Q&A: Don Berwick Reflects on Healthcare Reform, Part I

You know, it's a very, very difficult transition that we're asking healthcare leaders and providers to do.  Hospitals that for a century have been trained to focus on profit, revenue, and volume—they lament when beds are empty and celebrate when beds are full, and have targets for admissions, and so on—we're asking for something different now.

We're asking to be more oriented toward health and keeping people home. And not doing tests and procedures that don't help. And making sure that we not subject patients to things that don't help. These are changes in the mentality of the business models of organizations.

As I traveled around the country, I see how tough that transition is. They're trapped.

The most common metaphor from leaders is this: They've got one foot on the dock and one foot on the boat and they're drifting apart. One foot is fee-for-service, revenue-driven, grow the volume, do more and more, which is the dock, and the boat is, let's focus on what patients really need and decrease unnecessary care and the liability or harmable unnecessary care.

That's a very big change.

But there are some, a minority, that have actually trying to be intergrated systems of one type or another, and they're ahead of the game. They've formed relationships with their clinical staffs and are testing non-hospital based care.

There's a larger number wanting to do that but they don't know how to get there. They have stranded capital, and a workforce that isn't configured right for continuity, and still have boards oriented toward top line revenue in the short run. There's a substantial group that are hanging on for dear life hoping this will go away, the volume-driven organizations that have characterized the past.

We've been talking about hospitals, but physicians are in a very interesting position, on the one hand worried. Some are asking to be acquired by hospitals hoping to figure out how to survive. The others see opportunities to be leaders of change, and doctors, with gain-sharing arrangements, could stand to gain quite a bit by being more and more patient-centered.

With bundled and global payments and ACOs, (accountable care organizations), the possibilities are win-win because patients are better off at home, and their doctors are better off.