By David A. Kindig, MD, PhD
We knew it was coming, but I winced when I saw the headline: Medicare and Medicaid Chief, Never Confirmed by Senate, Is Stepping Down. The headline, of course, refers to Don Berwick, who has run this critical agency in the Obama administration since July 2010. He is a highly regarded pediatrician and heath policy expert, and the founder of the Institute for HealthCare Improvement (IHI), a nationally recognized organization that leads efforts to improve health care quality and contain costs. Under his leadership, CMS has released final rules for Accountable Care Organizations’ (ACOs) Medicare Shared Savings Program, developed the Comprehensive Primary Care Initiative, and launched the Health Care Innovation Challenge.
Berwick is resigning because his appointment is an Obama “recess” appointment not requiring Senate confirmation.
Why was he so objectionable to those having the power to confirm him? Put simply, throughout his career, he has shown vision and honesty about improving value in health care – which both parties agree is essential for national and global economic security. Most of his work has been in the trenches of healthcare institutions, showing and teaching about how quality can be measured and therefore improved while controlling costs.
But along the way he spoke frankly about what he saw and what he knew had to be done. In one 2009 published interview he said what gave partisan critics all the ammunition they needed: “The decision is not whether or not we will ration care – the decision is whether we will ration with our eyes open.”
Despite this concept having broad support, the “R word” remains politically anathema. In all my work with Donna Shalala I never heard this word leave her lips. Politicians are forced to use more cautious terms like “value” and “efficiency”-- which are technically correct, but don’t catch our attention in the same way. Our attention is exactly what is critically needed now.
Why is the word rationing so charged? The New World Dictionary defines it as “a systematic method for limiting access to a good or service when demand exceeds supply.” Perhaps the idea of limiting access to anything medicine has to offer is challenging to some, but the reality is that we are living in a resource-limited world where health care is far too often wasteful and ineffective. Analysts from both sides of the aisle suggest that substantial reductions in what we spend are required if our economy is going to thrive.
The question is, will it be done in the thoughtful and rational ways “with our eyes open” that Berwick has advocated, or simply by mindless across-the-board reductions such as might be triggered by the Super Committee’s failure of leadership?
The fact that there is so much waste and inefficiency means that we can cut costs without harming anyone; I don’t think this even qualifies as rationing. We get into more difficult territory when something provides some benefit but at great cost. Many population health advocates believe that such services should also be scrutinized, particularly when we are so underfunded for the preventive and social services we know are so effective in improving health. I noted with great interest an October 27 New York Times editorial on the mammography screening controversy which observed that “several thousand lives saved per year is not inconsequential….but the analysis inevitable raises questions as to whether the $5 billion spent annually on mammography screening and the millions more spent urging women to get screened might better be used for other purposes.”
This kind of rationing question is substantial and difficult, but should we approach our health care cost challenge this way with our eyes open, or in closed or mindless ways out of the public eye? I have always argued that rationing can be rational, which is all that Berwick was saying. Let’s hope that those who succeed him in this position will build on his accomplishments with a similarly candid approach.
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.
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