Don Berwick, President Obama’s reported nominee to lead the Centers for Medicare and Medicaid Services, has been a leading voice for improving clinical quality and empowering patients, themes he has discussed in the pages of Health Affairs.
Patient-Centered Care. In “What ‘Patient-Centered’ Should Mean: Confessions Of An Extremist,” a Health Affairs Web Exclusive article published last summer, Berwick argued for “a radical transfer of power and a bolder meaning of ‘patient-centered care,’ whether in a medical home or in the current cathedral of care, the hospital.”
Traditionally, the medical community has seen the question of patient-centered care through the lens of professionalism, said Berwick, the president and chief executive officer of the Institute for Healthcare Improvement in Cambridge, Massachusetts. In this framework, the medical profession possesses a special body of technical information beyond the reach of patients and others, and patient-centered care is important only to the extent that it furthers quality goals determined by the medical profession to be in patients’ best interest. Berwick argued for a more “consumerist” approach in which the power belongs to the patient as customer, not to the medical profession as producer. An ideal medical practice, he said, would give patients not just what they “need,” but also what they “want.”
This approach to patient-centered care would necessitate a number of striking departures from normal medical routine, Berwick asserted. For example, hospitals would have no restrictions on visiting hours except those chosen by individual patients. Patients and family members would participate in rounds and in the design of health care processes and services. Medical records would belong to patients, and clinicians rather than patients would need permission to access them. Technologies to facilitate shared decision making by clinicians and patients would be used universally.
Should patients’ “wants” override the professional judgment of clinicians on matters such as whether an MRI is needed? Yes, said Berwick: “Evidence-based medicine sometimes must take a back seat.” Would extreme patient-centeredness lead to the irresponsible overuse of social resources? No one can yet know the answer to this question; however, previous research indicates that greater roles for patients in decision making about surgery leads to less invasive care, and work by Dartmouth’s John Wennberg and Elliott Fisher “suggests that supply drives demand, not the other way around.”
Clinical Quality. Along with Dartmouth’s Elliot Fisher, Atul Gawande of Brigham and Women’s Hospital, and Mark McClellan of the Brookings Institution, Berwick recently gathered representatives of ten communities that provide high-quality, low-cost care for an influential Washington D.C. conference titled “How Do They Do That? Low-Cost, High-Quality Care In America.” “Of course, from a global perspective we already know that it’s possible to have the same or better care as we do in America for half the price,” Berwick said in opening remarks. But, he added, the sponsors had concluded that if they were “going to get public, political, and professional traction on cost and quality based on successful examples,” they had to draw on American examples if they could find them. “We can. We have,” he said.
Health Affairs Founding Editor John Iglehart described the conference on the Health Affairs Blog, and the Blog also featured an interview with Jeff Thompson, the CEO of Gundersen-Lutheran Hospital System in La Crosse, Wisconsin, one of the communities represented at the conference.
In a 2005 interview with Bob Galvin, director, Global Health, at General Electric, Berwick saw the slow pace of improvement as evidence of a failure of provider leadership. He concluded that external pressure would be necessary to move the system toward meaningful change.
Berwick offered support for performance incentives for hospitals and health systems, but expressed skepticism about the value of “pay-for-performance” schemes for individual doctors and nurses. He emphatically condemned the use of increased patient cost sharing as a tool for improving the efficiency of the health care system.
Berwick was also one of the signers of an influential 2003 open letter published in Health Affairs arguing that Medicare should take a leading role in advancing pay-for-performance. “At issue is not the dedication of health professionals but the lack of systems—including information systems—that reduce error and reinforce best practices, as such systems do in other industries such as aviation and nuclear power. We have concluded that such systematic changes will not come forth quickly enough unless strong financial incentives are offered to get the attention of managers and governing boards. As the biggest purchaser in the system, the Medicare program should take the lead in this regard,” the letter stated.