In his opening remarks Tuesday at the Institute for Healthcare Improvement's (IHI) 21st annual national forum on quality improvement, IHI President and CEO Don Berwick observed how many healthcare organizations have made great strides in addressing issues, such as patient-centered care, patient safety, and chronic disease care innovations. But this is occurring during a time of great unease at the national and even international levels—where solid answers to healthcare costs and coverage are becoming more difficult to come by.
Berwick told the 5,300 attendees in Orlando Tuesday that with current reform efforts in Washington—with an estimated 10-year, $1 trillion price tag—have also come with a debate that's balancing two options: Spend more money or do less for people. But neither of those ideas is going for work very well for the current generation or future generations, he said.
Increased spending on healthcare is "theft—theft of healthcare from schools and roads and museums, and the social safety net. That's theft from the future," Berwick said. Since spending more on care and doing less for people isn't an option, that creates a "mega-pickle."
And he doesn't see Congress making the major changes to alter this.
"Congress hasn't led us to a new care system, and I don't think it will. Congress won't give America even a vague prescription—much less a detailed set of rules for that," he said. "How could Congress possibly know enough to specify for every community, the exact design for … care that is safe, effective, patient-centered, timely, efficient, and equitable?"
To understand why they may be stuck in this situation, healthcare providers and organizations may want to review the "Tragedy of the Commons," a term from an article that appeared in Science magazine in 1968. It referred to a pasture or commons that has an optimum number of sheep—where there are just enough not to destroy the area. But as sheep are added, the area is soon overpopulated with sheep and is destroyed.
This can be related to healthcare reform—with all the stakeholders including hospitals, physicians, nurses, insurers, pharmaceutical manufacturers, suppliers, and even patient groups. "Like the villagers [in the commons analogy], rational healthcare stakeholders are eroding the common good simply by doing what makes sense to each of them separately," Berwick said. "In the short term, we each win. But in the long term, we all lose."
"This is a world with limits [and] it can be used up," Berwick said. But healthcare is not entitled to everything it has "and surely not entitled to everything it can get."
"Healthcare does not need everything it can get—not by a long shot. Not if what it's trying to do is give us what we need—comfort, answers, vigor, years, and health. We can have what we want," he said.
He added some systems are making progress in recognizing and dealing with limited resources in providing care in their communities, such as Cedar Rapids, IA; Everett, WA; Tallahassee, FL, and La Crosse, WI.
At the meeting, Kavita Patel, who assists the president's senior advisor, Valerie Jarrett, at the White House, said current reform legislation does not specifically define quality or even how to measure it; this is likely to fall under the review of the healthcare organizations.
While Washington can write the rules, the odds of "re-form" will remain zero unless action is closer to home—or essentially closer to the providers of care. Berwick suggested some ideas to get started:
- Understand your "healthcare commons"—its limits and boundaries, who uses its resources, and who is served.
- Adopt a goal—such as over the next three years, reduce total resource consumption of your healthcare system by 10%. This would be achieved without rationing or exclusion of needed services.
- Develop it fast—"because there isn't much time left," he said. "Do not wait for external rules to be made or to change. Do it yourself."
"We can wait for the rules to be written by others and for the laws on tablets chiseled by others to rescue us—but those rules will be less wise than the ones we can write," he said. "It is a very tough choice: Get everything we can or respect everything we have been given."