in the industry in the last several years and congratulated hospitals and providers for making tough choices.
"Thirty years ago, we didn't know patient safety was a problem. We thought healthcare infections came with the territory. Patient-centered care was the name of a focus group and most doctors would laugh at a 'checklist' and say it's cookbook medicine.
See Also: Berwick: Zapping Overtreatment, Costs Takes 'Courage'
"We've come a long way," he said. "Central line infections are down in intensive care units 53% between 2002 and 2009… and patient-centered care is now front and center (with)…hospitals opening their doors and taking away visiting 'hours.' They're putting patients on their boards, and are now saving thousands of lives" with efforts to prevent sepsis.
But it's "by no means enough," he said. America's hospitals must first slay its monsters, and that will not be easy.
Here are the 11 monsters Berwick has identified. Some are held within institutional culture, those in policy and law, and those in practice, that Berwick told the healthcare industry it must slay.
1. Instill confidence in science as a basis for action. Doctors and hospitals have triumphed in connecting medical decisions to science, and treat patients "according to facts, not according to myths or habits…But it's an incomplete triumph because we don't do it…We continue to allow quite senseless unscientific variation in practice to masquerade as autonomy."
And what comes from that is a confused public, and now it's become a suspicious public…made suspicious by politics, by exploitive accusations that scientific thought is elitist…a way to deny people what they need. We say science, we say evidence-based medicine, and the public hears 'rationing."
2. Use our global brains. While at CMS, Berwick says, he was told to never mention another country. "If you do, you'll take a cheap, demagogic shot from someone who questions your loyalty or says you're a socialist…
"But being different isn't a bad thing. What's missing is a chance to learn from our differences. Penicillin was discovered in Paddington, London, and now cures pneumonia in Peoria."
3. Learn from large systems. Somehow, American healthcare's thought leaders must learn how to improve care by experimenting with change in real time clinical environments, not by researching or adopting what happened in the past. But they haven't sufficiently developed, nor have they widely accepted, new investigatory approaches and they will have to get over that.
4. Name the excess. America spends 40% more on healthcare than it needs to. And that has been pushed by the argument that patients need more. "These claims are goodhearted…But it has been nearly impossible to claim what in our nation has become true, which is enough is enough. The particular monster here is very big and very scary. It's the scariest one."
Berwick points to Bernard Lown, MD, a cardiologist who invented the defibrillator and whose Lown Institute won the Nobel Prize in 1995. [Note: Berwick is a volunteer member of the Lown Institute Advisory Council.]
"Dr. Lown has concluded…that about half, maybe more, of the revascularizations that we do in this country—stents and coronary artery bypass graft surgeries for stable coronary disease—are unneeded. They don't relieve symptoms any better than medical management does; they don't lengthen life; and they don't prevent future heart attacks. They don't do anything."
This is controversial, Berwick allows. "But I'm just saying what if he's right. This is the monster under the bed. We're doing 600,000 stent procedures a year and 500,000 CABG operations.
"All those angiography suites and all those gleaming operating rooms, and proud technically brilliant cardiologists—what happens to them? What happens to the business model for the heart hospital? The stent vendor... when the evidence accumulates, if it accumulates, that what we do a lot of doesn't help anywhere near as much as we thought. It's very scary."
Berwick added that "it will take courage to name and address what I believe is a large proportion of American healthcare that just doesn't help people, but subjects them to risk."
5. Distinguish profit versus greed. The American healthcare marketplace generates "energizing entrepreneurship and what I'll call proper competition," Berwick said. "But on the other hand, it has cynical, calculating greed in it. And we do not have method sin public policy or in private to tell the difference between entrepreneurship and greed and act on it."
He gave three examples, one of which resulted in a pharmaceutical company raising a $300 cost for a course of a generic hydroxyprogesterone that interrupts premature labor—to prevent low-birth weight babies—to $25,000, largely borne by the Medicaid program and the taxpayer because 50% of labor and delivery costs are borne by Medicaid. "And the threat and cost of low-birth weight babies are concentrated in families with economic and social disadvantage."
Berwick emphasized that the three pharmaceutical companies he named "are not doing anything illegal. They're playing by the rules. But that's my point. Not everything that's legal is proper."
He called the drug companies actions that resulted in higher costs for necessary drugs both for the public and the taxpayer, "a take the money and run behavior," and said "a civil society is going to have to give politicians and regulators tremendous courage to follow through and say, "No. That's not okay.' "
6. Resist innovations that don't help. At a major convention last year, Berwick was escorted through an exhibit hall with 6,000 vendors, one for each of the 6,000 participants. "There was fiber optic this and robotic that, ceramic this, and disposable everything. And I am absolutely sure that somewhere in the acreage of innovation there was something that could help patients that was definitely worth the money.
"But every instinct I have is telling me that what is offered as innovation in healthcare is certainly not always and maybe not even mostly truly helpful, but adds complexity and risk and we need to tell the difference."
7. Expand roles and scopes of practice for non-physicians. "We need to support new models of care that provide expanded roles for non-physicians." However, he says, the legacy payment systems don't encourage these changes. We need help from the (professional) guilds, not their opposition," but he said, many "are fighting the change."
8. Defend the poor. This monster, Berwick said, is causing him to lose sleep because the nation fails to regard healthcare as a human right. "The social safety net is vulnerable and the will to protect" social services for the poor "needs constant reinforcement that government can't provide without hospitals' support.
9. Palliative and end of life care. Berwick blasted what he called "cruel rhetoric" that equated sensible discussion of advance directives and preferences with "death panels." "But the rule in Washington favors never ever mentioning end-of-life or palliative care, or advance directives. Not in government. That is a tragic silence and it has to stop."
10. Create Authentic Prevention "Hospitals cure disease but they do not prevent it. And they can not prevent it," because they aren't set up to do that today. "Prevention doesn't have any cathedrals. The result is continuing misallocation of effort.
"And if the Martians came here to visit, they would call this insane. We let bad things happen and then [hospitals] fix them. Well, why don't we stop them from happening? Simply put, we just haven't built the institutional structure for prevention."
11. Creating Transition Models Berwick referred to Alaska's Southcentral Foundation "Nuka System of Care," a project that won the Baldridge award for its success in emptying hospitals and decreasing the need for specialty care, as a care transition model monster that is scaring hospitals.
"It reduced hospital bed days for the population by 53%. Specialty visits fell 65%. These are the highest quality scores I've ever seen. And the highest patient satisfaction and staff satisfaction in history.
"And if we had results like NUKA's at a national scale, it would totally solve the U.S. government's healthcare problem without harming a single patient."
But, Berwick continued, "I'm this excited doctor who just got back from Nuka, and I rush into my CEO's office in my hospital and say, I have an idea, we can reduce our admissions by 53%..."
The AHA audience interrupted him with a long laugh.
"The fact that we all laugh is the problem. Wouldn't you want a healthcare system that makes itself as unnecessary as possible?"