Berwick: Don’t Reduce Helpful Care, Don’t Expect Top-Down Solutions from D.C.
I was a supporter of Dr. Donald Berwick‘s nomination to head CMS (Medicare and Medicaid at a federal level) – not due to politics but due to Dr. Berwick's deep understanding that better healthcare costs less, that the road to better healthcare is through quality improvement and methods like Lean.
Dr. Berwick gave his first public speech in his CMS role, it might be of interest to Lean thinkers inside and outside of healthcare.
In his speech, Berwick said a number of interesting things, including the following (from an article in Health Affairs):
Berwick, who has been accused by Republicans of favoring rationing of health care, said costs should be reduced by eliminating “waste, needless hassle,” and “what does not make sense in our health care system.” He emphasized that costs should not be reduced by eliminating any helpful care or by “harming a hair on any patient's head.”
Dr. Berwick talks about eliminating waste – unnecessary cost that doesn't lead to “value” for the patient. At the IHI National Forum last December, I heard Dr. Berwick speak passionately about how patients define value as a long, healthy life where they can do the things they want to do (I'm paraphrasing).
While Berwick talks about eliminating waste, I think there's a communication gap where some automatically hear that as rationing and denying care, for reasons I wrote about last week. A lot of people don't see how there's 30 to 50% waste in healthcare from inefficiency and bad processes. They think cost reductions means doing LESS, while Berwick said, again, we shouldn't reduce helpful care.
I'll give you a personal example — I had a small outpatient oral surgery procedure done a few weeks back. Having the stone removed from my saliva gland was clearly VALUE to me, the patient. The first time an x-ray was done, that was value, since it helped the dentist make the proper diagnosis and specialist referral. Now, the SECOND time I had the same x-ray, that was waste. The 2nd office found it easier to do a new x-ray instead of getting the records from the last office. Same diagnosis, same result — the 2nd x-ray was likely waste. That's the sort of thing we can eliminate, as opposed to telling me to just live with the swelling in my neck when I eat (a problem that is thankfully gone now).
Dr. Berwick is pushing a quality improvement agenda that would be familiar to those who have followed his IHI work – the “Triple Aim”:
As described in the Health Affairs article and by Berwick in his speech , the Triple Aim consists of (not surprisingly) three overarching goals:
- Better care for individuals, described by the six dimensions of health care performance listed in the Institute of Medicine's 2001 report “Crossing the Quality Chasm“: safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity.
- Better health for populations, though attacking “the upstream causes of so much of our ill health,” such poor nutrition, physical inactivity, and substance abuse.
- Reducing per-capita costs.
Berwick also made some comments that you'd think might reassure Republicans and other critics:
Berwick stressed that health care transformation “won't yield to a massive top-down national project.” He explained: “Successful redesign of health care is a community by community task. That's technically correct and it's also morally correct, because in the end each local community – and only each local community – actually has the knowledge and the skills to define what is locally right.”
This sounds like Lean. There's no reason (in my mind) to think all of the waste in healthcare is going to be magically fixed by a mandate from Washington D.C., just as the Big Three couldn't be fixed by a mandate from Detroit (or D.C.).
The federal government has been looking at “health insurance reform.” The rest of us need to get back to work improving quality, safety, and cost. Lean is one way organizations are finding they can have it all: better quality, safer care, lower cost, and (by the way) happier healthcare workers.
Maybe Republicans will be more willing to work with Dr. Berwick instead of demonizing him. It's such a polarized age (as I wrote about recently), I don't know if that will happen.
What do you think, on Dr. Berwick's comments and the “Triple Aim”?