Question: How do you know Don Berwick?
Jim Nathan: He founded and directed the Institute for Healthcare Improvement and for a decade, Lee Memorial has been participating in IHI initiatives, such as successfully reducing ICU infections. I first met him in 1997 and have spoken with him maybe four or five times since. A few years ago, he called me up and told me how proud he was of our organization because of the things we were working on. That meant a lot to me. I’ve had no discussions with him since he was nominated.
Q: What are his strengths?
JN: Providers of care know he understands our business. Quite often, someone comes into CMS who only sees it as an opportunity to cut costs. He understands that that in order to drive down costs, changes have to occur in the way healthcare is provided. It can’t just be slash and burn. There are legitimate ways to take costs out of the system through “process change,” instead of just ratcheting down costs. Don Berwick understands this.
Q: Do you think he is a good leader?
JN: He has the ability to inspire physicians and other clinicians to innovate and share. He gets his message across not because of any particular charisma, but because it’s hard to argue against what he says. He is well known in healthcare circles and can use his position to drive change faster.
Q: Why do you think he took the job?
JN: I think he was attracted by the ability to enact change through the most significant payor in healthcare. When the opportunity presented itself, he had to say, “If this is what I believe, I need to do it.” He would not have taken this job if he did not think he could make a difference.
Q: What challenges does he face?
JN: Dr. Berwick will be facing a complex bureaucracy, constant political gridlock, a Medicare funding mechanism that is rapidly headed toward bankruptcy and fear of unfunded mandates. In the best of times, any of these would be monstrous challenges.
Q: Do you think he can withstand political challenges?
JN: The healthcare community tends to see through rhetoric such as warning about “death panels,” but politically it is going to be challenging for him. It depends on much of his time has to be taken up with just defending himself. The political climate in Washington is all about “if you lose, I win.”
Q: Do you think he is good fit for the healthcare reform law he’ll implement?
JN: Yes, in the sense that the law requires teamwork, collaboration and evidence-based medicine. But it’s easier to say that than to put that into reality. He’s dealing with a massive, complex bureaucracy. How much of his time will he have to spend just defending the changes rather than leading them?
The healthcare reform law is still very poorly defined. For example, I have a lot of concerns about accountable care organizations. How do you include pre- and post-hospital care? How do you divvy up? How do you bring in disparate players? Who leads the ACO? ACOs appear to put 100 percent of risk on hospitals and nothing on doctors. There are conflicting incentives – DRGs for hospitals while physicians are paid on how many visits they have. Even with a healthcare system that has employed physicians, most practices function the same way as before they became employees.
Q: At IHI, Dr. Berwick has had great success in changing behaviors in healthcare. Will he be able to apply that approach to the whole nation?
JN: He will be taking shared learnings and will try to speed up the rate of change, which is basically what he did at IHI. But even at IHI he was frustrated. It takes time to make changes of this scope. He will have compelling monetary incentives at CMS, but can even these incentives change behavior fast enough? It’s hard enough to take a learning from one location and try to transfer it to another location. He’s leading a massive, complex bureaucracy.
He needs to satisfy the various players before everything blows up. Washington has only a certain amount of patient and we’re running on deficit spending. He is running under a time clock.
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