Five days after leaving his 17-month post as head of the Centers for Medicare & Medicaid Services, Don Berwick, MD, said his most rewarding moments were those in which he attracted the sharpest criticism—during the formation of rules governing accountable care organizations.
"We had a chance to work with the whole country in this thinking about what seamless care ... should look like," Berwick told a small group of journalists Tuesday in Orlando at the annual forum of the Institute for Healthcare Improvement. Berwick co-founded the organization 20 years ago.
"I think overall it was the best experience of my whole time there...It was just very interesting, with very vivid national dialogue. It was just the way democracy should work."
Even though he took the brunt of criticism, especially when numerous high-profile providers blasted the proposed rule's language for shifting too much risk their way? Even when major healthcare system leaders said they felt he was out of touch?
"It's learning," Berwick replied. "You know, I don't think of it as me being the brunt of criticism. I was the beneficiary of dialogue," he said.
Writing the ACO Rule
"We tried. The staff worked very, very hard. It was very complicated. There were about 30 variables...and we took a good shot. And remember, there were a lot of stakeholders. And out of that process came a much better rule informed by the dialogue."
The ACO rule was controversial, he acknowledged, because it required asking for tradeoffs. "You're trading off data sharing with privacy. You're trading off return to the trust fund with attractiveness to the healthcare organization financially. Because it's a gainsharing process, you have to have quality scrutiny with administrative burden. So you have these tensions.
Berwick, who had been appointed by President Obama to lead CMS in July, 2010 during a recess, left office last week after it was clear Senate Republicans would block his confirmation.
Berwick said that by the end of his tenure last week, "the amount of apparent interest [in the ACO rule] was great, but it still has to deliver. The test of whether the rule is a good rule is not just whether people say, 'oh that might work.' But whether it does work. We'll see about that."
While he was largely positive about his experience in Washington and what has been accomplished to reach his triple aim of better care, better health and lower cost through quality improvement, Berwick had less-than-kind things to say about some members of Congress for failing to understand the serious challenges the healthcare system in this country faces.
Optimism and Congress
I have two impressions, he said. "One is optimistic, and one is a little more challenging. "Look what's going on here at this meeting," he said, referring to the nearly 6,000 hospital executives, physicians and other clinicians attending the IHI forum. "You only need 20% to 30% of the industry to say now we're going to change, and I think we have that right in this forum."
But Congress is in another world, he said. "I think Congress has to catch up," he continued. "They're the ones who are behind. The nation is doing this and the Congress is missing the boat. And eventually, they'll be on the boat because eventually they will discover that after all, the change is here. I think I sense that. It won't go over (at the same pace) in every community. But there is not cause for despair here. There's cause for optimism. And Congress isn't connected."
Fraud and Other Cost Drivers
Berwick also said he was surprised that fraud, waste and abuse are a much more significant problem than he realized before joining the agency. He estimated the total at about $30 billion a year for the whole healthcare system and $8 billion to $10 billion a year just within CMS. "When I went there, I didn't know how big, but it is big...20% to 30% of the total bill."
He identified six major drivers of healthcare costs:
1. Failure of coordination: "When handoffs don't go well, costs go up and quality goes down," he said.
2. Process failures: When you're executing a process but don't do it correctly, scientifically or reliably. One big example, Berwick said, is hospital-acquired infections.
3. Overtreatment: "There's a lot done in healthcare that can not possibly help the patient and I'm not talking about end-of-life care. I'm talking about you and me when we go in when we have a viral cold and we get an antibiotic," he said.
4. CMS's own administrative burdens: Numerous record keeping and administrative requirements and forms. CMS has launched an effort to delete many of these mandates that don't add value or quality to care.
5. Pricing failures: "We have very good evidence first of enormous price differences of the exact same service between here and other countries. The differences are orders of magnitude," Berwick said. He gave as examples the costs of MRI testing, and certain kinds of durable medical equipment and prosthetics.
6. Fraud and abuse: Berwick said some of this is linked to organized crime. Authority in the Affordable Care Act has enabled federal agencies to pre-screen suppliers and providers to assure they haven't been implicated in prior scams.
Berwick, who recently got his own Medicare card, says he is looking forward to returning to his home in Boston. He and his wife are planning a cross-country ski trip at their home in New Hampshire, if and when the snow comes, because "Washington is a place where one gains weight because there's no time for exercise."
Walking the halls of the forum yesterday, Berwick seemed in excellent spirits as he greeted old friends, IHI co-workers, and hospital executives. He appeared genuinely surprised at being treated like a healthcare rock star, patiently withstanding lengthy applause whenever he was recognized during a session or keynote. He said, however, that it made him uncomfortable.
"One of my concerns in these few days of transition for me, is this overpersonalization. This really isn't about me. I had a great time [at CMS] I had a wonderful opportunity, but I'm ready for the next one...And I'm a little uncomfortable that this is about a person. It's about a nation, and how are we going to get to the answer."