Why Berwick Matters

Two cover stories in this week’s Time magazine debate a provocative question: Is America in decline?

Both the yes and no arguments are made persuasively, and I found myself on the fence after reading them, perhaps leaning ever-so-slightly toward the “no” side (optimist that I am). Sure, times are tough, but we’ve got the Right Stuff and we’ve bounced up from the mat before.

Then I considered the political fracas over Don Berwick’s appointment as director of the Centers for Medicare & Medicaid Services (CMS), and decided to change my vote, sadly. Yes, America is in decline, and this pitiful circus is Exhibit A.

Berwick, as you know, is a brilliant Harvard professor and founding head of the Institute for Healthcare Improvement. He is also the brains and vision behind most of the important healthcare initiatives of the past generation, from the IOM reports on quality and safety, to “bundles” of evidence-based practices to reduce harm, to the idea of a campaign to promote patient safety.

President Obama’s selection of Berwick to lead CMS last year was inspired. In the face of unassailable evidence of spotty quality and safety, unjustifiable variations in care, and impending insolvency, Medicare has no choice but to transform itself from a “dumb payer” into an organization that promotes excellence in quality, safety and efficiency. There is simply no other person with the deep knowledge of the system and the trust of so many key stakeholders as Don Berwick.

But Berwick’s nomination ran into the buzz saw of Red and Blue politics, with Republicans holding his nomination hostage to their larger concerns about the Affordable Care Act. In the ludicrous debate that ultimately culminated in Obama’s recess appointment of Berwick, the central argument against his nomination was that he had once – gasp – praised the UK’s National Health Service. Interestingly, without mentioning Berwick by name, Fareed Zakaria pointed to this very issue to bolster his “decline” argument in Time:

A crucial aspect of beginning to turn things around would be for the U.S. to make an honest accounting of where it stands and what it can learn from other countries. [But] any politician who dares suggest that the U.S. can learn from – let alone copy – other countries is likely to be denounced instantly. If someone points out that Europe gets better health care at half the cost, that’s dangerously socialist thinking.

I’ve argued that President Obama was right to use his recess appointment power to install Berwick as CMS director, and hoped – naively perhaps – that Don would win over his critics by the time his appointment expired in December 2011. And, in his eight months in the role, Berwick has done a terrific job. As always, his speeches on healthcare reform have been articulate and thought provoking (though one can see a heavy bureaucratic hand tamping down Don’s characteristic flair and penchant for provocativeness). He has appointed excellent people to key leadership positions, fleshed out some of the new CMS programs such as Value-based Purchasing and the Innovations Center, and will announce a major initiative in patient safety in the near future. Impressively, Berwick has accomplished all of this with at least one hand and several fingers of the other tied behind his back: doubt about his own future at CMS, uncertainty about the fate of the Affordable Care Act, and an unrelentingly hostile reception by the Republicans in Congress.

But my hopes were dashed by this week’s statement by Sen. Max Baucus (D-Montana) that Berwick’s is simply not confirmable by the Senate. This announcement followed a letter sent to the White House last week by 42 GOP senators, who argued – disingenuously – that Berwick’s “lack of experience in the areas of health plan operations and insurance regulation raise serious concerns about his qualifications for this position.” If the White House pulls the plug, he is likely to be replaced by his deputy, Marilyn Tavenner, a nurse administrator who ran two suburban hospitals for HCA and was Virginia’s Secretary of Health. The American Enterprise Institute blogger Joseph Antos praised her, sort of:

Tavenner has a reputation for making the trains run on time…. More importantly, [she] would not act as if she has a mandate to upend the health system, because she doesn’t.

In all likelihood, Tavenner would sail through her confirmation hearings, precisely because she won’t cause a stir.

But we need a stir!

From the moment of his nomination, Berwick’s plight has been a sad spectacle. I was particularly disheartened by the way he was treated during his testimony before the House Ways and Means Committee. It is too long and painful to watch the whole thing; if you’ve taken your Compazine, try a 5 minute stretch that begins precisely an hour into the testimony, as Representatives Davis and Reichert bait Berwick with a combination of hyperbole and rhetorical foolishness (“I’m not interested in an academic salon answer…”) that would make a middle school playground argument seem positively Shakespearean.

In the face of this kind of nonsense, I know of several superb physician-leaders who were offered positions in CMS – for roles that should have been once-in-a-lifetime opportunities to shape national policy – but turned them down. “Who needs this?” one told me. And they’re right.

The smart money is that the White House will fold on the Berwick appointment. The legendary Lucian Leape emailed many of Don’s colleagues yesterday, including me, asking that we sign on to a letter to the president in support of Berwick. Lucian wrote:

Watching the hearings and reading the statements being issued by the Republicans on this matter has been both disappointing and disgusting as we see our eminently qualified colleague disparaged by those who have no appreciation for what he has done and can do for our health care system.

I gladly signed this letter, and I hope you’ll do what you can to turn this around. Please contact the White House, your senators and representatives, and the media, and tell them that Don Berwick is the best hope we have to improve our healthcare system. Tell them that the Senate should hold hearings on his appointment, letting the chips fall where they may. Tell them to start acting like grown-ups.

If this good and great man is thrown under the bus, you’ll have all the evidence you need that our society is, in fact, in decline. Let’s not let this happen without a fight.

This blog post appeared at The Health Care Blog.