The rumors that I wrote about Friday are, in fact, true. President Obama will name Dr. Donald Berwick, president of the Institute for Health Care Improvement (IHI), to run Medicare and Medicaid. Berwick, who is a professor of pediatrics and healthcare policy at the Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health, will have to be confirmed by the Senate Finance Committee.
Just how tough will the confirmation hearing be? I’m not worried. Berwick can handle himself.
Granted, yesterday the New York Times called Berwick “iconoclastic,” i.e., someone who “smashes sacred religious images” or “attacks cherished beliefs.” But most who know him describe him a “visionary” and a “healer,” a man able to survey the fragments of a broken health care system and imagine how they could be made whole. He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. healthcare.
Berwick stands at the center of a healthcare movement that would reform the system from within. In 2005, Modern Healthcare, a leading industry publication, named him the third most powerful person in American health care. In contrast to others on the list, Berwick is “not powerful because of the position he holds,” Boston surgeon Atul Gawande noted at the time. (Former Secretary of Health and Human Services ranked no. 1, while Thomas Scully, the head of Medicare and Medicaid services captured the second slot.) “Berwick is powerful,” Gawande explained, “because of how he thinks.”
Listen to some of the clips below, from the film Money-Driven Medicine, produced by Alex Gibney, and based on my book, and you’ll understand what Gawande means. Soft-spoken, and charismatic Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it could be.
Berwick isn’t just another ivory-tower philosopher. He’s “an extraordinary leader when it comes to inspiring people and creating the will to move forward,” Dartmouth’s Dr. Elliot Fisher told me in a phone conversation Friday. “And he can teach people how to do it. He has demonstrated his ability to teach people how to implement change in a complex system.”
That is precisely what the Institute for Healthcare Improvement (IHI), the non-profit organization that Berwick co-founded in 1991 does, spearheading pilot projects aimed at “continuous quality improvement.” IHI targets problems like asthma care or safety in coronary surgery and then invites teams of medical workers from hundreds of hospitals to collaborate in what Berwick describes in his book Escape Fire, as “results-oriented, clock-ticking projects, which may last six months or a year.”
Berwick outlines the process: “A hundred teams working to improve cardiac surgery outcomes; 70 teams working to reduce Emergency Room waits . . .—guided by teams of faculty from around the country or around the world, meeting regularly in learning sessions . . . going home, sharing what’re learning, coming back together here, sharing again.”
IHI’s website (www.ihi.org) offers an abundance of resources. a team of health care professionals can sign up online courses that focuses on reducing Clostridium difficile infections, lowering the number of heart failure readmissions or managing advanced disease and palliative care. The interactive, two- to- four month web-based courses are called “expeditions” and include: check in calls every two weeks for faculty to provide advice and mid-course adjustments; ongoing opportunities to share with and learn from other participating organizations; opportunities for periodic check-ins with faculty.
Alternatively, readers who visit the website and scroll down to “How Did They Do That?” and discover that Models of Low-Cost, High-Quality Health Care Do Exist in the U.S.
So Berwick does that it can be done—and how to do it. Many of IHI’s initiatives have succeeded. But he also understands that reform not something that will happen in 2014 when the government flips a switch. It’s a process that already is happening –and that will continue in the years to come. Much depends on people on the ground.
The Will to Excellence
Berwick’s vision is generous. He is convinced that there are enough like-minded people within the health care professions to create a revolution: “The will to excellence is present everywhere in Health care,” Berwick told an audience at the National Forum on Quality Improvement in Health Care. “The will to do well, the quest for pride, the joy of achievement, the warmth of serving –these are natural capital, human traits. Not of all human nature, not all of the time, bu enough, plenty enough. We can waste them and deplete them,” he adds, referring to low morale in many parts of our health care system. “But the will to have pride in work is not scarce; it is everywhere abundant.”
Time and again, Berwick has seen IHI’s pilot projects work –without any financial incentives for the medical professionals involved. Hospital workers want change. Many are horribly frustrated to find themselves laboring in an system where the left hand and the right hand often fail to communicate, making much of their work seem redundant or even pointless. Berwick recognizes that these professionals would like nothing more than to turn their hospitals into efficient workplaces. And that such an opportunity might well be worth more than a 2 percent raise.
