continuous improvement and continuous cost reduction

Op-Ed Columnist

Dr. Berwick’s Pink Slip

By JOE NOCERA

Published: December 5, 2011

Dr. Donald Berwick was already in Massachusetts when I spoke to him Sunday afternoon. He was back in the Newton home where he’d lived for 30 years, being pleasantly interrupted during our conversation by his 2-year-old grandson. His last day in Washington as the administrator of the Centers for Medicare and Medicaid Services had been Thursday. Friday was packing day. Saturday was moving day. And, by Sunday, he was already talking about his too-short, 17-month tenure as the nation’s top Medicare official in the past tense. Which, alas, it was.

Earl Wilson/The New York Times

Joe Nocera

Dr. Berwick, I’m here to tell you, was the most qualified person in the country to run Medicare at this critical juncture, and the fact that he is no longer in the job is the country’s loss. Berwick started out as a pediatrician and health care researcher at the Harvard School of Public Health and eventually became vice president of the Harvard Community Health Plan (now known as Harvard Pilgrim Health Care). There, he became enamored with the ideas being promulgated by management gurus like W. Edwards Deming and companies like Toyota, which believed that companies could create processes — and a mind-set — that would allow for both continuous improvement and continuous cost reduction. Indeed, they believed that the two went hand in hand.

Latching onto these ideas, Berwick helped start — and, for the next 19 years, run — the Institute for Healthcare Improvement, which was devoted to applying them to health care. The result would be healthier patients who spent less time in hospitals — and a culture that wasted less money on things that didn’t lead directly to a healthier population.

As the insurer of one out of every three Americans, Medicare is in an enviable position to push for health care improvements, if it chooses to. And with a budget larger than the Pentagon’s — and a consensus that its spending must be brought under control — no government agency has a more urgent need to cut costs. Surely somebody who has spent his career focused on these two issues would seem to be just the ticket.

But there’s one more thing about Berwick: He believes that President Obama’s health care reform is “an important moral step toward universal health care.” As he put it when we spoke: “Because of it, our country is, at last, making health care a basic human right. It is a majestic thing.”

Naturally, this view made him anathema to Republicans, who blocked his nomination in the usual way. They pored through his old speeches and articles, plucked out a few comments they objected to — he once praised the British health care system! — and announced that they would never confirm him.

President Obama was not deterred the way he had been when Republicans objected to Elizabeth Warren becoming the chief of the new Consumer Financial Protection Bureau. Instead, in July 2010, Obama named Berwick to the post in a recess appointment that did not require Senate confirmation. But, like all recess appointments, it was temporary. Berwick left the post just weeks before his appointment was set to expire.

What did Berwick accomplish in those 17 months? A lot — though not nearly as much as he would have liked to. His focus, as it has always been, was on improving the quality of health care and cutting costs. “On my third day,” he said, “I held a staff meeting for all 5,000 members of the staff, and I said, ‘You all think that you are in the business of paying bills. Yes, you do that. But I also think Medicare can be a force for change.’ ” He added, “I tried to reconceptualize it as an improvement organization.”

As Berwick tells it — and others affirm — the Medicare staff had been hungering for such a mission. “We had a triple aim,” he says. “Better health care. Better health for the overall population. And lower costs. I thought that, my goodness, given the resources and the reach — and the great staff, which was a wonderful surprise — we ought to be able to help health care providers do much better.”

Health insurers and hospitals, who had generally thought of Medicare as little more than a stodgy, bureaucratic insurer, began to see it in a different light as well, as Medicare staffers, trained as “improvement coaches,” began to share ideas and push for simple, sensible steps that would, for instance, keep people with chronic medical problems from having to be constantly readmitted to the hospital.

Of course, 17 months is hardly enough time to complete such a transformation, and it is hard to know if Berwick’s emphasis on quality will stick. What he needed, most of all, was more time — precisely what the Republicans wouldn’t give him.

By refusing to confirm him, Republicans won a pointless victory against the president. But, if the day ever comes when they — and the country — truly get serious about reforming Medicare, they may regret giving a pink slip to the best man for the job.