Don Berwick Tells What He Really Thinks About CMS, Health Reform

Much has been written about Donald Berwick’s recent resignation under fire as Director of the Center for Medicare and Medicaid Services. He has been described as a visionary, a heretic or more accurately, a thoughtful physician and quality expert who tried to keep the concept of patient-centered care at the heart of the administration’s health policy.

I’ve read many of these articles and found Harris Meyer’s detailed history in Health Affairs of Berwick’s too-brief tenure at CMS , including a first-hand glimpse of his last few days at the helm of the agency, to be especially insightful. But I also wanted to direct readers to a speech given by Berwick earlier this month when he accepted the Picker Award at the Institute for Healthcare Improvement’s (an organization he co-founded) national meeting.  It’s a speech that is humble, offers gratitude to many, many people who helped along the way, is prescriptive and yet, also manages to implicate the culture of cynicism crippling Washington and impeding progress in truly reforming health care.

First a brief background: President Obama appointed Berwick to the CMS job in April 2010—a month after the historic health reform legislation was passed—while Congress was in recess. This tactic was deemed controversial but necessary as Berwick’s regular appointment would surely have been blocked by GOP critics who accused the Harvard professor of pediatrics and health policy of advocating rationing and of trying to turn the American health care system into a version of the UK’s “socialized” health program.

During his time at CMS, Berwick made significant progress on advancing government policy to support accountable care organizations, better coordination of care and made inroads in getting doctors to adopt electronic health records. He calls the Affordable Care Act “a majestic law” that serves as a “framework,” like an “architect’s sketch” that through regulations and guidance can be transformed into real programs and services that reach people. He tells Kaiser Health News, “I think Medicare and Medicaid were are and remain brilliant social investments.”

Mostly, Berwick tried to avoid responding to his most vociferous critics. But now free from the demands of public office, his Picker speech offers the opportunity to glean how he really felt about his run as CMS director.

“For me, the past 16 months have been quite an expedition; I feel like Marco Polo,” Berwick tells his audience. “Never having expected it, I journeyed into the world of national policy and politics at the most tumultuous time for both modern American health care and the modern global economy.

“I would have loved to keep at that job longer,” he adds, “But, as you know, the politics of Washington, and especially the politics of the United States Senate, said, ‘No.’”

Berwick’s speech is entitled,  “The Moral Test,” and refers to a quote by Sen. Hubert Humphrey that is inscribed on the building that houses the Department of Health and Human Services (HHS) offices: “The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped.” Berwick says. “I believe that. Indeed, I think that Senator Humphrey described the moral test, not just of government, but of a nation.”

Berwick, noting the rising rate of poverty in this country, continues; “The politics of poverty have never been power politics in America, for the simple reason that the poor don’t vote and the children don’t vote and the sickest among us don’t vote. And, if those who do vote do not assert firmly that Senator Humphrey was right, and if we do not insist on a government that passes the moral test – the thread will break, and shame on us if it does.”

The speech is eloquent, but it also reads like one hell of an exit interview; one that those among us who has ever been fired, “let go” or otherwise dismissed from a job can admire and appreciate. For example, Berwick aptly characterizes the political posturing that is so rampant in Washington and prevents real change and reform from occurring;

“Every morning at breakfast, the stewards of national policy and politics rush to scan the Washington Post and Politico and to wolf down the day’s Capitol Hill newsletters and blogs. What they are finding out is what each other says. Which Senator has raised an eyebrow? Which lobbyist has cried foul? Which Committee is launching which outraged inquiry into which shocking development. In Washington, a day without a shocking development is hardly worth getting up for. And, of course, who is ahead? Always, who is ahead?”

Berwick decries this obsession with political power and the cynical attitude that it engenders: “Cynicism diverts energy from the great moral test,” he says.

And to critics who tried to paint Berwick as a champion of “death panels” and “rationing,” he responds:

“The outrageous rhetoric about ‘death panels’ – the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas.”

He continues;

“If you really want to talk about ‘death panels,’ let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America. What happens in a nation willing to say a senior citizen of marginal income, ‘I am sorry you cannot afford your medicines, but you are on your own?’ What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins? Maybe a real death panel is a group of people who tell health care insurers that is it OK to take insurance away from people because they are sick or are at risk for becoming sick.”

As for charges of rationing, Berwick responds just as forcefully:

“It boggles my mind that the same people who cry ‘foul’ about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them.”

Finally, Berwick shifts to describing how health care can be rescued from the brink. And here is where he says it is necessary to talk about cuttings costs, not just “value improvement.”  “I would go so far as to say that, for the next three to five years at least, the credibility and leverage of the quality movement will rise or fall on its success in reducing the cost of health care…”

Berwick made headlines when he told the New York Times that “20 percent to 30 percent of health spending is ‘waste’ that yields no benefit to patients, and that some of the needless spending is a result of onerous, archaic regulations enforced by his agency.”

In his IHI speech, he goes further, sorting “waste” into six categories; overtreatment, failure to coordinate patient care, administrative complexity, out-of-whack pricing, fraud and abuse.  “[A]t the median, the total annual level of waste in just these six categories (and I am sure there are more) exceeds $1 trillion every year – perhaps a third of our total cost of production.”

The massive push to implement health reform continues. Marilyn Tavenner, previously second-in-command at CMS and a former health secretary from Virginia is now running the agency; but her confirmation is also not assured.  Brent James, chief quality officer at Intermountain Healthcare told Health Affairs that “From a health care perspective, [Berwick] was the best thing that happened to the Obama administration. It will be interesting to see how health reform fares in the face of this loss.”