Indeed, a year ago at the American Medical Group Association meeting, Berwick compared physician performance bonuses to exhorting [doctors and nurses] “to do better,” and said both were “very poor cousins” to healthcare system redesign. As he told Kaiser HealthCare News in an interview today: “I think we need to create more consequences for good and bad performance. But we have to learn our way unto that. . .. The danger is that you create ‘games and gaming’—which we can ill afford.”
In a 2005 interview published in Health Affairs, Berwick expressed his concerns: “I would draw a very dark line between the incentives that apply to organization . . . where I do want incentives in place — and incentives for individuals. . . . I want it to be good for an organization to be safe, and I want it to be good for an organization to manage chronic illness carefully . . .” He applauds the pilot projects in the health reform legislation that encourage Medicare to “bundle payments to doctors and hospitals,” with a bonus added to the bundle when teamwork leads to good outcomes at a lower price.
But “at the individual level,” he insisted, I don’t trust incentives at all . . . I think it feels good to be a good doctor and better to be a better doctor. When we begin to attach dollar amounts to throughputs and individual pay, we are playing with fire. The first and most important effect may be to disassociate people from their work.”
Here, I think Berwick is putting his finger on a potential problem in the current reform movement. Recently, I have talked to both doctors and nurses who were troubled by the new emphasis on “productivity” in organizations where they work. How many patients have you seen today? As Berwick put it in 2005, “We’ve got to support the underlying culture and the underlying system that makes healing, not scoring, the objective.” Today, he added, “we need to stop paying for through-put.” (At the same time, he recognizes that primary care physicians must be paid more. Anyone concerned on that score should listen to the first clip from the film below)
When I was writing Money-Driven Medicine, I discussed the issue of “pay-for-performance” (which is quite different from paying an organization for good outcomes) with former Medicare director Bruce Vladeck: “Quality and improvement strategies need to focus on reinforcing the norms and values of professional responsibility rather than on undermining them through the exercise of economic muscle,” Vladeck said. “Unless we can continue to assume that most providers and administrators want to do the right thing for most patients most of the time,” he added, “we are all sunk and no amount of economic incentives can salvage the situation.”
Tapping into that underlying professionalism, Berwick has said, is “like drilling for oil. There is so much pent-up need in the health care work force that, even without financial incentives for individuals, health care workers are eager to make a change.”
To some, Berwick may sound out of touch. Over the past twenty years, the notion that pride in a job well done drives excellence has been dismissed as simply sentimental. People are motivated, we are told, by money. We’re all rats on a wheel, looking for the cheese. That’s what makes people “tick” Dr. Robert Galvin, director of Global Health at General Electric, told Berwick in that 2005 Health Affairs interview.
If we want a CEO to perform, a seven-figure salary is not enough. We must give him stock options. In this context, Berwick may sound naive. But when I was writing Money-Driven Medicine, I didn’t find anyone in the health care industry who wanted to call him that. The sheer authenticity of his presence commands tremendous respect.
“The Enemy is Disease”
Meanwhile, Berwick understands the role that money plays in our highly-competitive for-profit system all too well.
At one of IHI’s National Forums, Berwick recalled phoning a hospital in Houston to learn about its reportedly successful innovations in pneumonia care. He was told that “the gains are enormous but the methods cannot be reported to the public—excellent pneumonia care offered the hospital local competitive advantage.”
He was stunned. “The enemy is disease,” he told his audience. The competition that matters is against disease, not one another. The purpose is healing.” Yet “in the storm of the health care crisis,” Berwick acknowledged “it is so easy to forget why we trouble ourselves in the first place. It is so easy—frighteningly easy—to become trapped in the sterile thesis . . . that our true, deep purpose is to gain and preserve market share in a vacant terrain of others whose purpose is precisely the same.” In other words, it is so easy to forget the patients.
