The recess appointment of Dr Donald Berwick as head of CMS has incited a furor among politicians outraged at what they claim are his advocacy for rationing and fondness for Britain’s National Health Service.
To support their claims, these politicians are using Berwick’s own words, in a way eerily reminiscent of the recent Shirley Sherrod debacle.
It started with Glenn Beck, master of the one-word quote, and then slipped over into more mainstream politicians.
What’s really troubling about all this, in addition to the blatant political motivation, is Berwick is pretty closely aligned with core conservative values.
Don Berwick is now, and has always been, a patient-centric, consumer-oriented ‘radical’ who’s concept for the ideal system is one that is almost entirely patient-focused. Here’s Berwick’s ideal health plan from a piece by Ezra Klein:
“(1) Hospitals would have no restrictions on visiting — no restrictions of place or time or person, except restrictions chosen by and under the control of each individual patient.
(2) Patients would determine what food they eat and what clothes they wear in hospitals (to the extent that health status allows).
(3) Patients and family members would participate in rounds.
(4) Patients and families would participate in the design of health care processes and services.
(5) Medical records would belong to patients. Clinicians, rather than patients, would need to have permission to gain access to them.
(6) Shared decision-making technologies would be used universally.
(7) Operating room schedules would conform to ideal queuing theory designs aimed at minimizing waiting time, rather than to the convenience of clinicians.
(8) Patients physically capable of self-care would, in all situations, have the option to do it.
“I suggest that we should without equivocation make patient-centeredness a primary quality dimension all its own, even when it does not contribute to the technical safety and effectiveness of care,” he says.”

Pretty radical, indeed – returning power to the patient, from the practitioner.
If Berwick’s opponents just took a minute to read what the guy really stands for, they’d discover he’s pretty much aligned with many ‘conservative’ principles – self responsibility, ownership, consumer-centered policies and practices.
Unfortunately, they just don’t care about who Berwick really is – they’ve decided he’s the stick they’re going to use to beat this Administration, regardless of whether he’s good, bad, or indifferent.
As Maggie Mahar noted in HealthBeat, “Thomas Scully, who led the CMS under President George W. Bush [said of Berwick] : “He’s universally regarded and a thoughtful guy who is not partisan. I think it’s more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now.”
Here’s hoping the recent Shirley Sherrod disaster has stiffened the backbone of the Administration and caused the wingnut media to think a little more deeply before throwing bombs.
And yes, I believe in the Easter Bunny too.

I don’t understand why those who believe health reform is socialism don’t have faith in the free market’s ability to control costs and deliver quality.
Here’s why I’m confused.
Several large health insurers have decided its time to get serious about managing costs; they’re introducing plans with limited provider networks and either no coverage for out of network providers or high deductibles and co-insurance/copays.
The plans, introduced by United Healthcare, Aetna, Wellpoint and others, are currently only available in a few markets as the healthplans test market receptivity.
Kudos to these insurers for finally getting serious about managing cost. While they are concerned about the potential for a repeat of the consumer backlash seen in the nineties, I’m betting the consumer backlash will be minimal.
The political backlash is a whole different story; more on that in a minute.
Most employees are all too aware of the rising cost of benefits; they have seen their premium contributions increase dramatically as the benefits plan has slimmed down. While some aren’t going to be happy if they have to pay more to see their favorite doc or go to the nearest hospital, their anger will be tempered by the knowledge that they are better off than many of their neighbors who have no insurance at all.
That wasn’t the case in the early nineties. Since 1993, the number of people without insurance has increased almost 20% to 52 million from 43.9 million.
Just as the benefits landscape has changed, so has the political. We’re already starting to hear some politicians complain that employers’ changes are evidence that ‘ObamaCare’ isn’t working as advertised, that the President’s promise that reform would allow you to keep your current plan wasn’t true.
These critics probably know their argument is specious at best. The reform legislation was specifically designed to allow employers to maintain control over their plans, the thinking being the free market will develop solutions to the cost and coverage problem.
And that’s precisely what is beginning to happen, albeit slowly and in baby steps. Health plans have realized that risk selection isn’t the path to success, quality and cost of care and more effective member health management is.
There’s a bit of hypocrisy, or perhaps more kindly, ignorance among those who criticized ‘Obamacare’ for its ‘socialist’ leanings and now fault reform for benefit plan changes implemented by employers seeking market answers to rising costs.
The cost control steps included in the reform legislation are weak, scarce, and small; stronger cost controls were discarded in order to get the bill past lobbyists and their friends in the Senate (and to a lesser extent, the House). As a result, we’re left with a bill that – de facto – relies on private insurers and employers to develop tools and methods to control cost.
Critics can’t have it both ways. Either decry the bill for its weak cost controls and governmental ‘takeover’ of health care, or slam it for forcing employers to change plans to control costs because the bill doesn’t do enough.
Trying to both results in one argument refuting the other.

