Donald Berwick and Reducing Health Care Costs
Writing in the Boston Globe this morning, former CMS Administrator Dr. Donald Berwick opined on various ways to control health costs. He endorsed proposals to cap health spending such that health care would grow more slowly than the economy – a growth rate even lower than that under Obamacare, and lower than the House Republican plan he has attacked. Berwick claimed that both slower growth in costs and achieving universal coverage could easily be achieved by eliminating inefficiencies in the system: “It makes no sense to say we cannot afford to make health care a human right without rationing. Don’t cut care. Cut waste.”
Cutting waste in health care is all well and good. However, Dr. Berwick’s prior writings make clear where and how he wants to reduce “waste” – by having bureaucrats limit access to patient treatments:
“As many as 80 percent of hysterectomies are scientifically unnecessary. So are more than a quarter of the drugs used for ear infections, most of the ultrasound tests done in normal pregnancies, and almost half of the cesarean sections in the United States. Isn’t this, with all due respect, some form of assault and battery, however unintended?”1
“One over-demanded service is prevention: annual physicals, screening tests, and other measures that supposedly help catch diseases early.”2
“Aim 10: Reduce the total supply of high-technology medical and surgical care and consolidate high-technology services into regional and community-wide centers…Most metropolitan areas in the United States should reduce the number of centers engaging in cardiac surgery, high-risk obstetrics, neonatal intensive care, organ transplantation, tertiary cancer care, high-level trauma care, and high-technology imaging.”3
“Most people who have serious pain do not need advanced methods; they just need the morphine and counseling that have been available for centuries.”4
“Are routine colonoscopies a social good? What about routine pap smears? Routine smoking cessation counseling? Routine well-baby visits?”5
“Neonatal intensive care, like every other part of American medicine, has been swept into the rising tide of concern for health care costs. 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.”6
For Dr. Berwick to claim now that lowering health costs can be accomplished in a pain-free manner by reducing “waste” is to repudiate the vast majority of his writings over the past 30 years, most of which have focused on reducing access to specialized care like cardiac centers, ultrasounds in normal pregnancies, neonatal intensive care units, and many preventive services. There is another way to lower health costs – by empowering patients, not government bureaucrats – but Dr. Berwick has consistently rejected this approach: “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.”7
It is perhaps unsurprising that Dr. Berwick would attempt to re-write history; he apparently would be following President Obama’s lead in that regard. But a selective memory cannot hide the fact that the way liberals would control skyrocketing health costs involves many of the same reductions in access and/or care that Berwick himself previously described.
[1] “Why the Vasa Sank,” speech to 9th annual National Forum on Quality Improvement in Health Care, December 1997, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 129-130
2 “We Can Cut Costs and Improve Care at the Same Time” by Donald Berwick, Medical Economics August 12, 1996, p. 186
3 “Buckling Down to Change,” speech to 5th annual National Forum on Quality Improvement in Health Care, December 1993, in Escape Fire: Designs for the Future of Health Care by Donald Berwick (Jossey-Bass, 2004), pp. 28-29
4 “Reforming Care for Persons Near the End of Life: The Promise of Quality Improvement” by Joanne Lynn, Donald Berwick, et al., Annals of Internal Medicine July 16, 2002, p. E-118
5 “Health Services Research and Quality of Care: Assignments for the 1990s” by Donald Berwick, Medical Care August 1989, pp. 769-770
6 “Techniques for Assessing the Impact of New Technologies in the Neonatal Intensive Care Unit” by Donald Berwick, Respiratory Care June 1986, p. 524
7 “A Transatlantic View of the NHS at 60” by Donald Berwick, speech at NHS Live, July 1, 2008