In part 2 of this profile, I’ll talk about what Berwick has to say about fragmentation–and variations in care in different parts of the country. Why can’t the Kaiser Permanente model work everywhere. What does he mean when he says that we haven’t even tried “transparency”? What will Medicare ask of U.S. hospitals? Just how much waste does the think there is in the system? How quickly can Medicare move to eliminate that waste?
The misinformation, disinformation, demagoguery, and backlash have already started: http://blogs.myspace.com/index.cfm?fuseaction=blog.view&friendId=74508082&blogId=531774450
Obama To Appoint Dr. Donald M. Berwick To Head Medicaid/Medicare: Our worst nightmare…
Boy–he sounds dreadful. I feel bad for Medicare patients.
Thank you for the head’s up and the link.
Yes, no doubt there will be a backlash and much demagoguery.
Though this particular blogger that you link to is so off the wall (calling Berwick a “Cuban-style doctor) that it’s hard to believe many people take her seriously.
Even in her picture, she looks well . . . mean-spirited. I don’t mean physically unattractive–I mean that her soul shows on her face.
I still think Berwick should be okay with confirmation by Senate Finance. He is very gracious, intelligent, not an egomaniac, actually listens to people (as a good doctor does), understands where they are coming form , their concerns. And he has a sense of humor- he’s quick on his feet.
In normal times, a confirmation committee would definitely like him.
But these are not normal times, so it could be unpleasant.
But Senate Finance is not a lunatic group– the committee did, after all, manage to pass pretty acceptable legislation, thanks to Harry Reid, Jay Rockefeller.
Poor Harry Reid. He’s going to have to oversee this. And it looks like he will be rewarded for his efforts by losing his Senate seat.
I applaud Nancy Pelosi– but as a friend (Joanne Kenen) recently pointed out to me, she had an easier job, a bigger margin.
Reid was working with virtually no margin– nerve-wracking, probably took a couple of years off his life. And because he is less charismatic, telegenic character, he’s not getting us much credit as Pelosi. (Not her fault, and understandable. She’s the first woman Speaker.)
Perhaps the White House will name him an ambassador to someplace nice? (If he and his wife have any interest in moving to another country.)
In any case, Reid will go down in history as one of those in the vanguard of passing this historic legislation.
If I were his wife, I would say “Harry, five years from now, no one will remember exactly how many terms you had in the Senate. Fifty years from now, history books will name you as one of the people who brought health care reform to the U.S.”
Leah– You might want to
listen to the film clips, or go to IHI’s website and read before rushing to judgment.
I’ve never met anyone how knows Berwick or who has heard him speak who doesn’t like and respect him.
I’m an economist. I find the statement
” Over the past twenty years, the notion that pride in a job well done drives … by money.”
Highly ironic. I suppose it may be true that, over the past 20 years, non-economists have adopted the view that people are motivated by money. However, economists have faced the fact that this simple model does not correspond to reality.
I was just at a seminar by a hot shot young economist in which the sane view that money is a poor motivator was the motivation for an experiment (a real experiment — part of how economics has become less sterile is that it has become more empirical with actual experiments from time to time).
A leading figure in the movement to tell economists to pay attention to psychologists and sociologists is George Akerlof who has been awarded the Nobel prize. He argues that, like it or not, you can’t understand the economy without introducing the concept of morale. He makes this argument with data and no one has managed a coherent counter-argument.
This even newer approach to economics whose slogan might be “how about some common sense for a change.” is well represented in the Obama administration already. Another proponant is Austan Goolsbee who was and is a leading Obama advisor.
The fact is that no matter how cynical one is, the facts give one no choice but to admit that morale is important. This won’t be news to businessmen, at least not to successful businessmen. It is sad that it is news to policy makers (but they’ve heard the news by now).
Even the thought that Dr. Berwick could be understood as anything other then a visionary, healer, and a representative of what is good in health care and the world is unbelievable. Read his books, watch his videos, and take his lessons to heart. No one person will fix health care, but Dr. Berwick will definitely be on the team that does.
