As keynote speaker during the 2013 annual meeting of the American Association of Hip & Knee Surgeons, Donald M. Berwick, MD, once the administrator of the Centers for Medicaid & Medicare Services (CMS) in the Obama administration, tried to sell the audience a bridge.
To be precise, he sought to convince them by using the metaphor of building a bridge to a new model of delivering and paying for health care in the United States. That model, he explained, would move away from a “system designed around volume and doing more and more” and toward one “organized around wellness instead of sickness.” It would be, he said, “disruptive, but better for patients” and would have as its centerpiece the Affordable Care Act (ACA).
Donald M. Berwick, MD
The challenge, however, is to address the issues of chronic illness and prevention. “For most of the burdens that we’re going to face in our own lives, there will be no cures, no miracles. These diseases come with aging and the progression of our lives. There is technical mastery over the ways to keep people well as long as we possibly can. But we didn’t build a system for continuity. We built a system for interventions, and orthopaedic surgeons are the masters of that system.”
As for prevention, Dr. Berwick said, “We didn’t build a system to address it. We can fix heart attacks, to some extent. But why do they happen? You know as well as I do that most of what determines health status lies outside health care. It’s what we eat, how we exercise, violence in society, the air we breathe. It’s poverty, inequity, and injustice.
“We have,” he continued, “arrived at a moment where the social enterprise surrounding health care is to build a system capable of addressing the social needs, chronic illness, and prevention. It’s a very hard job.”
The new approach is needed for dire economic reasons, he said. Health care has been stifling economic growth. “For the past decade, every single nickel of wage increase to laborers hasn’t gone to the workers, and it hasn’t gone to the companies. It’s all gone to health care,” said Dr. Berwick, who is seeking the Democratic nomination in the Massachusetts governor’s race.
Act for needed change
Telling his audience of surgeons that “if you want to be an improver, you need to get about the job of change,” Dr. Berwick said the ACA is central to the change in two ways. The first is trying to make health care a human right. “We’re the only democracy that doesn’t declare that,” he said. “If you don’t think that it’s a good purpose for a civilized society, then we disagree.”
The other aspect of the ACA involves initiatives such as “trying to change payment measurements and create accountability, so that we can develop new forms of delivery of care that are better than the ones we have today in helping people journey through chronic illness, and hopefully upstream toward prevention,” said Dr. Berwick.
This effort applies the principles of science to health care. “In the scientific approach you would do with healthcare delivery exactly what you’re doing with hip implants,” he said. “You would try to understand why aren’t we meeting needs, and what the new system would look like. You would decide to improve. Then, you would take an idea, test it, and decide if it is better. Plan, do, study, act—systems theory. The same is true for the reinvention of American healthcare delivery. It’s science at work on a large scale.”
Dr. Berwick recalled his time working with the Alaskan Native healthcare system, which set out to improve service to villages with “prevention-oriented, home-focused, and vitality-based care.” A team focus used nurses, nutritionists, and behaviorists to coordinate care.
“The aim is not to do things,” he said, “to turn machines off, not on, because people are kept healthy.” The efforts in Alaska achieved a 50 percent decline in emergency department use and a 53 percent decline in hospital bed-days.
According to Dr. Berwick, a system designed around home and wellness takes full advantage of resources in the community and patient and is organized around seamlessness and continuity. “You cannot say it cannot be done. It is not a technical problem; it is one of will.”
Choosing to change
Although some physicians resist the changes sweeping through health care, Dr. Berwick said he believes “there’s courage out there.” He cited the Choosing Wisely campaign to curtail overuse.
“That’s courageous and costs physicians money up front. But you can defend the status quo or do what we need to do, which is to provide better care at lower cost,” he said. “I hope you take that challenge. I’ve never seen a moment when there was such an opportunity to do it. As physicians, we are in the best position to do it. It will be dislocating and very uncomfortable. But it is centered on patients. If we don’t get engaged, the hospitals will take over.”
Change has a moral imperative, he said. “Social inequities are growing, not decreasing. The bigger challenge is to connect your work to the larger social enterprises. You have to put a stake in the ground on the social need you are going to address, or you will become irrelevant. If we don’t make health care a human right, bad things will happen to the poor and to working families.”
Dr. Berwick summarized his guiding principles as follows: “Put the patient first. Center the work on the need. Put the poor first among patients. Start at scale—let’s go big, not with pilots. Reduce the prices. We have to get the money back [from health care] and apply it to purposes like schools and infrastructure. Do it locally; don’t wait for Washington.”
After the speech, Dr. Berwick was asked about the possibility that provisions and incentives in the healthcare overhaul will push physicians to avoid treating less healthy patients and those at risk of complications.
“On the moral front, I trust physicians more than that,” he said. “We need to have a standard that we will not turn away patients based on risk selection, even if the toxic political environment or the payment nonsense makes it hard. The high ground will win. The public wants us to heal.”
Terry Stanton is a senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org