Donald Berwick, Medicare Reform, and Rationing
Earlier this week, CMS Administrator Donald Berwick was quoted in Politico as saying that the House Republican budget plan for Medicare amounts to rationing. Some may view these comments as more than a bit rich, seeing as how much of Dr. Berwick’s academic career focused on determining the cost-effectiveness of various treatments. I’ve attached below my signature a mere sampling of quotes from Dr. Berwick’s various journal articles, which among other things evaluated the cost of “adding a year of life” to low-birthweight babies. Congress has yet to receive an answer to the simple question: If Dr. Berwick doesn’t believe in rationing care, then what exactly was the point of all these cost-effectiveness studies he undertook – were they all conducted just for fun?
Second, some may view it as HIGHLY hypocritical for Dr. Berwick to have spent so much of his career talking about all the “waste” in the health care system, only to turn around and criticize Republicans for wanting to withdraw care by reducing some of this “wasteful” spending. Dr. Berwick has repeatedly said up to half of all health expenses are “waste,” and as recently as 2008 stated that national health spending should be about 8% of GDP – less than half of where it is now. (A sampling of his quotes are below.) Did the House Republican budget suddenly made Dr. Berwick believe that all this “waste” is now essential spending – or does Dr. Berwick’s objection stem from the fact that the Republican budget lets PATIENTS AND DOCTORS make the choice about what is and is not essential spending, rather than government bureaucrats like him?
Dr. Berwick actually conceded the latter half of this inconsistency himself, in an op-ed published in this morning’s Wall Street Journal in which he attempted to claim the Administration’s plan for Medicare reform was superior to the Ryan budget. He talked about improvements in efficiency that have been made in private markets:
Improving quality while reducing costs is a strategy that’s had major success in other fields. Computers, cars, TVs and telephones today do more than they ever have, and the cost of these products has consistently dropped. The companies that make computers and microwaves didn’t get there by cutting what they offer: They achieved success by making their products better and more efficient. We can do the same when it comes to health care.
Of course, there is a BIG difference between health care and the other areas Dr. Berwick discussed – they don’t have government paying a good portion of the bills, and federal bureaucrats micro-managing firms’ every move through various mandates and regulations. In addition, consumers have the information they need to make smart choices (information which is currently lacking in many sectors of health care), and firms have financial incentive to improve, because they know they will lose business if they do not.
Dr. Berwick’s op-ed this morning was designed to bolster the case for the Administration’s position that only government bureaucrats are sophisticated enough to manage (or micro-manage) the nation’s health care system. But by correctly pointing out that health care should look more like sectors in which consumer power drives innovation, Dr. Berwick actually undermined the White House’s own argument.
“The need to balance effectiveness against cost has shifted the burden of proof onto the shoulders of those who use or propose to use expensive technologies.”[1]
“An important recent study estimated that adding a year of life, adjusting for the quality of life, cost about $22,000 for newborns weighing 500 to 999 grams and $3,200 for those weighing 1,000 to 1,499 grams. By comparison, quality adjusted life years added by screening procedures for coronary artery disease commonly cost about $10,000…”[2]
“The approach used here, detailed cost-effectiveness analysis, can help to organize a large body of technical information, putting that information to work for those policy decisions that we are ready to make.”[3]
“About 8% of GDP is plenty for ‘best known’ care.”[4]
“My personal belief is that waste in health care systems in most developed countries at least surely exceeds 50% of their total resource use. For the USA, with health care costs 40% higher than the next highest nation, the figure is probably even greater.”[5]
“I have said before, and I’ll stand behind it, that the waste level in American medicine approaches 50 percent.”[6]
[1] “Techniques for Assessing the Impact of New Technologies in the Neonatal Intensive Care Unit” by Donald Berwick, Respiratory Care June 1986, p. 524
[2] “Techniques for Assessing the Impact of New Technologies in the Neonatal Intensive Care Unit” by Donald Berwick, Respiratory Care June 1986, p. 524
[3] “Cholesterol, Children, and Heart Disease: An Analysis of Alternatives” by Donald Berwick, Shan Cretin, and Emmett Keeler, Pediatrics November 1981, p. 729
[4] “Take Two Policies and Call Me in the Morning” by Donald Berwick, speech to Healthcare Management Association and Massachusetts Hospital Association, October 22, 2008
[5] “Crossing the Boundary: Changing Mental Models in the Service of Improvement” by Donald Berwick, International Journal for Quality in Health Care October 1998, p. 436
[6] “‘A Deficiency of Will and Ambition:’ A Conversation with Donald Berwick” by Robert Galvin, Health Affairs Web Exclusive January 12, 2005, p. W5-8