Reading List: Promising Care
A conversation with author Donald Berwick, MD
In Promising Care: How We Can Rescue Heath Care by Improving It, ($45, John Wiley & Sons), Donald Berwick, MD, former administrator of the Centers for Medicare & Medicaid Services and current candidate for the governor of Massachusetts, shares his speeches and thought development on healthcare over the last two decades. He talked to Healthcare Finance News about the importance of shifting mindsets and business models to embrace the morality of caring for patients and society.
Q. Please give us a brief description of your book, and share with us what you think is its most important take away for readers.
A. It’s my second collection of speeches. I published the first one about 12 or 15 years ago. It’s called Escape Fire. It was a collection, I think, of about 11 speeches. I used to be the chief executive of the Institute for Healthcare Improvement. Each year, IHI has a major national meeting called the National Forum on Quality Improvement in Healthcare. It’s the flagship meeting of the organization. It just celebrated its 25th anniversary last December. Each year for the entire sequence, except for the one year I was in Washington, I gave the keynote address at the National Forum. In that keynote address, I tried to summarize what happened during the year in the world of quality and healthcare reform. So, the first book, Escape Fire, is the collection of the first 11 speeches. This book, it’s called Promising Care, is a collection of speeches since that first one. What I did this time was include the speeches from the IHI National Forum, but I also put in a number of other addresses that I’ve given through the past decade, such as a keynote speech at the British National Health Service 60th anniversary; a graduation speech I gave at Yale Medical School – my daughter graduated; a gradation speech I gave at Harvard Medical School and so on. I don’t know the number – something like 15 speeches. And what they do – this reaches back about 10 years – the speeches themselves reflect an evolution of what’s happening in healthcare change and improvement; what we’re learning; and in particular, changes in my own views through that time as to what was important to be emphasized.
Q. How can your book be of use to finance administrators?
A. They’ll see the evolution of thinking from about a decade or 12 years ago when we knew by then that improving the quality of individual healthcare, making it safer, more science-based, more patient centered, would have the benefit of saving lives and reducing human suffering, but also generally save money. … (And) using improvement and quality as a tool for financial improvement as well. Most other industries already know that. If you go into any globally competitive product or service industry today – any company – they will already know that higher quality is a route to lower costs for the consumer. Not always. Sometimes costs go up when you add features … but generally, if you make a product more reliable, you make the production itself more efficient, you will lower the cost to the consumer and improve the quality of the product and thereby have your company do better. It does better by getting more market share and by reducing the cost of production. And more satisfied consumers are willing to pay higher prices. So that was the beginning, really, of the quality movement in healthcare two decades ago and the early speeches reflect that.
As time went on, my own thinking broadened. At first, just to understand how massive the level of waste in healthcare is and what it’s various forms are. So there are speeches in the book about how much waste there is and what forms of management and executive leadership and process science can reduce waste. ... Then, I think there’s an evolution to broaden the whole terrain of inquiry from just acute care, which is basically hospital care, to think more about health and well-being in communities with the same dynamic at work – higher quality and lower cost go together. … IHI introduced the idea of the Triple Aim. The Triple Aim is better care for individuals, better health for populations and lower costs by improving processes and products and services.
Beyond that, there’s increasing consciousness through the book about the relationship between healthcare as a component of industry and society and its effects on other industries. So, showing how healthcare improvement is really going to be needed in order to allow us to have the society that we want, the communities we want, the roads, the schools, investments in the social safety net and giving more advantages to families, especially low-income families.
I went to Washington DC to run Medicare and Medicaid for President Obama in 2010. I spent 17 months there so the speeches since then also are commentaries on the political environment and how healthcare reform now has become enmeshed in the politics of America and how that’s on the one hand somewhat good news because it increases people’s awareness of what needs to change, but it’s also enmeshed in the rancor and the anger … that’s going on in the country right now. So the later speeches are really about the way we act together as a society and work together as communities. And it’s really asking for more civility and a higher sense of stewardship of the resources we have and a very, very strong plea for social justice and returning to care of the poor and care of the disadvantaged, and disabled, elderly and children, as essential to the society we want to build, so those features have more policy relevance.
You may know that I’m running for governor of Massachusetts. (I do. How’s that going?) It’s going really great. The last few speeches were already at a time in which I was thinking about this and thinking more and more about public leadership and the public policy environment is crucial to the communities we want.
Q. Boston-area health economist and blogger Austin Frakt recently tweeted, "In all seriousness, a dimmer political spotlight on health policy could help create an environment in which fixes/compromises are possible.” You've spent time in both the political arena and in healthcare. What do you think? At this point in time, could more progress be made if the political glare on healthcare dimmed?
A. Yes. I wrote an essay in the Journal of the American Medical Association just a few months ago called “The Toxic Politics of Healthcare,” and it describes how the current environment is so contentious that it is toxic to the changes. If somehow it could be depoliticized, the technical answers are actually now available. We know a lot more now. We know how to make healthcare safe. We know how health prevention should be done. We know more about what integrated care, community-based care, really looks like. So if we were treating this like the problem of getting to the moon or building the interstate highway system – a major national project – we could be making a lot more progress than we are right now.
Q. It seems that many of the best practices of caring for people, or preventing illness, will, to some degree, reduce profits of providers. How can these providers re-imagine and launch a new business model that will allow for profitability while meeting the Triple Aim?
A. It’s exactly as you said. All businesses evolve over time. If you’re still making buggy whips, you’d be out of business. You have to change your business model as the social need changes, as technologies change, as consumers’ positioning changes. And if healthcare is in this massive tectonic era shifting from hospital based to home and community, shifting, I hope, from simply treating illnesses to preventing them, a shift from regarding healthcare as the best route to health to actually thinking more about the factors in society that produce health – these will of course disrupt the current business models. They have to. But they also create enormous new business opportunities. The organizations that are willing to change now and actually have the courage, I think, and the intelligence to move into the production of health, well-being and prevention and have very, very high quality for acute care, I think that if people want to survive, will try. Any executive, or in your case, any finance officer, who simply try to keep doing what they’ve always done in a changing environment is going to have a very rough time in maintaining profitability and organization-wide talent.
Q: Is there something about your book that I haven't asked that you would like to add that you think is important for readers to know?
A. I think it’s the ethics – we have talked about it a bit – but some of this is technical: How should your readers help their organizations migrate into a new business model that will be more responsive to what we now know we need to do? But I think there’s another issue here, which is what kind of society do we want to have? And whether the fundamental issues – the fundamental goals of social justice and equality and compassion – will infuse the healthcare industry as they always have and should have. I don’t shy away from raising the moral question. Indeed, one of my speeches is called “The Moral Test,” and I think that’s something that your community, like all communities that are staked with healthcare, ought to be taking really seriously right now.
