On April 19, 2010, President Obama nominated Dr. Donald Berwick to head the Centers for Medicare & Medicaid Services. Berwick is a dangerous choice for seniors and baby boomers who will be depending on Medicare.
Berwick confesses to having a love affair – a “romance,” he says – with the British National Health Service. In a speech commemorating the NHS’s 60th anniversary, he praises its orderliness, frugality, redistribution of wealth, and explicit rationing. “Behold the mess – the far bigger, costlier, unfair mess” that is health care in the U.S., he says.
Berwick has radical plans to transform American medical care. He laid them out in his “Triple Aim” plan published in 2008 in Health Affairs. He concedes the “pain of the transition” will entail “the disruption of institutions, forms, habits, beliefs, and income streams in the status quo. . . .” The new Obama health law will allow Berwick to transform Medicare without any further approval by Congress or the American public. The law authorizes the executive branch to create pilot programs – reorganizing how and where patients are treated, what choices they have, how their doctors are paid, and what medical services they can get – and then expand these programs on a nationwide basis as quickly as possible.
When the president campaigned for his health legislation, he told people with insurance not to worry. If you like your doctor and your coverage, you won’t have to change, he repeatedly promised. Americans didn’t vote for the pain of transition. Yet Berwick’s writings indicate the large changes in store for Medicare patients.
First, expect an environment of medical scarcity, meaning fewer MRIs and other equipment and longer waits to be treated. Applauding the British system at its anniversary, he said, “You [the NHS] plan the supply; you aim a bit low; historically, you prefer slightly too little of a technology or service to much too much; and then you search for care bottlenecks and try to relieve them.”
Second, expect that your own health choices will be “managed” by a “medical home.” You will no longer be the one deciding when to see a doctor or consult a specialist. Medical home is this decade’s version of HMO-style medicine, according to the Congressional Budget Office, with a primary care provider to oversee your access to costly services such as visits to specialists and diagnostic tests. In his “Triple Aim” plan, Berwick says not to expect your primary care provider to be a physician. Many, perhaps most, will be nurses or physician’s assistants. Currently, Medicare patients can decide to see a doctor and Medicare pays. Not in the future.
Worse still, if you do get to a doctor, don’t expect the doctor to be able to make decisions based on your individual case. Physician autonomy is a thing of the past, argues Berwick, who wrote an essay called “The Epitaph of Profession” in the 2009 British Journal of General Practice.
Berwick earned accolades for his 100,000 Lives Campaign, a superb effort to codify and disseminate guidelines to keep patients safe from infections, bedsores, and other unintended consequences of medical care. In the area of patient safety, guidelines should be rigorously enforced. There are no disagreements about the need for clean hands. Patient safety rules are like the rules a pilot follows in the cockpit. But beyond patient safety, in fields from cardiology to obstetrics, there are numerous disagreements on what are best practices. Yet Berwick argues aggressively for almost eliminating physician leeway.
In his “Triple Aim” plan, Berwick deplores the American heath care system as “designed to respond to the acute needs of individual patients.” His plan is to “anticipate and shape patterns of care for important subgroups.” Subgroups could be defined by age, affliction, or socioeconomic status. Woe to you if you’re not in a favored subgroup or part of the plan. In his beloved British National Health Service, those decisions are made by what he lauds as the “maddening, majestic machinery of politics.” The elderly fare poorly in that system, as you can see by visiting a ward reserved for their care in a British hospital. You will find long rows of beds, sometimes even without a privacy curtain, and cancer survival rates far lower than current survival rates in the U.S.
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