We will soon know much about what Donald Berwick is, especially with the anticipated acrimonious vetting process that will take place in Congress. It is much more important to know WHO he is, and there is no better source than Donald Berwick himself, in his own words. In that regard, I’ve included a link to the nine brief video clips from “Money Driven Medicine” in my qotd message today, letting Dr. Berwick speak for himself.
Thanks very much for this, Maggie.
Robert– A very interesting comment– and I agree.
When I first wrote that sentence I said “Over the past 20 years, economist have dismissed the notion . . .”–
Then I crossed out economists.
I would say that over the past 20 years much of “corporate America has dismissed . .” and Reaganomics encouraged the idea that if you taxed people they wouldn’t work as hard or be innovative, which again suggests that our only motive is money.
But more intelligent people in the corporate world have figured out how “paying for performance” (constantly measuring and rewarding) can, as you say, undermine morale.
In Money-Driven Medicine I write about what happened at Hewlett-Packard when they tried a similar scheme. It didn’t work.
The whole idea of paying teachers for their student’s performance (i.e. test scores) also is doomed to failure. (It’s already causing a great deal of gaming– teachers simply change the students’ scores on the tests; many prinicpals encourage them to do this.)
“Teaching to the test” also undermines teachers’ morale– there’s nothing creative about it. There is a playbook, and they are supposed to stick with the playbook. As a result, they know that they are not teaching what that particular group of students needs.
And you are absolutely right, economists in the vanguard of their profession have been studying psychology and sociology.
This has led them to conclude that most human beings do not act rationally, in their own self-interest, much of the time.
This sheds a whole new light on investing behavior–that’s the literature I’m most famliar with.
It reveals that “markets” are only as rational (or efficient) as we are–not very.
Don– although we have disagreed about some things in the past, I suspect we agree about Berwick.
Letting him speak for himself is a superb idea. That’s why I put the clips on this post. Thanks for the link.
I agree. It is
And no, Berwick is not the Savior–but he is one of group of people who understand what must be done, adn who are dedicated to the cause.
Berwick will attract others like him. For long time, vmany ery intelligent people with high values and vision just haven’t been going into government.
They just didn’t feel that they would be allowed to do the job well.
Now, in Medicare, they will be.
I think Berwick’s approach is encouraging. However, haven’t read enough yet to decide if it is or has potential to be more than just an improvement in a really bad system – more of what I’d like to see.
I wrote the following to IHI to see if some of the issues I’m concerned about are yet or will be addressed. If nothing else, I feel that addressing the conflicts of interest among chemical/pharm industries, regarding the profits they make through creating and “curing” disease, is essential. I haven’t read Maher’s book yet, which may address this issue.
Here’s my comments/questions to IHI:
I have done a great deal of research on the effects of low-level toxins on disease, as well as prevention of health problems exacerbated by the health care industry.
For example, any upper respiratory infection I and others may get is often due to some kind of toxic exposure like paint or perfume or pesticide fumes – usually exposures prolonged in a workplace setting. If we go to a doctor’s office for treatment (usually only as a last resort), I and others are often faced with more of the same exposures because of lack of education among health care providers. Furthermore, the stress that comes with the physical condition is usually exacerbated by the facility’s response to a patient either trying to avoid the office exposure (asking someone to call them in from outside when ready) or trying to educate the doctors/nurses about the need for them to educate themselves and their patients on toxic exposure issues.
Betty Bridges, a former nurse, forced to leave the profession after her own exposures at work made it impossible to continue, has provided an no-frills info site about the adverse effects of fragrance exposures: Fragranced Product Information Network. How well is her very reputable and well-researched info received by or communicated to health care professionals?
Another issue, pesticides, really has me bewildered. When my father was near death and on a ventilator (prolonged in my opinion because the nutritionist and doc refused to switch his feeding formula from a high-carb cheap version to one with omega 3 and other lung supporting nutrients), and the hospital suggested he be moved to a longer-term care facility, I called to see what their pest control policy was.
I had first of all been the only one to suggest no one enter his room wearing scented products (visitors, including my nephew), but when I asked the proposed facility about pesticide spraying I was told they weren’t sure and so I was given the name of the independent contractor paid to spray that facility.
