I often emphasize the potential for wasted resources in ineffective health care to fund population health investments. And I have praised Don Berwick for his lifelong and more recent leadership in health care improvement.
Both of these threads came together last month when I heard Don give the George W. Gay Lecture in Medical Ethics at Harvard. Always a compelling speaker, he riveted the audience with the very human story of a newborn exchange transfusion gone very wrong when he was a pediatric resident. His immediate point was the lost opportunity then to confront the errors promptly and openly to prevent reoccurrence. He asserted that this was an ethical responsibility of physicians and health care systems if quality is to be continuously improved.
But then he went one step further. In the list of six IOM principles for a quality health care system, efficiency is the one often not fully embraced. He put it very starkly: “Waste is theft.” He explained that resources spent on health care that we know doesn’t work – or may even be dangerous – are not available, in a resource limited world, for other investments known to be effective. It represents theft of resources that could otherwise be used for effective treatments. He likened the prevention of such wasteful practices to the ethical responsibility of “first do no harm” and using error reporting as a path to quality.
His lecture didn’t address rationing extensively (the failure of Congress to confirm him as CMS head was due in part to his views on this subject). But he did note that this concept of “theft” avoids this contentious terminology, since rationing doesn’t apply to ineffective care.
Don noted, as others like the New York Times editorial page have recently, the new educational initiative “Choosing Wisely” issued by nine medical specialty boards which identified the top five tests and procedures in each specialty (such as routine annual electrocardiograms and antibiotics for mild sinusitis) which are costly and have no proven benefit. While only educational and voluntary, this is certainly an important first step and should be supported by those sharing concern for health care “theft.”
Although Don’s talk was primarily in the clinical care domain, I have no doubt he would endorse using some of the resources not “stolen” for prevention and social investments outside of the health care system. It is extremely difficult to capture these resources and then find ways to redirect them to effective purposes. The Population Health Branch of the Center for Medicare and Medicaid Innovation, established under his leadership, is considering such mechanisms.
Importantly, preventing waste is not the ethical responsibility of physicians alone; everyone in the health care system shares this responsibility. But Don’s placing it as a fundamental ethical responsibility of physicians elevates it to a level not previously suggested.
Don Berwick served us well in his public role, but it is good to have him back where he can fully express his views and exhort us to where we need to go.
David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health. Follow him on twitter: @DAKindig.