Does clinical medicine have the courage to lead health care reform? A former pediatric resident at Boston Children’s Hospital recently asked this question before a standing-room-only audience during the hospital’s annual Blackfan Lecture. I’m talking about Donald Berwick, MD, MPP, FRCP—co-founder and president emeritus of the Institute for Healthcare Improvement (IHI) and Administrator of the U.S. Centers for Medicare & Medicaid Services (CMS) from July 2010 to December 2011.
Berwick, who may run for Massachusetts Governor in 2014, didn’t just ask physicians and hospitals to embrace health care reform, as they’ve come to embrace quality improvement programs and checklists. He urged them to lead. To rescue health care.
In 1998, the Choluteca Bridge was one of the few in Honduras to withstand Hurricane Mitch. Unfortunately, the river beneath it had moved, leaving a bridge spanning dry land. “This,” Berwick declared, “is American health care.”
So why can’t we move the bridge to the river? Following Gloria Steinem’s advice to name a problem before trying to tackle it, Berwick outlined 11 uncomfortable challenges—11 “monsters under the bed” that need to be faced.
1) Instilling confidence in science as a basis for action
There’s a mistrust, fueled by politicians, of applying evidence-based standards to medical practice, Berwick said. It often surfaces when the evidence indicates that a test or intervention isn’t necessary.
“The public has been made suspicious because of exploitive accusations that scientific thought is elitist,” he said. “We say ‘evidence-based medicine,’ and the public has been taught to hear ‘rationing.’”
But the problem comes in part from medicine itself. “We’ve allowed senseless, unscientific variation in care—variation that makes no sense—to masquerade as professional autonomy,” Berwick declared. The current Choosing Wisely campaign, spearheaded by the American Board of Internal Medicine Foundation, is trying to counter this tendency.
2) Using global brains
When Berwick was up for Senate confirmation as CMS Administrator, detractors tried to use the fact that he had praised some elements of the British National Health Service to obstruct his appointment But not thinking globally hurts us, Berwick said. “Patients are suffering if we close our eyes to what we can learn from everyone everywhere.”
3) Learning in large, dynamic systems
“If you want to improve health care, you have to work in a very messy world,” Berwick noted. “As what you’re trying to change gets more complex and more non-linear, you have to shift from evaluation to continual learning.”
Not being able to learn in a dynamic, changing environment limits risk-taking and slows progress, he argued. It’s the difference between taking a water sample from a still pond versus a rushing river.
“If you sample from the river at one time, you don’t know much about the future at all. Learning in rushing waters is not an exercise in census taking, it’s an exercise in prediction, and the methods of learning are different.”
4) Naming the excess
“It has been nearly impossible in public dialogue to claim in health care that enough is enough,” Berwick lamented. “It’s much easier to sell the public on the claim that we need more.”
Bernard Lown, MD, has been one minority voice naming the excess. Now in his 90s, Lown has spent decades documenting overuse of coronary revascularization procedures, concluding that half or more of them don’t help patients any more than medical management. If he’s right, said Berwick, imagine what would happen to all our angiography suites, heart hospitals and stent vendors.
“It’s going to take courage to name and address the large proportion of American health care that simply doesn’t help scientifically,” Berwick said. “The forces for turning that inquiry aside are going to be massive. But if we could harvest that waste, that excess, it would put other things we want in closer reach.”
5) Fair profit vs. greed
While entrepreneurship is good, there’s “too much cynical calculating greed,” Berwick charged. Here, he critiqued the pharmaceutical industry, citing two cheap generic drugs that skyrocketed in price after being patented by drug companies: Makena, a drug that interrupts premature labor, and Colcrys, a patented form of the 3,000-year-old gout drug colchicine. In both cases, companies took advantage of legal loopholes in FDA regulations, according to Berwick. A third drug, Epogen, continued to be overutilized by dialysis centers despite new evidence that it can worsen outcomes; when usage did start to drop, dialysis providers kept being paid for using Epogen until Medicare’s payment rules caught up.
