A Few Tricks in His Doctor's Bag

by Jonathan Cohn | April 5, 2010

As some of you you may have noticed, I took a short vacation after President Obama signed the Patient Protection and Affordable Care Act passed. It seems that Obama and his advisers didn't.

With the ink on the presidential signature barely dry, administration officials announced that Don Berwick would be the president's choice to run the Center for Medicare and Medicaid Services.

Who's Berwick? And why is his impending appointment so important? Let's start with the second question.

CMS, as the agency's name suggests, administers the government's two massive insurance programs: Medicare and Medicaid. That gives it purview over the insurance coverage for tens of millions of Americans.

But the influence of CMS will extend far beyond those two programs. In order to make medical care more efficient, the Affordable Care Act envisions CMS changing the way Medicare pays for medical services. The hope is that these changes will force the providers and producers of medical care to change their behavior--by, say, focusing more on treatments that work or avoiding preventable errors. The government would save money. So would everybody else. And the quality of care would actually improve.

To make this happen, CMS needs a leader who not only understands this mission but believes in it.  And that's Berwick.

Health policy wonks treat Berwick like a celebrity, throwing around words like "pioneer" and "visionary." He's a Harvard-educated pediatrician who, during the 1980s, took charge of improving quality for the Harvard Community Health Plan, a managed care organization with a reputation for doing what HMOs were always supposed to do: Provide better care for less money.

Over time, Berwick increasingly turned his attention away from curing individual patients to curing the medical care system as a whole. He eventually established the Institute for Healthcare Improvement, a perch from which he became something of an evangelical for improving the quality of care. If you recall reading or hearing about a groundbreaking report chronicling the huge financial and human costs of medical errors, then your familiar with Berwick's handiwork, since he was one of the people behind that study.

People who know this field better than I do have enormous respect for Berwick. And they seem positively thrilled by the announcement, as the Century Foundation's Maggie Mahar noted on her blog, The Health Beat:

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.” ...
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.”

Bob Wachter, a leading scholar of hospital medicine at the University of California-San Francisco, offered even more effusive praise on The Health Care Blog:

While the health reform bill will have many effects, one of its most profound will be to unshackle the Centers for Medicare & Medicaid Services (CMS). Under the legislation, CMS is now far freer to undertake a variety of pilot programs and demonstration projects designed to improve quality, safety and efficiency, and to convert the successful ones into policy. And, if that wasn't enough for those who have long been praying for a more activist CMS, we now learn that President Obama will select Don Berwick, the world's most prominent advocate for healthcare quality and safety, to be the next CMS administrator. Although I've sparred a bit with Don over the years on matters of philosophy, I think he is a superb choice.

Don’s story is well known--a Harvard pediatrician and policy expert who became passionate about improving healthcare well before it was fashionable, he ultimately left his full-time academic perch to pursue his calling. In 1991, he founded the Institute for Healthcare Improvement, which ran on a shoestring for its first decade, fueled largely by the considerable power of Don’s vision and personality. ...

IHI became the essential organization--a source of networking, best practices, conferences, sustenance, courage, and more. To many in the quality and safety world, IHI became their church, and Don its Pope.

I admire Don enormously, and have no doubt that the world is a far better place thanks to his, and IHI’s, work. I've seen scores of examples of Don's impact over the years, at hospitals, nursing homes, and clinics in the U.S. and around the world.

Berwick will have to go through Senate confirmation and, I'm sure, Republicans will try to use those hearings in order to litigate health reform all over again.

A recent Boston Globe article suggested that critics have raised questions about whether Berwick's Institute has exaggerated the success of pilot quality programs it helped start. I suppose the Republicans might seize on that, as well, although the disputes sound like minor academic quibbling to me.

Of greater concern, perhaps, is the fact that Berwick is a relative novice at politics who has never run a large organization. A lot will depend on the people around him and how the administration chooses to organize the implementation of reform.

I still think, as I wrote recently, that the administration needs one point person to coordinate the activity of all the different agencies working on health care. And I wonder if it should be somebody not just outside of CMS but outside of the Department of Health and Human Services, as well. (CMS is part of HHS.) But that's a more complicated question for another time...

Photo used under a Creative Commons license from Flickr user Sarah G...

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