A year after leaving his position as administrator of the Centers for Medicare & Medicaid Services, Don Berwick, MD, talked with HealthLeaders Media. This is the first part of the interview. Part II is here.
Don Berwick, MD, walked away from the Centers for Medicare & Medicaid Services' headquarters last December, a few weeks after he turned 65 and became eligible for its services.
After 18 months as administrator, he was compelled to leave, he acknowledges, because he knew political opposition to President Obama—unfairly re-focused on a comment Berwick made about the British healthcare system—would block his appointment's required Senate confirmation.
So he's spent the last year at home with his family in Boston and New Hampshire, but also in visits to hospitals and other caregiver organizations, listening to complaints and problems and giving advice.
He's been hearing organizations say they're finding their own solutions to reach the so-called triple aim of better care for individuals, better health for populations, and reductions in per-capita costs. It's a concept he introduced in 2008.
Berwick, a pediatrician, co-founded the Institute for Healthcare Improvement 23 years ago. Some say he was the brains behind the quality/value movement leading to many provisions now engrained in the Patient Protection and Affordable Care Act and the regulations that followed.
So what does he think now, after a year away from CMS, about the pace and direction of healthcare reform? And now that PPACA has passed Supreme Court and presidential election hurdles, would he return to CMS?
He spoke with HealthLeaders Media on Monday about Medicare, and the coming era of "all-or-nothing" metrics, and about scoring providers on how well they keep patients in their homes, and out of healthcare settings. The interview lasted more than an hour. This is the first of two parts.
HLM: We hear rumors you might return to CMS to spearhead the transition to health insurance exchanges in 2014.
DB: I am happy being home with my family. And have no plans beyond that.
HLM: There is criticism that the pointy-headed healthcare policies wonks in Washington and Boston are out of touch with the front lines of the healthcare delivery system and don't have a sense of the real world. When you visit communities, do you hear people talking about problems you didn't anticipate?
DB: Let's start with your premise. We've been very much in the real world. IHI, the organization I used to lead, has relationships with thousands of hospitals and clinical groups around the country, and at the [IHI] national forum coming up next week, there will be 6,000 people from hundreds of hospitals and healthcare organizations and probably 49 countries.
To regard the improvement movement as being out of touch with the front lines is wrong.
And at CMS, there [are] 5,500 people who work there, and I was at first just astonished and then delighted with the level of competence and dedication of the workforce. There's so much unknown about the agency. And I visited all the regional offices, who know their doctor groups and clinical settings very well
The other thing I did was [reduce] administrative waste, which adds complexity where it's not needed... and the amount of administrative waste within CMS was quite high. I challenged the agency to identify outmoded regulations and rules and procedures that didn't make much sense.
An early request of the staff was, let's have a target of 50 rules and regulations that could be removed without harming patients, and would simplify life and make things better.
When we published the regulation, which was at the request of the White House, which was advocating for decreased complexity, we had about 100 rules that were removed with one stroke.
And we had enormous numbers of public meetings getting feedback on every regulation that we proposed, with comments and I read a lot of those comments.
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.
HLM: Do you see more aggressive regulatory changes to value-based purchasing incentives and readmissions penalties, for example, more conditions added to the three that are now susceptible to readmissions penalties?
DB: I have a 3-year old grandson. I noticed at age 2, a child can stack blocks about four to six high. With my grandson last weekend, we stacked 24. Development is underway and the same is true with these metrics. We're just in the earliest episodes of learning how to measure at all.
The measures we really want to get to are global, around total system performance, "all or nothing" metrics, where you don't get partial credit if you leave something out, or measures that have to do with patient well-being and comprehensive care. That's where we need to go, but we're still on that journey.
HLM: What do you mean by "all or nothing"?
DB: Let's say for a diabetes patient there are six things that should be done, check eyes, check feet, check A1c, and so forth. If you don't do one, you get zero, even if you did all the other five.
It's like buying a car and everything is fine except they left out the right front brake. That's a zero. That car is broken. In healthcare, perfection is the goal, it's really key.
HLM: When will we start seeing "all or nothing" in regulations?
DB: They're already here on the private side. Lots of organizations are setting their own efficiencies very high, like Health Partners in Minneapolis, which has been using these for a decade. And the National Quality Forum has composite measures that are making progress. There's no question this is the way we should be going.
HLM: What other kinds of measurement do you see in the future?
DB: Measures of patient voice, through the patient's eyes. We're getting more careful and thorough about asking patients about their experiences, and having that be the goal, and making sure that transparency, above all, is the rule. Transparency almost always helps.
HLM: I've heard talk about functional outcomes.
DB: Those are very important, obviously. For example, for patients with stroke, to what level of function do they return?
HLM: What I've been hearing is that there's a disconnect between value as a goal and a fee-for service world. How fast do you think that will tilt to one based on performance?
DB: I don't know. But you can improve in a fee-for service world. That's been done for decades, but it's better if you have a system in which payment is comprehensive and global, so people can put resources where they need to be. So you can send nurses to someone's home if you want instead of building a new (cardiac) cath suite.
Fee for service is a serious problem. It drives volume, it drives overuse. No payment scheme is perfect, but fee for service seems to have particular toxicity. Yet as I go around the country, some communities are really ready now to take a major step away from fee-for-service, almost completely. Others are clinging to it because they think there's something very good about what it does for the freedom of caregivers.
I think there's going to be a lot of variation around the country, with Massachusetts getting away from fee-for-service, Maryland trying to build on its tradition of the all-payer system, and Arkansas is moving toward bundled payments.
End of Part 1.