Dr. Donald Berwick’s appointment as head of the Center for Medicare and Medicaid Services came as “a breath of fresh air” at the agency, according to CMS chief medical officer Dr. Barry Straube.
During a presentation on patient safety at the National Quality Colloquium today in Cambridge, Mass., Straube took a moment to note the arrival of his agency’s new head.
"Don Berwick is our administrator, finally," Straube said. "It’s a breath of fresh air to all of us."
Berwick spent much of his career working on ways to systematically overhaul healthcare systems to improve patient outcomes and safety, also the theme of the colloquium. Straube, highlighting the systemic changes the Affordable Care Act will bring to CMS, said Berwick will help hasten the agency down a path it’s already started on.
"He will add the next step up in what we’ve been trending towards at CMS," Straube said "and that’s focusing both on the integration of care and population health."
Berwick, unlike some of his career-bureaucrat predecessors, is a professor at Harvard Medical School and Harvard School of Public Health in pediatrics and healthcare policy, respectively. He also co-founded the Institute for Healthcare Improvement.
President Barack Obama’s nomination of Berwick as CMS administrator brought about a fervid addendum to the healthcare reform debate, as partisan Republican opposition threatened to derail the appointment. Obama’s use of a recess appointment to skirt the political battle to bypass the deadlock prompted attacks from the right of Berwick’s praise of the United Kingdom’s single-payer, publicly funded National Health Service. The attacks, based on an out-of-context aside, suggested that Berwick would "ration" healthcare.
According to Straube’s presentation (PDF), CMS is the largest healthcare payer in the world and, at a projected annual cost of $784 billion, will be providing care for 114 million people during its 2011 fiscal year.
Straube’s address followed a 40-minute talk by Brigham and Women’s Hospital surgeon, HMS professor and bestselling author Atul Gawande, who took a page from the late Rep. Tip O’Neill’s (D-Mass.) playbook in pointed out that all medicine is local.
The healthcare reform debate emphasized that working local systems cannot be centrally directed, Gawande said, meaning that providers must take control of what happens at the community level. Criticizing the current healthcare system for approaching medical conditions with overly complex solutions, whether they be devices or administrations, Gawande said there is too much reliance on expensive components and procedures and not enough focus on the chain of events that must go right in order to improve quality and safety for patients.
"One essential characteristic of medicine is that it requires the successful functioning of systems, assemblages of people and technologies" he said.
Patients demand the best drugs, devices and specialists in medicine, but haven’t paid attention to how to make them fit together, Gawande said.
"When [Berwick] was at the Institute for Healthcare Improvement," Gawande said "[he] noted how wrong-headed this is. ‘Anyone who understands systems will know immediately that optimizing parts is not a good route to system excellence,’ Berwick said, and he gave the example of a famous thought experiment of trying to build the greatest car by assembling the greatest car parts. … What you’d get is a very expensive pile of junk. And that’s often what we’ve done in medicine."
Gawande said the U.S. has the best training and technology lacks an emphasis on teamwork and checklists, two of the most basic universal organizational systems available — both practical solutions at the local level.
Straube agreed with Gawande’s assertion about the local nature of medicine, saying, "CMS is going to be increasingly focused on trying to facillitate local healthcare," but admitted that the agency has not yet met the needs of its constituents.
"I think there’s a tension that … locally we have not solved these problems," he said.
Straube and Gawande both lamented the disparities between the cost and quality of healthcare at the community level within the U.S., agreeing that, in some cases, there’s an inverse relationship betweent the two.
The Affordable Care Act’s national mandate will help CMS coordinate local efforts,Straube said, but there are still "very good evidence-based best practices that need not be reinvented over and over at each individual local level."