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Frum Forum


Berwick's Bad Medicine

July 13, 2010

By David Gratzer

In the spring, the White House announced that Dr. Donald Berwick, a Harvard pediatrician and health-policy expert, would be the nominee to lead the Centers for Medicare and Medicaid Services.

It was then that I ordered a copy of Escape Fire—a collection of Dr. Berwick’s speeches. In the coming months, Dr. Berwick has sparked incredible controversy (a point I’ll return to in a moment). But in reading through his speeches, I can’t help but feel that he isn’t the “revolutionary” his many supporters suggest. Rather, he comes across as somewhat entertaining, somewhat clever, and—like most keynote speakers at health-policy conferences—somewhat light.

His lectures include clever stories about his kid’s baseball games, rockets, and explorer James Cook. As for the policy prescriptions, they tend to be sweeping if substance-less.

Here are his five recommendations from a 1994 speech:

  1. We must change our focus from integrating structures to integrating experiences.
  2. We must learn to use measurement for improvement, not for judgment.
  3. We must move beyond the naïve search for best practices to a much healthier mode of learning from one another.
  4. We must shift thinking from reduction of local cost to reduction of total cost.
  5. We must compete against disease, not one another.

Just so you know that I haven’t completely manipulated his hard-hitting analysis, here are “six ideas that represent for me appropriate foundations for design for the era of change that will be responsive to the new context of care” that he describes in a 1995 speech:

  1. Reduce waste in all its forms.
  2. Study and apply the principles of continuous flow.
  3. Reduce demand.
  4. Plot measurements related to aims over time.
  5. Match capacity to demand.
  6. Cooperate.

I never attended any of these speeches, but just can’t see the gasps from the audience when he announced that first point about waste—or the sort of challenging questions and comments that would have followed when, say, the executive from the Florida managed care company argued that hospitals and insurance companies should seek to reduce only some types of waste. Ditto on 3, 5, and 6.

Dr. Berwick’s work, of course, shouldn’t just be measured by his Anthony-Robbins-does-health-policy rhetoric. Rather, his work at the Institute for Healthcare Improvement can be weighed. There, he has spent decades championing causes like more hand-washing in hospitals and the use of check-lists.

Of course, Dr. Berwick’s work has created a stir in Washington. After being nominated, the President appointed him administrator of CMS as a “recess” appointment. Setting aside the issue around recess appointments, Republicans and conservatives have been harshly critical of the good doctor. Sen. John Cornyn, (R- TX) calls him “an extremist.” Conservative Mark Levin is even sharper: “We have another Marxist in our midst.” Pointing to his fondness for Britain’s National Health Service, critics have suggested that he would bring U.K.-style rationing to the United States.

Let’s be clear: Dr. Berwick isn’t an extremist and he isn’t a Marxist. And, no, your grandmother will not be euthanized under his watch. But he is an ideologue, one who looks fondly on government and government systems—he has, as has been widely quoted, professed his love for Britain’s National Health Service. And for a person charged with overseeing $800 billion a year in health spending, that is a big issue.

Ultimately, Dr. Berwick is impractical in his policy positions. In a piece that I’ve just co-authored with my colleague and friend Paul Howard, we note that he sees a consumer revolution rising out of careful government management—as if the iPhone and its competitors were the result of good central planning. Like too many in health policy circles, “he has fallen victim to the Harvard Disease: the idea that having experts peer through reams of data will lead to system wide improvements. Thus, he writes fondly of the “—centralized stewardship in the NHS.’”

And Dr. Berwick fails to appreciate the private sector. As we observe:

Here is the biggest irony: despite his hostility to profits and markets, many of the quality and process improvements Dr. Berwick champions were borrowed from the private sector—from hotel chains, 3M, and Proctor and Gamble. Let’s just state the obvious, yet again: these innovations arose from consumer choice and market competition.

Telegraph columnist Janet Daley, who is an American by birth but has lived in the United Kingdom for 45 years, makes another point: Dr. Berwick doesn’t really understand the British system either.

Dr Berwick professes a love (which he describes in ecstatic terms that will have a tragicomic ring to most British ears) of just those evils of a national health system with which we are exasperated: the calculated rationing of treatment, and the ruthless enforcement of uniform cost limits, which often puts the most advanced medication and procedures out of reach of patients whose lives might have been extended or transformed by them. Dr Berwick thinks that our own dear National Institute for Clinical Excellence (Nice)—which is scarcely ever out of the headlines for denying some poor suffering victim a remedy that is available in other countries—is simply wonderful.

Unfortunately, Dr Berwick is quite right to draw these particular conclusions about the inevitable consequences of state-sponsored health care. Which brings us back to [Health Secretary] Lansley and his not-really-all-that-radical reform of the NHS. At a time when both the demand for care and the scope of medical innovation are virtually infinite, a tax-funded health system must involve rationing and often the outright denial of advanced, cutting-edge treatments. There may be no theoretical limit to what miracles medical science can deliver, but there is certainly a limit to what taxpayers can subsidise, or to what governments can spend if they are not to starve every other public service to the point of death. The Government’s refusal to cut NHS funding—at whatever cost to other departments—is rightly condemned as wrong-headed and politically cowardly.

So why the inevitability of those aspects of our system which we most dislike? Why is Dr Berwick correct when he says that the NHS way of doing things is basically sensible, given the principles on which it rests? Because we have—and America is apparently about to embrace—an approach to health funding which is inherently self-limiting. Rationing is what happens when you do not have enough of something to go around. And health care that is paid for entirely by taxation creates shortages where they need not exist.

Dr. Berwick takes over CMS at an interesting and important time—at the point that America is beginning to really feel the weight of health-care spending on both the public and private sector. But like many in the White House, just when sober analysis is needed, we have Dr. Berwick arrive with his ideological inclination: that more government will save the day.

He’s wrong, as is the White House. And that is reason to fret his appointment, all partisan rhetoric aside.

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