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.
You can read more about the Triple Aim via free articles at the Health Affairs website.
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”?
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Did you mean “There’s no reason” or “isn’t” in the following quote?
His approach does sound like he’s not going to do a top down approach, but that begs the question of how to bring about the change that’s necessary.
Thanks for catching the typo, now fixed. Yes, I meant “there’s no reason…”
How to bring about change without being top down? If we look at the hospital or health system level, you can teach methods (like Lean) without mandating exactly what gets improved or how (in what specific way). Maybe he will take a similar approach (if he directly promotes Lean and other methods).
Mark, excellent post. I passionately refuse to discuss the politics of healthcare improvement because it’s so mind-numbingly frustrating, but I’m glad you are brave enough to tackle it on your blog.
What I would like to discuss is the paragraph where you mentioned your recent outpatient oral surgery. Specifically, I’d like to discuss the way you defined value in that paragraph.
As you stated, having the stone removed was clearly value. You also classified the first-pass X-ray as value-added and the second-pass X-ray as non-value-added. This makes sense to me.
However, I observed a value stream mapping workshop last week where value was defined differently. They were using the classical triple requirements: customer willing to pay for it, done right the first time, and changes the form/fit/function. In this strict model, X-rays would not be classified as value since it doesn’t change the form/fit/function of the patient. The underlying assumption of this model is that the product flowing through the value stream is the patient. Is this always correct?
One participant in the workshop brought up the idea that the product is not the patient; rather, the product is the development & delivery of a treatment plan. Under that model, value would be defined differently because things that change the form/fit/function of the treatment plan would be classified as value-added. Under this model, first-pass X-rays would indeed be classified as value-added because it furthers the development of the treatment plan.
Is this totally off-base?
I kind of see it as a two-phase product: 1) development of the treatment plan and 2) delivery of the treatment plan. Development and design work should kind of follow TPDS principles, such as set-based concurrent engineering (think of a team-based healthcare units where the MD, RN, RT, etc. all collaborate up-front on a diagnosis). Then, the delivery work should follow TPS principles that we all know and love.
Again, is this totally off-base?
Sorry for the excruciatingly long coment. Feeling kind of chatty today!
Mike – I don’t think you are off base at all. I agree that the “product” in healthcare is not “the patient” but more along the lines of a “proper diagnosis and treatment.”
I very much consider proper diagnostic work to be “value” – how can you treat/fix me without knowing what to do?? X-rays change the “form” of the diagnostic/treatment process.
This is one point on which I disagree STRONGLY with Dr. John Toussaint and the book “On the Mend.” They define value very narrowly as something like “take out the tumor.” If I had cancer (which was not my case here), I’d consider diagnosis of the tumor to be value. I argued this with the authors during editing of their book, but they held to the narrow definition.
I’m not considering diagnosis “necessary waste” either. It’s value.
Either way, the biggest wastes in healthcare are waiting and poor quality. Quibbling over whether diagnosis is value or waste isn’t the biggest pressing issue out there.
Making a difference from the top when change needs to come from the grass roots level is a huge challenge. It’s hard enough in a modestly sized organization or enterprise, let alone across the nation in a slow-moving and contentious arena such as healthcare today. I like Berwick’s ideas and approach.
The “triple aim” captures the key points of improvement and the lean thinkers among us know that doing #1 and #2 (easier, better, faster) should accomplish #3 (cheaper).
Aim #2 is probably the most interesting from the perspective of understanding value in healthcare because it implicitly recognizes something we’ve discussed before: that the desired outcome is health in the first place. This could lead to a profound philosophical challenge: an understanding that it’s possible to view MOST of healthcare (tending the sick) as rework. Not that tending the sick ceases to be an absolute necessity (some scary room for misunderstanding there! No death panel rants, please!), but rather that avoiding the causes of disease, preventing illness and injury and nurturing healthy lives come to be understood as the core value-adding activities.
These are, of course, the things that have added most to wellness and longevity (e.g., treated municipal water, sewers, vaccination) but as a society I think we lost track of that as we were drawn to the great leaps medical technology made in the 20th century.
Berwick is a great person for this job. His biggest challenge will be how to actually get health care system improvements adopted. And through IHI he has a ton of experience, not just with improving health care conceptually but the hard work of getting organizations to actually adopt improvements.
We have let the health care system degrade to the point that it is not just a health care issue but a huge economic burden and a huge personal burden. Many things have to be done. Eliminating waste is one. Improving care is another. Improving the health of the people in the country is another. Reducing cost is another. Reducing economic dislocations is another. Cost is a large part of the, but even if costs decreased 25% over the next 5 years (which they won’t) they would
1) still be way way to high
2) and not eliminate the dislocation to people and businesses due to the way the current system works (allocation of extremely high cost to small pools – small businesses, individuals…)
I couldn’t pick anyone better than Dr. Berwick to try and fix the system (sorry Mark :-). But the problem is so huge the great improvements he makes will still leave us with enormous, economy threatening problems.
We need decades of all sorts of great work just to get back to a place where the health care system in the USA is mediocre (looking at the cost for the benefits received). The last 30 years have been very bad. Even with lots of good things being done but lots of people.
And the idiotic political posturing that has prevented reforming the broken practices the last 30 years shows no sign of letting up. A few people are trying to fight the special interests but they are not making great progress.
Yes, Dr. Berwick is certainly the best person for that job.
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[…] the Lean methodology, value is defined by the patient (in terms of outcomes and quality of life, as Don Berwick has talked about). But, the doctors know more about medicine than we do as patients and they can be very influential […]