A year after leaving his position as administrator of the Centers for Medicare & Medicaid Services, Don Berwick, MD, talked with HealthLeaders Media. Berwick discussed death panels, the challenges of implementing healthcare reform, Medicare and Medicaid fraud, and the improvement movement. This is the second part of the interview. Part I is here.
HLM: Let's talk about the huge bulk of Medicare spending at the end of life—one in four Medicare dollars spent in the last year—some of which would be avoided if (Medicare or health plans) required patients to sign an advance directive to say what they would want. Do you think we can revisit this issue with common sense?
DB: First the whole death panel thing was a travesty, demagoguery at its worst that really harmed patients, building things out of thin air that had no relationship with reality, and it was tragic for our country. It made end-of-life care a 'third-rail' topic, with people on both sides of the aisle reluctant to discuss it.
But the big piece of this does not have to do with saving money. It has to do with people having control of their own lives.
We know for certain that as people approach end of life, not only are they costly, but they're in pain, they suffer from shortness of breath, and symptoms that can be helped with proper treatment. They're isolated from families, put into intensive care units, hooked to machines when most of them don't want that, yet we do it anyway.
What we need is choice. Do they want to be at home or in an ICU? With their loved ones or with lots of nurses and doctors? If someone wants every machine and every tube, I'd say sure, it's your life. Of course you can get that. But if they don't, that's hurting people, and what we have to get away from.
HLM: So how do we reduce costs of end-of-life care if Washington won't go near it anymore?
DB: I think you'll see, or I hope, local communities, states, civil societies pick up this issue and say, "Oh no you won't. If you're too scared to discuss this in Washington, well we're not. We're going to make it real where we live."
The story now is in La Crosse, WI. Nobody is ordering anyone to do anything, like sign advance directives, but the whole community is now embracing the idea that they want control over their own lives. So if you live in La Crosse, the odds are you will have an advance directive, and people will know your wishes and honor them. This was first done by Gundersen Lutheran (Health System), and they did the right thing.
And there's The Conversation Project by Ellen Goodman, the Pulitzer Prize winner, where tens of thousands of people are getting on the website and learning how to have "the conversation" that gives you control of your own life. This is a problem that will be solved by society, more likely than the federal government.
HLM: Now that the Supreme Court has ruled and a presidential candidate's threat to overturn PPACA has passed. Is it full speed ahead to full implementation?
DB: I surely wish we could come together and lay aside our swords. But I think feelings are so raw and debates so angry, it is unlikely people will calm down suddenly and all come together. I suspect there will be legal challenges, but they won't prevail.
But the biggest risk now I think has to do with administrative needs to implement this law correctly, both at the state and federal level, and setting up the exchanges properly. Helping the uninsured become insured is a difficult set of tasks.
And if I were opposed to the ACA, which I am obviously not, and I wanted to continue to be destructive, I would simply starve the administration of resources so that information systems aren't modernized, potential beneficiaries aren't notified, so that people become confused. And I would slow down implementation of payment changes. I would do everything I could on the administrative and funding side to impede the law.
That's short-sighted, and doesn't serve the public well. But I'm a realist.
HLM: You mentioned that a big surprise for you at CMS was the amount of Medicare and Medicaid fraud. Can you elaborate, especially on Medicaid fraud which we haven't heard much about?
DB: It's a small minority, but they are professional in their criminal behavior, even so that when you shut them down, they come back. I began to see that one of the serious costs of fraud is that we have to screen everybody. It's like if there's a terrorist, we have to do body scans on everybody, and everybody ends up in security lines. That was an eye opener for me.
HLM: Can you give an example?
DB: There was one case where a dentist was charging for root canals in little kids. Kids don't need root canals. He said he was doing a lot but he actually wasn't doing any. Well, when the fraud unit got to him, he started doing root canals on children.
And I remember the case of one child who had, as I recall, something like 14 root canals. For real. When I arrived at CMS there had been set up some very effective mechanisms...and we were beginning to work on predictive analytics using hard data to spot patterns where something was amiss. I thought that was terrific, and assume it's still very much underway.
HLM: How is the improvement movement changing today?
DB: It's maturing. In the early days, the improvement movement was focused on individual processes, and the theory of how you can take a process, redesign it, and end up with a better result. That's the basics, and they're now largely well in hand. We've been doing that now for 20-25 years.
Now we're seeing the improvement movement get more directly involved with the economics of healthcare, such as with the introduction of LEAN production and thinking, and the Toyota production process. These are, in effect, the methods of quality improvement brought to bear directly on the costs of care, so that we reduce waste while we help people more.
The next step, I think, is the connection of improvement to policy. In general, in Washington I'd say that a substantial majority of policy makers do not understand improvement. They have not seen what I have had a chance to see, which is what it's like when doctors and nurses, pharmacists, and managers get together to learn and apply improvement methods.
They haven't realized how much good can be done when we set about to save money by improving the processes and outcomes of care.
They don't see that—the savings potential. The CBO (Congressional Budget Office), the OMB (Office of Management and Budget), the political operatives, their staffs and senators and representatives are generally not familiar with the financial benefits of health care improvement.
So, there is a gap between the improvement movement on the one hand, which has a lot of knowledge about using improvement to achieve cost reduction, and the responsible public policymakers and public servants who formulate regulations and laws.
And I have to say the same gap often exists between the improvement movement and the C-suite in medical organizations, hospitals and large systems. There is too much distance between the front office and the front line, and so executives can fail to appreciate quality as a business strategy, just as policy makers can fail to appreciate quality as a public policy strategy.
We're approaching a time when that gap should and will close, when people who identify themselves with quality improvement get to see themselves as potential leaders for solutions to the largest problems in healthcare, which include equity, justice, cost, and reliability. As that happens, the quality movement will really be moving into the big time.
I came out of the improvement movement. That's my original knowledge base; but I and many others are learning how to bring our knowledge into the political arena. That bridge needs to be built.
HLM: You said something last year that made me almost fall out of my chair. That the best healthcare reform legislation was campaign finance reform.
DB: Right. Right now, with $2.7 trillion in play, the status quo is very, very loud, and very well funded, and heavily connected to campaign finances, because lobbyists have earned entry into the politicians' doors. They speak loudly, and they do not always defend the interests of the poor.
The importance of making sure that medical treatment actually works, the toxicity of overtreatment, the need for better valuation of clinical practices—all of those things don't have the voice that the status quo has.
HLM: Which lobbyists are you referring to?
DB: Anyone whose job depends on the status quo, and for whom changes are painful. They would rather see things continue or even get more support for what they do.
HLM: So how have you been spending your time in the last year?
DB: For the 30 years prior to CMS, I had been deeply engaged with the improvement movement in the US and abroad, trying to help healthcare get better.
All that got interrupted by my stint in Washington, because there are ethics and procedural guidelines one has to follow, and that disrupted some of those long-standing professional and personal relationships.
So I've been working and visiting with hospitals, healthcare systems and physician groups who are trying to think about the new climate they're in, and how much better care can be with redesign.
And abroad, in Singapore, England and New Zealand, studying what they are doing and learning. Singapore, for example, is very concerned about its aging society, and continuity of care. Their population is growing very fast because they have long lifespans.
And I've been really interested in visits with communities around the U.S. where I see interesting changes starting to take place, where organizations are thinking hard about how to adopt strategies focused on patient centered and community based care.
HLM: What questions should I have asked you that I didn't?
DB: You didn't ask me the optimist or pessimist question. The answer is, I'm an optimist. I like what I'm seeing at the local community level. And the next couple of years, the story of healthcare in America may be told community by community rather than from inside the Washington beltway.