The medical system Donald Berwick prefers in the United States

by James Gaulte, MD

Apart from some apparently radically contradictory expressed views on patient “centeredness” and patients being in control, the newly appointed head of CMS, Dr. Donald Berwick, has made it clear what sort of medical system he would have for the United States.

What he wants is well explained in this commentary from National Review Online as is the authors’ reasoning of why that sort of authoritarian central planing never seems to work. The following is from that article:

Ideologues on the left favor a single-payer system for, well, ideological reasons of material egalitarianism. But for technocrats like Berwick, who shape the liberal policy consensus, the single-payer system is the most efficient way to manage health care. Top-down control, in their minds, ensures that every participant in the system serves the broader public good: hospitals and doctors only perform the tests and procedures they need to; private companies make enough money to get by, without excessive profits; and “integrators” mandate best practices for all parties based on the best available evidence.

From Berwick’s extensive writing and speeches we see that he favors a system in which data is dispassionately collected, analyzed and, in the most scientifically validated method, a cost benefit analysis is performed so that the proper testing, procedures and medications are dispensed in a fair, equitable, humane and compassionate manner.

Mandated best practices would impose order on the chaotic unplanned, helter-skelter mess we have today. By the same token someone should impose order on the chaotic, unplanned mess that is our “grocery delivery” system. Getting food is even more important that health care. By that I mean the thousands of groceries across the country in which most of us find, most of the time, everything we want. and if we don’t, we go to the store down the street.

Contrast that with the iconic empty grocery shelves of the USSR which fixed the chaotic market with best practice central planning.

It is difficult to imagine that someone still thinks central planning is more efficient that market mechanisms. Most anti-markets theorists decry what they believe to be the lack of morality of markets while agreeing that markets are most efficient.

So what could be wrong with this technocratic approach? The NRO essay suggests the following for starters:

Even if you believe that technocrats could better organize our health-care system, Berwick’s approach only works if the narrow interests of Congressmen, labor unions, general hospitals, the AARP, etc., have no influence on the writing of law. No one who watched Democrats make the Obamacare sausage can harbor any illusions on this score.

In other words, it would work only if we change human nature and the folks in government (both the legislative and the executive branches) miraculously are no longer vulnerable to the incentives and pressures and biases and, yes, even self interest, that is the plight of the rest of humanity. Technocratic administration in theory and technocratic administration in practice could not be more different.

A second point from NRO’s critique:

Technocrats may believe they can marshal statistics and analysis to optimize the health-care system, but they are not omniscient. Their analyses rely on too many assumptions and on unreliable data. This is why government programs always result in colossal amounts of waste, fraud, and abuse.

So, how well did the central planning work out in the USSR? Hint: There is no USSR anymore.Starvation and near starvation characterized both the Russian and Chinese central planning of farming.

Berwick longs for a situation in which “leaders with plans” can roll up their sleeves and get this chaotic,leaderless medical system on the right road. I can think of little worse that putting self anointed leaders with plans in charge of medical care or, for that matter, grocery distribution.

James Gaulte is an internal medicine physician who blogs at retired doc’s thoughts.

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