Now that Don Berwick has returned home from Washington, what’s to become of Medicare?
The former head of the Centers for Medicare and Medicaid, widely acknowledged as one of the brightest and most effective health care executives in the nation, was only there for 17 months, a victim of politics. That’s sad, disheartening, and deeply concerning.
Here was a guy whose life’s passion is to improve the delivery of health care; one who founded and turned the Institute for Healthcare Improvement into one of the most effective agents for change in the nation; who, by all reports was doing a masterful job at CMS changing the culture to one of continuous improvement in the quality of care delivered while reducing the cost of that care.
Yet Dr Berwick couldn’t get approved by the Senate. He was rejected by Republican Senators who vilified him for such blatant transgressions as:
– complimenting one aspect of the British National Health Service (while ignoring Berwick’s pointed criticisms of NHS),
– explicitly acknowledging the US health care system rations care, and calling on politicians to acknowledge that fact as well (a quote remarkably similar to one from GOP Rep Paul Ryan)
These attacks were misguided, politically motivated, and in most instances relied on taking highly selective, out-of-context quotes to misrepresent what Berwick was actually saying.
For those unfamiliar with IHI, the basic premise was to take improvement techniques learned in industry and seek ways to apply them to health care. IHI has had a major impact on all areas of health care; their Improvement Map is widely used and demonstrates the Institute’s focus on bringing quality improvement – carefully thought out and rigorously evaluated – to health care.
What bothers me – a lot – about this is politicians decided that demagoguing and scoring political points was more important that reforming Medicare.
What Don Berwick was trying to do was exactly what needs doing – reform CMS to improve quality and strip out unnecessary cost. If we are ever to get health care costs under control, we have to do so by rationalizing what services get delivered, in what setting, by which providers, to which patients. CMS can be, and under Berwick has been, an enormous force for positive change.
The good news – to the extent there is any – is Berwick’s replacement is an accomplished, effective health care exec with a long history of achievement. Marilyn Tavenner.
Here’s a quote that bodes well for her tenure:
“The only way to stabilize costs without cutting benefits or provider fees is to improve care to those with the highest health care costs.”
Here’s hoping Ms Tavenner is actually allowed to do just that.

The expansion of Medicare to include coverage for prescription drugs was a political masterstroke. In a single move, the GOP won the hearts and votes of seniors. The result was significant – larger Republican majorities in Congress, and re-election for George Bush. (I know, there were a few other issues and a poor candidate at the top of the ticket for the Dems)
That was less than a decade ago.
Now, the GOP has decided on a policy of self-immolation. Paul Ryan’s Medicare plan likely cost the GOP a previously safe seat in upstate New York, has led several Republican Senators to vote against the plan, and resulted in erstwhile Presidential contender Newt Gingrich alternately slamming and praising Ryan and his plan.
While GOP loyalists will argue that Ryan’s plan is meant to save Medicare, that assertion is false on its face. In reality, it transfers the risk to seniors, a risk that Medicare assumed when it become law in 1964. One can argue as to whether or how much risk seniors should assume; one cannot argue that the Ryan plan will save Medicare.
But that’s beside the point.
What Ryan et al forgot was that seniors guard Medicare like momma bears guard their cubs. I find it bizarre that the same party that single-handedly passed Medicare Part D in an effort to win this crucial voting block has pulled a 180.
Part D worked to keep the GOP in power. Ryan’s plan may well have the opposite effect.
In fact, this may be worse. Tea partiers – well, at least some folks who seem to share the same agenda – are mad that the GOP passed Part D, seeing it as an unaffordable expansion of Federal entitlement programs (I agree). So, there’s a ‘base alienation’ issue here as well as a senior vote alienation problem.
Ouch.
For more on this, see Bob Laszewski’s excellent piece.

There’s been a good deal of complaining about the future costs of health care under reform, some of it justified, some not. In particular, the release of the Medicare Trustee’s report last week noted that the date when Medicare intake is lower than outflow has gotten nearer due to the poor economy.
There’s a misconception here.
Reports indicate “The Medicare hospital insurance fund will be exhausted in 2024, five years earlier than last year’s estimate, government accountants now figure.” That’s NOT what the report says. In reality, the HI fund will not be exhausted, but rather insufficient to pay ALL projected hospital costs. In 2024, it will be able to cover 90%, slowly decreasing to 75% in 2048 than back up near 90% in 2085.
However, even that overstates the problem, as it is highly likely the IPAC’s provisions will kick in to reduce costs well before then. I’d also note that the Medicare Actuary predicted reform would add thirteen years to the HI fund’s adequacy; the new figures cut that to an eight year addition due to reform.
As Maggie Mahar pointed out:
“Today [last Friday, actually] the Trustees affirmed that “projected Medicare costs over 75 years are about 25 percent lower because of provisions in the Patient Protection and Affordable Care Act.” The Trustees highlight one plank in the ACA that will save tens of billions by reducing “the annual payment updates for most Medicare services (other than physicians’ services and drugs.)”
Here, the Trustees are referring to the provision in the legislation that shaves Medicare’s annual increases in payments to hospitals, skilled nursing facilities, home health agencies, and other institutions by 1 percent a year, for ten years, with the goal of spurring them to become more efficient. This means that if, in a given year, hospitals normally would receive an adjustment from Medicare that raised reimbursements by 3%, under the new law their reimbursements would climb by just 2%. (Note: this provision does not apply to doctors, only Medicare Part A providers.) Over the decade, the Congressional Budget Office estimates that this change will save $196 billion.”
This is not to say Medicare’s cost problems are nonexistent – far from it. We absolutely have to get costs under control. The ACA is part of the answer; increasing revenues and reducing expenditures are two other parts of the solution. Of course, we can eliminate the need to increase revenues if Medicare starts negotiating drug prices and Congress eliminates some of the dumber provisions of the Medicare Modernization Act.