With Donald Berwick's appointment, the doctor is (finally) in

By David Ignatius
Friday, July 9, 2010

President Obama got serious this week about the ticking time bomb in his new health-care legislation -- the lack of any clear plan to reduce costs and improve quality. What he did was install someone who can use our behemoth Medicare and Medicaid programs as laboratories for change -- so that reform doesn't bankrupt the country.

Obama was positively dictatorial about it. Rather than wait through a protracted confirmation process and another Republican circus about "death panels" and "rationing" of care, he pushed through a "recess appointment" of Dr. Donald Berwick as administrator of the Centers for Medicare and Medicaid Services (CMS), which oversees how these giant programs spend their hundreds of billions.

Berwick's specialty is studying how the system can provide better care at lower cost. His nomination, announced in April, had been held up partly by a bogus debate about funding for his Institute for Healthcare Improvement, a nonprofit think tank in Cambridge, Mass., where Berwick is also a professor at Harvard Medical School.

The CMS post has been unfilled since 2006 and Obama finally decided enough, already. The White House said Republicans "were going to stall the nomination as long as they could, solely to score political points." This is one job that truly can't wait: The longer we delay efforts to cut costs, the worse the health-care mess will be.

In a rational world, Republicans -- caring about the fiscal dangers for the country if we don't reform the delivery system -- would have endorsed Berwick's nomination by acclamation. But Washington isn't a rational world. It's a never-never land where politicians from both parties bewail our debts and deficits -- and resist efforts to do anything about them.

Liberals, too, often overlook the crucial issue of efficient, low-cost delivery of care. Yes, it's a moral obligation to expand access, as the new legislation will do. But unless we reform the delivery process, the result will be a nightmare -- universal access to a bloated, costly mess. Health-care experts such as Denis Cortese, a former chief executive of the Mayo Clinic, and Toby Cosgrove, chief executive of the Cleveland Clinic, argue that we should use our existing "public options" such as Medicare and Medicaid to create models of lower-cost, higher-quality care that can spread nationwide.

One of the good features of Obamacare (redeeming its many flaws) is that it mandates such experiments in the public health-care programs. As Atul Gawande noted several months ago in one of his superb New Yorker essays, such a process of experimentation makes more sense right now than trying to impose, at one stroke, a change in the nation's entrenched culture of fee-for-service health care. Such pilot programs will demonstrate what works -- and build momentum for comprehensive change.

That's Berwick's challenge -- to encourage an urgent process of innovation. If you want a sense of what he will bring to the job, check out the Web site of his institute (http://ihi.org). He describes some of the ideas he has been developing over the past several decades for implementing change. The list includes "breakthrough series collaboratives" to share knowledge; "bundles" of procedures that establish protocols for treating common problems; the use of medical records to better forecast bad events; and the use of operations research to improve the efficiency of emergency rooms.

These experiments will take the nation into new and difficult territory. The system that's coming is one in which doctors won't be so quick to order tests and procedures; it will force us to take better care of ourselves; it will require that we plan how we want to be treated at the end of our lives.

Republican critics who claim to be worried about funding for Berwick's institute can review online its detailed rules for avoiding real or perceived conflicts of interest, and its refusal of funds that are linked to specific drugs, medical devices or diagnostic tools. Members of Congress might consider adopting similar ethical standards.

If you're still not convinced Obama did the right thing, take a look at this comment Berwick made in a recent speech (found by Washington Post blogger Ezra Klein) in which Berwick talks movingly about his own fear of being a patient: "What chills my bones is indignity. . . . It is the image of myself in a hospital gown, homogenized, anonymous, powerless, no longer myself."

Berwick's patient is now the nation's health system. He will have the task of driving reform, even as our new law expands access to care. I'm glad Obama didn't wait another day.


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