I learned from the contractor that volatile pesticide sprays were indeed, to my never ceasing amazement, used in the very rooms where patients on ventilators were being treated!!!! — Clearly there is a disconnect between impartial, scientific-based information about the adverse effects of spray pesticide use (esp in buildings) vs how this information is applied to health care delivery/prevention. http://www.pesticide.org
is an excellent source for info on the adverse health effects and alternatives to what is termed the “spray & pray” method.
As a grad student of public health, I questioned some in my cohort, those in the profession already, about their knowledge of what types of pesticides were sprayed in their facilities. I learned that none had any idea. When I asked one director of a health dept in NC to find out, I learned that a pesticide, a carbamate, banned for use on golf course (because it killed wildlife) was being used indoors in his health dept! When I asked my local health dept the same question, the director responded rudely, stating it was not her job to know that information.
The third issue is cleaning products used in hospitals and health care facilities. When my daughter had jaw surgery years ago, leaving her with swollen sinuses, that condition nearly turned serious after cleaning staff used a volatile spray cleaner in the hospital room’s toilet. I complained, and then being very aware of the breathing problems that resulted, quickly asked for a mild decongestant (had to demand actually) which prevented her condition from getting out of hand. The situation was checked into and I was told the product had been improperly used. However, research provides a plethora of truly eco-friendly products available then and now that could have prevented any irritation (for most individuals).
What I am finding from years of research is that all of these offending and unnecessarily toxic products are made by companies with conflicts of interest. They all have pharmaceutical subsidiaries. With perhaps rare exceptions, manufacturers of every product that causes or exacerbates health problems -from skin and mucous membraned irritation to depression and other neurological symptoms to cancer – profit from the sale of these products as well as the sale of products made by their subsidiaries, ie, the “cure.”
Finally, I find a reluctance within the entire health care system to listen to my suggestions to use least toxic products and proven methods of pest control, much less review my research, as well as a reluctance to consider non-drug-based treatment of the maladies caused by these types of exposures, which can affect every part of the body. I know people who have found their own more natural ways of healing, after learning the hard way about what the “system” has to offer, only to have to pay for insurance that does not cover the treatments that work for them — solid, substantiated treatments proposed by some University Alternative Medical departments.
I can personally testify to the huge amount of money I have saved taxpayers and myself by simply changing my diet (eliminating sugar, trans fats and adding organic food and a few supplements) and eliminating as many exposures to toxicants as possible. I can personally testify to how *homeopathics and orthomolecular medicine can effectively treat brain damage and its severest manifestations, such as paranoia, delusion, schizophrenia. My daughter was damaged by an overdose of Halcion used off-label by a dentist. Homeopathic treatment closely monitored and overseen by an educated, competent consultant is a viable and FAR LESS COSTLY alternative for taxpayers and patients, in terms of money and adverse effects/trauma.
Which brings up my last concern: Halcion, and drugs like it, documented to have been kept on the US market (but banned in the UK and elsewhere) after FDA committee members with clear conflicts of interest voted to keep it there.
Even after Pharmacia (Halcin’s mfg) was convicted of the crime of marketing another of its drugs off-label and fined the largest in US history, it apparently continues to profit by “paying” certain receptive doctors/dentists to promote the off-label use of Halcion, even at ridiculously high and illegal (against state board rules) doses. How does any patient or honest doctor have the time to keep up with this type of corruption and the biased, misinforming marketing that accompanies it? How can we have a good health care system, without ending this kind of corruption?
Is or will IHI and/or Medicare Medicaid be addressing any or all of these concerns?
Suppose you had to go on a six-month ocean voyage, with no stops in port, with ample provisions and sailors, but with only one other profession represented on board in addition, and you could decide which it would be. Would you ask for your lawyer to come along? your accountant? your Congressman? Would you dare even to ask for your favorite movie star? Or would you say: “Bring a doctor. What if something happens?” The terror of having no answer to this question is precisely what the medical profession saves us from.