“It’s the rules that are often the problem,” Berwick acknowledged. “They leave room for behaviors that are harmful and extremely costly. Try to change the rules, and you meet the monster under the bed.”
6) Innovations that do not help
Under the banner of innovation comes a lot of waste and unproved value, and many so-called innovations can lead to worse care at higher cost, Berwick asserted. We should demand evidence.
“Not all change is improvement, and not all innovations help,” he said. “Public policy is extremely weak in its capacity to deal with this.”
Under the Patient Protection and Affordable Care Act, Medicare must cover therapies that are scored A or B by the U.S. Preventive Services Task Force, indicating sound scientific backing. “That has been attacked thoroughly as government-run healthcare,” Berwick said.
7) The obstructive behavior of guilds
In this case, “guilds” mean physician organizations, particularly those that have stood against change. Berwick called on physicians to support new models of care, especially models that expand the role of non-physicians, give new power to families and patients and make bold use of telemedicine.
As a young pediatrician, Berwick flew to remote villages on the Bering Sea Coast to care for their children. Now rural Alaska has AFHCAN telemedicine carts—stations loaded with medical instruments that gather and forward patient data to a hospital in Anchorage, which provides real-time consults. The carts have paid for themselves 10 times over.
“We need the help of the guilds. It’s got to be guided by evidence, but it is time to change,” Berwick noted. “We need to say not ‘no,’ but ‘how?’ The legacy payment systems don’t support innovations.”
8) Defending the poor
Inscribed on a Department of Health and Human Services building is this:
“It was once said that the moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those who are in the shadows of life—the sick, the needy and the handicapped.” (Hubert Humphrey, 1977)
Berwick feels that we’re failing this moral challenge. State legislatures are voting against participation in the Medicaid expansion, leaving millions of poor people without health care coverage.
Berwick believes that without pressure from the public, government will not have the will to protect the poor. “We need continual reinforcement of the premise that health care is a human right, period.”
9) Addressing palliative and end-of-life care
“You saw the cruel rhetoric about ‘death panels’—it took over the end-of-life care debate,” declared Berwick. “The rules in Washington at the moment favor never officially mentioning care at the end of life. Only a few very courageous members of Congress do it. You can’t talk about palliative care or advance directives.”
The Conversation Project, started by IHI and journalist Ellen Goodman, is one place where individuals can speak up and assert their wishes for appropriate care at the end of life.
10. Authentic prevention
“We haven’t built sufficient institutional structures for the prevention of illness,” Berwick asserted. “The cathedrals of our time—hospitals—cure disease, they don’t prevent disease. They’re nowhere near the changeable causes—the behavioral choices, nutrition, inequity, injustice, pollution, poverty.
“Prevention has no cathedrals, and the result is a massive misallocation of effort and resources. We need groundbreaking, habit-breaking redesign of care.”
11. Navigating the transition state
This is possibly the greatest practical hurdle to genuine health care reform.
“The problem isn’t the destination—who would not want a system that gives us better health and better outcomes?” he said. “The problem is the transition—it’s stranded capital, the new building, a misaligned workforce, an oversupply of specialties. It’s business cycle management.”
Alaska’s Nuka System of Care has mastered the transition. It’s a population-oriented, prevention-based, total integrated care system in which doctors, nurses, pharmacists, therapist, behaviorists and social workers work as a team—reducing emergency department use by 50 percent, hospital admissions by 53 percent, specialty utilization by 65 percent, and primary care utilization by 20 percent.
“They’re changing the model of care with half the money we have in the rest of America,” says Berwick. “Results like this, at scale, would solve America’s health care problems. But a normal hospital CEO who saw these figures would be at risk of being fired by the board.
“U.S. health care executives and boards are starting to get it, but very few know how to navigate through that transition. So what you’re seeing play out is a series of maladaptive reactions, as our business models remain oriented around volume.”
Can large health care organizations move away from the “last man standing” mentality? Berwick thinks physicians should be like Max at the end of Where the Wild Things Are, when he gets on his boat to sail away.
The wild things cried, “Oh please don’t go – we’ll eat you up – we love you so!”
And Max said, “No!”