Interview with Berwick: "This is not free money that health care takes."

In the last week, I spoke at length with Dr. Don Berwick, former CMS Administrator under President Obama.  I have found him at every turn to be thoughtful, modest and compassionate.  He is an approachable, engaging fellow with enough energy, frankly, to put those half his age to shame.

We are proud to be hosting him as our keynote at our first State of Reform Health Policy Conference in Oregon on Dec 13th.  We will also be hosting him at an event the same day in SeaTac.

The following is excerpted from those discussions, some of which included members of the media.

On his time since leaving CMS.

I’m one year out of CMS.  My last day was Dec 2.  And I’ve been taking this time during the last year to reconnect with the networks that I had before I went to CMS in the health care improvement world.

I have been impressed and quite inspired by a lot of what I’ve seen.  I’ve seen hospitals and physician groups and others actually facing reality.  They know that times are now different.  The unsustainability of health care costs and the evidence on defects in care coordination, safety and so on, are now not just interesting problems, they are core to their own survival and safety of the system.  Many are in the game now, and that’s been quite inspiring to see.

On how communities are moving towards reforming health care:

These are organizations (hospitals) trained for a century to rely on revenue driven, topline driven, volume driven business models – that’s how they’ve developed, that’s who they are – and now they have to unlearn that, move into coordinated systems, and learn how to celebrate an empty bed instead of a full bed.

Physicians seem to be largely woken up…  All that said there is still a substantial minority still rooted in the past.

I’m seeing very exciting innovations in the local setting:  tele-medicine, care coordination, waste reduction, patient safety.  It’s like walking through a diamond mine, where I look at the wall and see a diamond.  It’s quite stunning and it keeps my hope alive.

I think the public is still concerned and scared.  They’ve been trained through complexity and partly through misrepresentations that things are going to get taken away.  I think we’re at an important juncture now in the next year or two is to explain to the public that better care at lower cost can come together.

On provider, hospital and system consolidation and the resultant cost pressures:

The key test of the success of health care reform in the next few years is the triple aim: better care, better health, lower cost.  Lower cost means lower premiums.  It means that payers see that costs go down or at the very least stabilize or not go up faster than the cost of living.  If that doesn’t happen we will have broken faith with the needed changes in health care, because it is possible to have better care at lower cost.

Health care delivery systems are facing kind of an identity crisis here.  Are you going to behave in such a way as to take advantage of the new license you’ve been given to continue to raise prices and costs?  Or, are you going to take advantage of the new license you’ve been given to really redesign care so that costs fall while patients get help?

This is not about rationing.  This is not about withholding care.   It’s about getting costs down by improving care.  So I am watching, like you, very closely to see if these places are going to do that right.

I don’t know if choice or consolidation is the key here.  There are several places in the country which are essentially monopoly health care systems  that are doing fine. They are actually working very well to control costs because they care about their communities, they are deeply embedded in their communities, they are accountable to their communities, and even though they may be almost the only game in town, they are acting  the way we should all be looking for – highly cooperative and understanding that an extra dollar taken for health care that is not needed is a dollar denied, for a school, for a road, or a laborer or a corporation for its competitiveness.

This is not free money that health care takes.  It’s coming from somewhere else and the opportunity costs are very high.

On Oregon’s model of reform:

Oregon’s evolution with Gov. Kitzhaber’s leadership is quite interesting.  It could be one of the real breakthroughs in the country.

Oregon is the right size at about 3 million. It’s got a history of collaboration.  It’s high performing.  So I’m optimistic about that leadership.  Oregon also has the challenge of being quite impoverished in some areas.  One of the challenges of the state is going to be meeting the needs of the disadvantaged segments of the population thoroughly treating health care as a human right, as it should be.

On Washington State’s efforts at reform:

The Puget Sound Health Alliance does reflect in its history the kind of payer-provider platform for a conversation about what kind of care system we want in the region, and I think if that Alliance is able to be vibrant and really pull the employers, the payer, the providers, and health plans together that would be very exciting.  It’s in the marrow there to make that possible.

Seattle, especially is troubled by a highly competitive environment, which I think may be leading to somewhat less inter-organizational cooperation than I’d love to see on a regional basis.

Certainly in the northwest you’ve got some of the great examples of progressive and inventive delivery – in the world not just the country –  Group Health in Puget Sound, Virginia Mason, Everett Clinic, Seattle Children’s Sand Point Dental Clinic and others showing the way.  And I hope the state is smart enough to take advantage of those examples and spread them quite widely.

I also like the role that some of the employers are playing in the Seattle area, especially Starbucks and Boeing and others, are seeing the possibility of actually being more active in helping care get better for their employees.

So, I’m optimistic.  It’s one of the regions (Oregon and Washington) in the country that’s a real bright spot.

On hospital facility fees:

Once you decide to pay for healthcare in pieces, you have to price the pieces.  This is a very complex process…  But, we’ve made this bed that we’re sleeping in right now.  If we want to be paying for the cost of operating a hospital we ought to be doing it directly (rather than through facility fees added on to care).

On employing physicians by hospitals:

I think it can go either way.  It can be good either way.   The fundamental flaw in American health care delivery is fragmentation, a lack of coordination and team work.  This especially effects people with chronic illness.  So, they see 8 or 10 doctors a year, they go in and out of hospitals… and you end up with all sorts of damage.  Patients get hurt.  Mistakes get made.  So this is a highly costly defect in terms of human suffering.