Berwick’s CMS Assignment

“You could nominate Gandhi to be head of CMS and that would be controversial right now.”

That’s what Thomas Scully, GW Bush’s former head of the Centers for Medicare and Medicaid (CMS), told the Washington Post’s Ezra Klein before President Obama appointed Donald Berwick, M.D., head of CMS on July 7 without going through congressional hearings.

“He’s [Berwick] universally regarded and a thoughtful guy who is not partisan. I think it’s more about…the health care bill, ” said Scully.

CMS has been without a permanent head since 2006. Berwick will lead the department through the implementation of the trillion dollar health care reform legislation that is designed to cover 32 million uninsured Americans and make health care more cost-effective.

Congressional Theater

Conservatives had been eager to grill Berwick over his views on health care rationing, his support of Britain’s national health system and use the public hearings to push their agenda to overturn “Obamacare.”

Berwick would have had to defend statements such as those in a 2008 speech to Britain’s NHS, where he said:

U.S. Senate Hearing/Wikimedia CommonsYou have historically put primary care…where it belongs: at the forefront. The NHS is a towering bridge between the rhetoric of justice, and the fact of justice…You could have protected the wealthy and the well, instead of recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just, equitable, civilized, and humane must—must—redistribute wealth from the richer among us to the poorer and less fortunate.

The President however, short circuited the political theater by appointing Berwick while Congress was out of town in what is called a “recess appointment.”

The Administration made the announcement on the White House blog and issued the following statement:

“Dr. Berwick has the support of hundreds of health care groups and experts, including the AARP, the American Medical Association, and the CMS administrators under the most recent Republican presidents. As Mark McClellan, who served as Administrator under President George W. Bush from 2004-2006, said: ‘Don [Berwick] has a unique background in both improving care on the ground and thinking about how our nation’s health care policies need to be reformed to help make that happen.’”

When the Administration announced that the President intended to nominate Berwick to the post back in April, Republican Senator Tom Coburn of Oklahoma, a practicing obstetrician, said, “One concern I have is that he’s an advocate of cost comparative effectiveness. There may be one or two or three ways of doing something. I want to do what’s best for the patient, not necessarily what’s cheapest.”

Focus too much on cost effectiveness, and “all of a sudden you’re rationing care, ” Coburn said.

Rational Rationing

Klein wrote in the Post that Senate Republicans have used past Berwick quotes like, “’The decision is not whether or not we will ration care; the decision is whether we will ration with our eyes open, ‘ to hang Berwick with the dreaded rope of rationing. Mitch McConnell [Senate Minority Leader], who never settles for a light touch when he can find a giant stick, calls Berwick an ‘expert on rationing.’ Of course he is. All health care policy experts are experts on rationing. The question, as Paul Ryan [Republican Congressman] told me, isn’t whether we ration, but who rations, and how.”

One physician group, Docs4PatientCare, an organization that claims “thousands of concerned physicians, ” put out a statement by one of its leaders, Fred Shessel, M.D. The statement read:

This is a man who has made a career out of socializing medicine and rationing care for the very young, the very old and the very sick. It is a backdoor power grab. It is dragging our country down the road to socialism and we should resist it.

So who is Berwick?

Is he the medical socialist and dreaded bureaucrat who will put the old, young and sick to death through rationing, or is he the nonpartisan thoughtful quality guru who will help bring the government’s unsustainable growth rate of health care spending under control?

As head of CMS, Berwick will have a big say in deciding how one-quarter of all federal dollars will be spent.

Medicare and Medicaid spent a combined $750 billion in 2009, insuring 112 million people, according to a January report from the Congressional Budget Office. The Children’s Health Insurance Program spent $8 billion on health benefits for 11 million low-income pregnant women and youths.

Health care costs have been consuming an ever-growing share of the federal budget and costs for Medicare and Medicaid are expected to grow each year by seven percent over the next decade, according to the nonpartisan Congressional Budget Office.

Berwick in Short

Donald Berwick, M.D.
photo courtesy of apqc.orgBerwick was Vice Chairman of the U.S. Preventative Services Task Force from 1990 to 1996, and former President Bill Clinton appointed him to the Advisory Commission on Consumer Protection and Quality in the Health Care Industry in 1997 and 1998.

He earned an “Award of Honor” from the American Hospital Association in 2002 and the appointment to honorary Knight Commander of the Most Excellent Order of the British Empire in 2005, the highest prize afforded to non-British citizens for efforts to improve international health care quality.

Berwick teaches pediatrics and health care policy at his alma mater, Harvard University. He also practices pediatrics at Boston Children’s Hospital and at Massachusetts General Hospital. He has published more than 130 scientific articles, books on health care policy, and is also a member of several editorial boards of medical journals.

Unknown Coverage and Payment Record

One former CMS coverage official told us that very little is known about Berwick from a coverage and payment standpoint. He is primarily known as a “quality person, ” and his impression is that using quality measures and physician reporting tools is a more important criterion for Berwick.

North American Spine Society (NASS) President Ray Baker, M.D., told us that advancing the discussion on value is a high priority for his society. “We will work with Dr. Berwick to continue these efforts.”

Baker said NASS members believe that comparative effectiveness (CE) should remain a scientific process and the society supports steady funding for such efforts. He said policies coming out of CE should permit individualized treatment and should not be used to influence coverage decisions.

Baker added that providers should be protected from medical liability claims if CE guidelines are followed.

Moving forward, Baker said NASS hopes that Berwick will use these principles as a foundation in the pursuit of comparative effectiveness research.

Conservative’s Best Friend

“Berwick, whether they [conservatives] know it or not, is one of the best friends they could have in the administration. That’s because insofar as Berwick is a radical, he’s a radical in favor of a patient-centered health care system—a position that has traditionally been associated with conservatives, not liberals, ” wrote Klein in the Washington Post story titled, “The Conservative Case for Don Berwick.”

Klein continued:

An overarching aim for an ideal practice [is] that its patients would say of it, ‘They give me exactly the help I need and want exactly when I need and want it, ‘ writes Berwick. He means it. When a patient wants someone in the room and the doctor doesn’t, Berwick believes the patient should win.

Berwick Patient-Centeredness Proposals

Here’s a list of Berwick’s proposed reforms: 

1. 
   

   Hospitals would have no restrictions on visiting—no restrictions of place or time or person, except restrictions chosen by and under the control of each individual patient.

“I suggest that we should without equivocation make patient-centeredness a primary quality dimension all its own, even when it does not contribute to the technical safety and effectiveness of care, ” writes Berwick.

Klein concludes that there is much in Berwick’s vision that conservatives will find appealing.

The reality of the situation is that Barack Obama just put an advocate for a patient-centered health care system in charge of much of health care reform. Conservatives have scored a big win here, even if they don’t know it yet.

Where you stand on whether or not Berwick is a medical socialist boogeyman or whether he is the right guy to fix the federal health care budget, depends on where you sit. Right now the man in the Oval Office has the chair that counts.

We found that Donald Berwick, M.D., will not fit neatly into anyone’s political caricature. But for those who love political theater, cheer up. Even recess appointments eventually have to go through congressional approval. The show will go on.