Op-Eds Speaking Truth to the Powers-That-Be
In yet another stunning reversal, President Obama and many leaders in the Democratic Party have backed away from support of a true consumer champion.
In September it was Elizabeth Warren, then acting head of the Consumer Financial Protection Bureau (CFPB). This month it is Dr. Donald Berwick, acting administrator of the Centers for Medicare and Medicaid (CMS).
Nominated by Obama in April, 2010 to head the $700 billion agency and help guide the implementation of the Affordable Care Act (ACA), it didn’t take long for forty-two Republicans to sign a pledge promising to block his confirmation, asking the president to withdraw his nomination.
With no confirmation hearing scheduled by July, Obama made a recess appointment. Unfortunately without a Congressional confirmation, the job would have expired at the end of 2011. Recognizing that he would never gain Republican approval and not receiving the kind of aggressive support that might have turned the tide from either the White House or the Democratic congress, Berwick chose to resign a month early.
So what did Berwick do to earn the enmity of the Republicans? His biggest sin, according to the conservative think tank Heartland Institute which has waged an extensive and sophisticated online anti-Berwick campaign was a 2008 comment praising Britain’s single-payer healthcare system. Heartland is backed by Koch brother Charles, and Dead Billionaires Club, and Club for Growth members like Sarah Scaife, WalMart founder Sam Walton’s Walton Foundation, Exxon-Mobil and many others. 
Opponents like Glenn Beck and Andrew Breitbart chose to distort his comments and to discount 30 years of experience as a clinician and policy expert who possesses an incredible international network, calling him the “second most dangerous man in the world.” They used loaded words like “rationing”, “radical”, “revolutionary”, “socialism” and even “death panels” to scare the public into believing Berwick was out to destroy medicine. This could not be farther from the truth.
Son of a solo primary care doctor, pediatrician Berwick received his medical degree from Harvard Medical School and a Masters in Public Policy from Harvard’s Kennedy School of Government. As a clinician he saw that even when his patients were admitted to the best hospitals in the United States, there were often significant medication errors, duplication of tests and procedures that put the patient at serious risk and little coordination of care among various specialties.
As a professor of health policy and management at the Harvard School of Public Health, he recognized that this fragmentation of care was a huge driver of costs. Berwick founded the Cambridge-based Institute for Healthcare Improvement (IHI) focusing research on reducing costs while improving the quality of health care.
As President and CEO of IHI, Berwick spent decades emphasizing the need for evidence–based criteria for medical treatments and comparative effectiveness research (CER) to make smart decisions about appropriate use of resources while maintaining quality and safety.
Patients place their trust, and often their lives, in their doctors’ advice about treatment and care. Yet most would be shocked to learn that their doctors do not always have all the scientific evidence required to make the best decisions. No data to compare the effectiveness of one treatment approach versus another.
That is an especially serious problem today, as so many new, and often more complex medications, procedures, devices and tests are introduced.
No one wants their doctor to simply guess what is best for them.
As part of the stimulus bill (The American Recovery and Reinvestment Act of 2009) Congress called on the Institute of Medicine (IOM) to recommend a list of the top 100 topics for the initial focus of a new national $1.1 billion investment in CER.
In a June 2009 interview in Biotechnology Healthcare, Berwick, explained the three levels of analysis that make up CER.
One of the fundamental aims of comparative effectiveness research is to help doctors avoid ineffective or more costly approaches that might not work or, worse, allow a patient’s condition to deteriorate by delaying more effective treatment.
First on the list of 100 prepared by the IOM was a comparison study of the effectiveness of different treatment strategies for atrial fibrillation.
It is a condition affecting 2 million Americans in which the heart rhythm is very irregular, raising the risk of stroke. In the past, most patients were given medications to try to control the rhythm.
More recently various surgical procedures and catheter ablation have become popular. There really has been little actual research, though, comparing these ways of treating the disease. It makes the decision by doctors as to which is best for which patient difficult if not impossible.
Other areas IOM wants to comparatively evaluate include:
In addition, the IOM has prioritized the use of the results and the best way to practically implement this research by patients, clinicians, payers, and others. How this information is used is critical.
Some skeptics have complained that policy decisions will be based ultimately only on cost. Berwick said that to remain ignorant of the cost implication of a drug or treatment or procedure that is only marginally better than what is already out there is “simply bad policy. The degree to which it is linked directly to policy and decision is a matter of choice.”
As the administration has tried to engineer reform of our healthcare system, the public, prompted by opponents of more transparency in medicine has voiced fears of rationing. Berwick points out that “we are already doing that, but without good information”.
The IOM’s panel report clearly states: “The new program is not about rationing care — it doesn’t call for insurers to use the results for coverage decisions — but about finding unbiased information to make the best choices for a given patient. To do that, the research must include typical patients — usually sicker ones than drug companies enroll in the studies required for sales approval.”
Everyone agrees that health care costs are too high. Not everyone however, understands as Berwick does, that quality could and should be improved. As Dr. Eli Y. Ashahi, professor of medicine at Brown said in a recent Medscape video discussing the National Blueprint for Great Healthcare in June, 2011: “At a time when the country is facing the twin challenges of quality and cost, it is hard to think of a better person to lead the charge.”
Today most Republicans and even many Democrats have turned their backs on Berwick, who has been the most vocal champion of better care at lower cost and more attention paid to the needs of patients.
The irony? GOP front-runner Newt Gingrich once praised Berwick’s approach to quality in a 2000 Washington Post editorial:
“Don Berwick at the Institute for Healthcare Improvement has worked for years to spread the word that the same systematic approach to quality control that has worked so well in manufacturing could create a dramatically safer, less expensive and more effective system of health and health care.”
The media has blamed Republican obstruction for Berwick’s resignation. Yes, they have played an important role. Might the situation have turned out differently if the President and the Democrats had been more vocal about promoting their candidate?
The Obama Administration may have cut Berwick loose because his status as a lightning rod for Republican health care reform angst was further complicated by his prickly relationship with Capitol Hill Republicans. The New York Times notes:
On the few occasions when he testified before Congress, Dr. Berwick held his own, defending the health care law against criticism from Republicans. But his strained relations with Republicans limited his effectiveness as an advocate for the administration on Capitol Hill — a big part of the administrator’s job.
Berwick knew that his days in the job were numbered, but, even David Whelan at conservative Forbes observes:
“One insider I spoke to said Berwick knew he would have to leave, but stuck around this long to start the Partnership for Patients, a $1 billion program that funds research in his old area of work.
“But to me, even as someone who’s been skeptical of the ObamaCare approach to reform, the Berwick resignation is part of a troubling pattern where engaged, interesting thinkers get booted out of positions of power.”
After Elizabeth Warren resigned, the White House nominated Roger Corday to step in . Just as with Warren, Cordray’s confirmation is still languishing. There has been no effort from the administration to educate the public about the CFPB’s important role and why Cordray should be its head.
At CMS, Berwick will be replaced by his personal deputy Marilyn Travenner, a nurse and former head of Virginia’s health department under then Democratic Governor Tim Kaine.
One wonders if she will fare any better than Warren, Cordray, or Berwick.
Sadly, the “good news” for those who were wary of Berwick is that, according to Ezra Klein’s Wonkblog in The Washington Post, “Travenner isn’t associated with a grand vision for health reform.”
Once again the White House and the Dems have chosen to hide behind the safety of bureaucratic mediocrity rather than to exhibit bold leadership. Losing Berwick, a champion of real healthcare reform means we all lose in the end. Frankly, that is not the kind of change we can believe in.