Don Berwick to lead Medicare and Medicaid

While the health reform bill will have many effects, one of its most profound will be to unshackle the Centers for Medicare & Medicaid Services (CMS).

Under the legislation, CMS is now far freer to undertake a variety of pilot programs and demonstration projects designed to improve quality, safety and efficiency, and to convert the successful ones into policy. And, if that wasn’t enough for those who have long been praying for a more activist CMS, we now learn that President Obama will select Don Berwick, the world’s most prominent advocate for healthcare quality and safety, to be the next CMS administrator. Although I’ve sparred a bit with Don over the years on matters of philosophy, I think he is a superb choice.

Don’s story is well known – a Harvard pediatrician and policy expert who became passionate about improving healthcare well before it was fashionable, he ultimately left his full-time academic perch to pursue his calling. In 1991, he founded the Institute for Healthcare Improvement, which ran on a shoestring for its first decade, fueled largely by the considerable power of Don’s vision and personality.

Then came the IOM reports on safety and quality (reports that Don had a major hand in crafting), followed by a national movement that promoted transparency, pay-for-performance, tougher regulatory and accreditation requirements, increased media and legislative interest, and voila: IHI became the essential organization – a source of networking, best practices, conferences, sustenance, courage, and more. To many in the quality and safety world, IHI became their church, and Don its Pope.

I admire Don enormously, and have no doubt that the world is a far better place thanks to his, and IHI’s, work. I’ve seen scores of examples of Don’s impact over the years, at hospitals, nursing homes, and clinics in the U.S. and around the world. Just recently, I spoke at a large Indiana patient safety meeting. Don had filmed a video greeting to the group, which was projected over lunch. These things are always awkward – people rarely cease their conversations to listen to a disembodied speaker. But when Don’s face came up on the screen, everybody stopped what they were doing, riveted by the force of his vision and his unique ability to touch and inspire people doing the hard work of change. His effect was astounding; it always is.

My mild beefs with Don and IHI have come from the fact that he has generally put his nickel down on the “Just Do It” side of questions regarding the importance of evidence in patient safety and quality. Although IHI’s 100,000 Lives Campaign promoted many key practices and energized thousands of providers and leaders, the choice to turn Rapid Response Teams into a national standard of care was, in my opinion, premature, backed by insufficient evidence that such teams really work. And IHI’s assertion that the campaign saved 122,300 lives crossed that crucial line that separates scientists from spin-meisters.

Moreover, when I hear Don speak, I often find myself awed by his poetic words and powerful ideas but shaking my head in mild disagreement. The latest example: I find Don’s version of patient-centeredness, described in his article aptly entitled “Confessions of an Extremist,” to be hard to swallow. In essence, he argues the consumerist view that patients should be able to get nearly anything they’d like, regardless of the evidence or cost. You might recall that he first articulated this idea at the ABIM Summer Forum a few years ago (I wrote about it here), to a mixed audience response (to be charitable). In a healthcare system rapidly going broke, such a philosophy just can’t work.

Don is a brilliant guy, and he understands this, of course. So why articulate this point of view? I believe that Don has seen his role to date as that of the Passionate Outsider, a provocateur trying to push us out of our collective comfort zone. Even when I find myself disagreeing with him, I admire him for that, since it would be far easier, and far less effective, to traffic around the margins of the status quo.

How will Don’s philosophy jibe with the realities of running an organization whose yearly budget is $704 billion, larger than the economies of Denmark and Argentina combined (if CMS were a country, its GDP would make it the world’s 18th largest), an agency slated to run out of money in about 7 years? It’s hard to know.

But if Don Berwick is at the helm of CMS, you can bet on an ambitious agenda (and the agency has plenty of tools to carry one out, as described in this recent NEJM article) in quality and safety, a larger focus on removing waste from the system, greater efforts to promote transparency but a measured approach to pay-for performance (Don favors the former and has been ambivalent about the latter, as shown here and here), increased attention to capacity building (which is, after all, what IHI has done best), promotion of more physician-hospital integration and care coordination (via new models like Medical Homes and Accountable Care Organizations), and a far more vigorous use of the bully pulpit. In short, while his “extremism” will be tempered, I can’t see Don Berwick being intimidated or beaten down, even by the Washington bureaucracy. In an agency and an industry sorely in need of fresh approaches, that’s got to be a good thing.

In any case, it’ll be one hell of a ride. Or, as Joe Biden might say, a Big F-ing Deal.

Bob Wachter is chair, American Board of Internal Medicine and professor of medicine, University of California, San Francisco. He coined the term “hospitalist” and is one of the nation’s leading experts in health care quality and patient safety. He is author of Understanding Patient Safety, Second Edition, and blogs at Wachter’s World, where this post originally appeared.

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  • Dr Lemmon

    I hope we do not start spending money and grading performance on quality initiatives that are shown not to improve outcomes. The Optimize HF trial comes to mind. The same standards that JCAHO use to grade hospital performance in managing CHF were found not improve hospital deaths, outpatient deaths after discharge and did not reduce readmission rates. Yet we are still spending time and money implementing them. The LEAPFROG safety initiatives did not improves outcomes or reduce deaths. In the Journal Health Affairs recently (Mar/Apr 09) orthopedic surgeons using quality guidelines for hip and knee replacements had no fewer complications or reductions in mortality than those that did not follow the guidelines. We have seen failure of tight glucose control to reduce strokes and MIs in diabetics (ACCORD trial June 2008, NEJM) yet HbA1c less than 7% is still the mantra despite clear harm in at risk patients (I am graded on this one). Recently the ACCORD BP study showed a slightly higher death rate in diabetics with BP kept in the 120 range compared to 140. Also an admission that the JNC guidelines were best guesses in this regard.

    I have just barely touched the surface on this topic.

    Quality is great. Guidelines are great as long as they are guidelines and not rules. Let’s not continue to pursue initiatives it the data shows they are ineffective. These things cost money and time and often the hype does translate into real improvement in outcomes. More bureaucrats, more rules, more inefficiency and waste is not the answer.

  • Rod

    Recognize primary care for their efforts to call patients, review history properly, spend time with patients. Less time means more tests. Medical schoools and Residencies need to train students better. Knee jerk reflex to do more tests than listen to patients. No value for follow up on phone, follow visit. System should abolish RVU placing more $$ value for procedures.

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