Dr. Berwick's introduced his topic for the evening, The Future of Healthcare, by stating that "what America needs now is the mobilization of a "civil society" (like Europe.) He then shared a lovely personal side to his life with one of his grandsons, showing how the grandson had grown over the past 4 years - the change in healthcare, like seeing a child grow, is like bread rising in the oven - you don't see it happen moment by moment, but if you check back over time, you see the growth over time. Dr. Berwick also brought up Gloria Steinem in the feminism fight, and he adopted one of her first rules for fighting for change, and that is to Name the Enemy (in women's rights, one of the key enemies was date rape.)
One of the grandsons was afraid of monsters in the dark. Dr. Berwick brilliantly outlined a set of 11 Healthcare "monsters" that we don't name in our fight to cure healthcare - the gist of Dr. Berwick's talk is that these unnamed creatures will keep us from advancing if we don't fight them. The 11 monsters he brought up, in four categories and with great examples for each, are familiar to us all:
Uses of Knowledge
1. Lack of scientific basis for medical decisionmaking. Randomized Controlled Trials are not the right
tool for figuring out how to fix HC, but we need to figure out how to fix it.
2. Need to use Global Brains, not just American ones - a European cure...
3. We don't achieve learning in Large Systems - "Improvement" was a bad word (we should be perfect already; don't imply we need to improve! Quality "Assurance."
Nature of Waste and Excess
4. Waste - 50% of cardiac revascularizations are unnecessary, according to world famous CV surgeon
and inventor of dilantin. Cost effectiveness was thrown out of the ACA... The American public
doesn't understand how much "too much" we have in the system. A "Choosing Wisely" campaign
has been launched to try to deal with this problem.
5. Profit vs. Greed - in a legal but morally reprehensible way, drug companies and others gouge the
healthcare system for all it is worth. Example: patenting an already OTC drug and increasing price
from $300/dose to $25k/dose, costing Medicare millions. Makena for Pre-term labor, Colcrys for
Gout, EPO NOT used for dialysis, but nobody takes the drug cost out of the reimbursement that
was established when the codes were created!
6. Innovations that don't help - more fiberoptics, etc. etc. etc.
7. The behavior of "Guilds" - physician socities and hosptial associations (AMA, AHA, etc.) that
promote the well being of the provider over that of the system.
Priorities in Care
8. Defending the Poor - Humphrey's Moral test 11/4/77 - a society is one that is judged by how it treats
its young, elderly, and poor...
9. Palliative and EOL Care - each person will face EOL. What do you want yours to look like?
10. Authentic Prevention - getting people to pay attention their health to prevent the need for care
Transition Planning
11. There is no business transition model, particularly for hospitals, to go from being paid for CARE vs.
being paid for HEALTH. How do we get people aligned around reducing hospitalizations?
My question, after reflecting on Dr. Berwick's points and his apparent appeal to moral codes and regulation to fight the monsters and fix the issues, is why can't we get the MARKET to figure out the right answers? It is impossible to expect that government and "well meaning" oversight will ever kill the monsters; best to be indirect and let choice and following the money do the work! Once people are insured, under the ACA, we can start to work the financial incentives with Patients, Providers, and Payers to help people make the most sensible decisions about their own care - PATIENTS CAN CHOOSE THEIR OWN PATH WHEN IT IS THEIR POCKETBOOK AND THEIR LIVES AT STAKE. The market will create solutions that patients can choose - like online care, minute clinics, telemedicine, health care directives, hospital based vs. office based procedures (which insurers can help direct patients to with information about the cost to them and quality metrics for each, etc.). Dr. Berwick's background is clearly "Preparation H" with a BA, Medical Degree, and Kennedy School of Gov't background, but he missed HBS - the Business School - in the mix. Check out Herzlinger and Bohmer and Christenson and Gawande, and see what they might do to fight the monsters in healthcare, by applying manufacturing and business and innovation principles. That might really work (if our government's current stalemate is any indicator of the efficacy of government in managing change!)
A great forum in all.... I just wonder if the folks in the middle really want to change healthcare, or just keep talking about it.
To give you a bit of background on Dr. Berwick:
Donald Berwick, M.D.
Dr. Berwick is the United States’ leading advocate for
high-quality healthcare. In December 2012, he stepped down as the administrator
of the Centers for Medicare and Medicaid Services. For 22 years prior to that,
he was the founding CEO of the Institute for Healthcare Improvement, a
nonprofit organization dedicated to improving health care around the world. A
pediatrician by background, he has also served on the faculties of the Harvard
Medical School and the Harvard School of Public Health.
Donald M. Berwick (born 1946) is a former Administrator of the Centers for Medicare and Medicaid Services. Prior to his work in the administration, he was President and Chief Executive Officer of the Institute for Healthcare Improvement[1] a not-for-profit organization helping to lead the improvement of health care throughout the world. On July 7, 2010, Barack Obama appointed Berwick to serve as the Administrator of CMS through a recess appointment. On December 2, 2011, he resigned because of heavy Republican opposition to his appointment and his potential inability to win a confirmation vote. On June 18, 2013, Berwick declared his candidacy for governor of Massachusetts.
Berwick has studied the management of health care systems, with emphasis on using scientific methods and evidence-based medicine and comparative effectiveness research to improve the tradeoff among quality, safety and costs.[2][3][4] Among IHI's projects are online courses for health care professionals for reducing Clostridium difficile infections, lowering the number of heart failure readmissions or managing advanced disease and palliative care.[5] In March 2012 he joined the Center for American Progress as a Senior Fellow. [6]