I’ve just about had it with the GOP’s demagoguing about deficits.
The party of fiscal responsibility, of low taxes and small government, of controlled spending and personal responsibility – that party – seems to have rediscovered its roots of late, with strident calls for fiscal restraint, an end to wasteful government spending and strict adherence to pay-as-you-go guidelines.
This from the party that added over $9 trillion to the deficit the last time they passed a health care bill.
Let’s return, for just a moment, to the early and mid oughts, the halcyon days of the Bush Administration, when the entire government was under the firm control of the fiscally prudent.
Here’s what those wise stewards of the nation’s wealth did.
Point One
Pass Medicare Part D with no funding – short term, long term, any term. Hell, they would’ve been more fiscally prudent if they’d included a few hundred million to bet on the horses. At least that would have shown some desire to pay for the thing. But no, the GOP decided to NOT set aside funds, or raise taxes, or cut other programs; they just passed Part D, committed to paying for it out of ‘general funds’ and to hell with the future.
The latest Medicare Actuary report indicates the GOP-passed Part D program has contributed $9.4 trillion to the $38 trillion Federal healthcare deficit. (page 126)
The Bush-era GOP makes President Obama, Pelosi, Reid, and the rest of those spendthrift Dems look like a bunch of cheapskates; even a GOP analysis finds “the new reform law will raise the deficit by more than $500 billion during the first ten years and by nearly $1.5 trillion in the following decade.”
Point Two
Prevent CMS from basing reimbursement on effectiveness. As I said a couple months ago, “‘the Republican Congress and Administration was responsible for preventing Medicare from considering any cost-benefit criteria in determining whether and what Medicare would pay for procedures, drugs, treatments, devices, etc. Yep, these deficit hawks thought it was just fine for we taxpayers to be forced to pay for procedures with very little efficacy. (Medicare Modernization Act)
Hmmm, wise stewards indeed…
How’d the GOP get away with this? Simple. The Republicans suspended Congress’ PAYGO rules, the requirement that any bill that spent more money had to be offset by more revenue or cuts elsewhere.
By the way, those PAYGO rules? The Dems reinstated them.
From all the caterwauling from the GOP side of the aisle, you’d think that Mitch McConnell, John Boehner, Newt Gingrich et al were well practiced in the art of controlling spending, of not spending what you don’t have.
And you’d be wrong.
According to the Wall Street Journal, speaking about a recent effort to extend unemployment benefits, McConnell said “The principle Democrats are defending is that they will not pass a bill unless it adds to the deficit,” McConnell voted for both Part D and MMA.
Speaking about the health reform bill a couple months ago, Rep. Paul Ryan of Wisconsin, “the top Republican on the Budget Committee, said “Hiding spending does not reduce spending. We all know this bill is a budget Frankenstein. It is a house of cards. It is going to give us a huge deficits now and even larger deficits in the future.” Ryan voted for Part D and MMA.
Here’s party leader Newt Gingrich: “Republicans, I think, are going to draw a very firm line against any kind of tax increase that would kill jobs, and that’s very hard for liberal Democrats to live with because all of their plans require bigger spending, higher deficits and more taxes, and it’s a fundamental disagreement about the nature of the world.”
I could go on, but you get the point.
What does this man for you?
I’ve had, and voiced, deep concerns about the health reform bill and its associated costs. What makes me, and should make you, really angry is the demagoguing by elected officials who’ve done exponentially more to damage our fiscal future than even the most pessimistic assessment of the health reform bill.

Why do we need health reform? Don’t we have the best health care system in the world?
No. Not even close.
According to a study released yesterday by the Commonwealth Fund, “Compared with six other nations–Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom–the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives.” [emphasis added].
The report goes on to note “Newly enacted health reform legislation in the U.S. will start to address these problems by extending coverage to those without and helping to close gaps in coverage–leading to improved disease management, care coordination, and better outcomes over time.”
While there’s no question there are some very, very good hospitals, physicians, and other providers in the US, this isn’t about individual providers – it measures the entire ‘system’.
The report was based on surveys of patients and primary care providers and data on outcomes from previous Commonwealth Fund research.
While the report notes a major failing of our system is a failure to provide coverage for all Americans, even when access issues are not considered, we still rank below the other countries on most measures. This is particularly valid when considering cost, the only area where we rank far above the other six countries.

The top-ranked country overall is the Netherlands, followed by the oft-decried Brits. But the most troubling finding is not a shortcoming on one of the various measures of quality or cost; the US ranks lowest in living long, healthy, productive lives.
“The U.S. ranks last overall with poor scores on all three indicators of long, healthy, and productive lives. The U.S. and U.K. had much higher death rates in 2003 from conditions amenable to medical care than some of the other countries, e.g., rates 25 percent to 50 percent higher than Canada and Australia. ”
What does this mean for you?
The newly-enacted reform bill will help improve access, quality, technology usage, and other metrics.
But we’re still going to be – far and away – the most cost-inefficient system in the world.

For the Chinese treasure fleets, voyages went progressively further from their home ports, until, some believe, they circumnavigated the globe. Before we explore the ‘other side’ of the work comp world, we need to consider what lies just out of sight over the horizon.
Once we think about sailing past what we can see from land, we are forced to guess what lies ahead. Fortunately we can look back and recall what others experienced on similar voyages. Unfortunately, unlike the Chinese of 1421, no one has ever sailed on these particular ‘seas’, thus we’ll have to make a rather scary climb up the ratlines leading to the top of the highest mast, over and into the crow’s nest.

So what can we see from our ‘crow’s nest’?
Today we’ll confine our discussion to health system bargaining power; about 30% of comp medical dollars go to facilities.
Among health systems and large multi-specialty groups, provider bargaining power is already growing, and is impacting the largest of the group health plans. The increasing leverage enjoyed by large provider groups and health systems is going to be felt from New England to southern California, as systems and provider groups use their dominant market positions to force non-governmental payers to increase reimbursement.
By watching what is happening to group health plans, those in the work comp space are seeing their future. I’ve already discussed the ability of providers such as Sutter Health in northern California to demand – and get – double-digit increases in reimbursement from Wellpoint and other huge healthplans with seemingly-immense buying power. Recall that facility charges account for about a third of work comp medical expense; if work comp payers in California see similar increases, we’re looking at an increase of three points in the loss ratio…

I understand that many states have fee schedules, California included. I also understand that many work comp PPOs, including those operating in the Golden State, have deals that give their clients lower-than-fee-schedule rates at participating hospitals. At some point Sutter et al are going to start asking why they are giving work comp payers this great deal.
I would expect that shortly after that question is posed, discounts will disappear, or at best, become far less attractive.
One could argue that hospitals, health systems, and large provider groups will be loathe to give up what amounts to a very profitable payer line. That’s true so far as it goes, however:
– many providers are highly skeptical of payers’ ability and actual effort to direct injured workers to their facilities;
– providers are facing what could well be a significant influx of new patients as previously-uninsured gain coverage and seek the care they’ve not been able to access until now, making the few additional work comp patients less significant; and
– providers in many areas are already able to force work comp networks to pay at or very close to fee schedule, as those networks know they ‘have to have’ that system or payers will not consider their network. BayCare in the Tampa Bay area is just one system that leveraged their position several years ago, Sutter Health in NoCal and Partners in Boston have similar approaches.
What does this mean for you?
Fortunately, since work comp is a required coverage (except in Texas), payers can just pass the additional cost on to their policyholders.
Unfortunately for payers who choose that ‘strategy’, some of their competitors will figure out solutions that give them a ‘sustainable competitive advantage’.