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Why won’t the Senate confirm Donald Berwick?

This is disturbing (from Washington Monthly):

In November 2010, the U.S. Department of Health and Human Services issued a study that covered just the 15 percent of the U.S. population enrolled in Medicare. It found that each month one out of seven Medicare hospital patients is injured—and an estimated 15,000 are killed—by harmful medical practice. Treating the consequences of medical errors cost Medicare a full $324 million in October 2008 alone, or 3.5 percent of all Medicare expenditures for inpatient care.

With so many Medicare patients are dying from potentially avoidable medical errors, we were glad that President Obama used a recess appointment last year to place Donald Berwick as head of Medicare. Berwick has spent his career working to help hospitals improve their quality of care, while reducing infections and errors. He understands the problem, on a deeply personal level:

Well, we were relieved… until we came across this news a few days later:

“The Senate will never vote to confirm Dr. Donald Berwick as CMS administrator”, Sen. Max Baucus (D-Mont.), chairman of the Senate Finance Committee told reporters earlier today. According to Modern HealthCAre, Baucus said that he has discussed Berwick’s nomination with Republican senators and they plan to oppose Berwick under any circumstances.

This is despite the fact that the AARP, three Medicare directors who served under Republican presidents, and plenty of others all support his nomination. What gives?  

The Case for Donald Berwick

The health care industry has already taken some steps to eliminate medical errors. For example, hospitals, according to The Fiscal Times’s Merrill Goozner, have begun “adopting checklists for eliminating hospital-acquired infections and the equivalent of the Toyota manufacturing system for making steady improvements in hospital procedures that can end procedural and medication errors.”

But real reform will require fundamental changes– making hospitals more transparent about best practices, improving the coordination of care among providers, and a payment system that rewards quality of care, not just the quantity.

Probably the best-qualified person in America to lead the health care system toward these changes is Donald Berwick. We’ve written about him before. He’s a professor of both clinical pediatrics at Harvard’s School of Medicine and health policy and management at Harvard’s School of Public Health. And in 1999, he co-founded the organization for which he is most famous (at least in health policy circles): the Institute for Healthcare Improvement.

Patient-Centered Care

How does the Institute propose to improve health care? By improving quality and (finally) putting the patient at the center of the health care system. The organization is known for its 100,000 lives campaign, referring to the nearly 100,000 Americans who are killed every year due to medical error– deaths IHI hopes to prevent.  But when Berwick talks about improving quality, he means more than simply preventing post-operation infections:

“I suggest that we should without equivocation make patient-centeredness a primary quality dimension all its own, even when it does not contribute to the technical safety and effectiveness of care […]

An overarching aim for an ideal practice [is] that its patients would say of it, ‘They give me exactly the help I need and want exactly when I need and want it.”

To that end, here’s a list of reforms he proposes– things both sides of the aisle would agree with:

  1. Hospitals would have no restrictions on visiting — no restrictions of place or time or person, except restrictions chosen by and under the control of each individual patient.
  2. Patients would determine what food they eat and what clothes they wear in hospitals (to the extent that health status allows).
  3. Patients and family members would participate in rounds.
  4. Patients and families would participate in the design of health care processes and services.
  5. Medical records would belong to patients. Clinicians, rather than patients, would need to have permission to gain access to them.
  6. Shared decision-making technologies would be used universally.
  7. Operating room schedules would conform to ideal queuing theory designs aimed at minimizing waiting time, rather than to the convenience of clinicians.
  8. Patients physically capable of self-care would, in all situations, have the option to do it.

That’s what Berwick means by patient-centered care.  If anything, it’s a concept more associated with the right, who talk a lot about “government bureaucrats getting between you and your doctor.” Conservatives should love this guy.

Yet instead, 42 Republican Senators recently signed a letter calling for the removal of Donald Berwick as head of the Centers for Medicare and Medicaid Services.

The Conservative Case for Berwick

Senators opposing Berwick’s nomination point to his admiration for Britain’s health system, calling him, “an expert on rationing.” They cite “controversial” statements he’s made in the past like, “The decision is not whether or not we will ration care, the decision is whether we will ration with our eyes open.’’ Of course, Berwick was simply arguing that the current system of private insurance also rations care– a point that even Republicans agree with.

For example, here’s Congressman Paul Ryan, defending a Republican budget proposal that tackles Medicare spending:

Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?

Berwick would agree with that statement! Ezra Klein lays out the conservative case for his nomination:

On those questions, Berwick is something of a bulwark against the sort of rationing conservatives fear. He wants patients elevated above either government or providers. He wants to start by improving quality so we can get rid of what we don’t want before we’re forced to decide what we truly need. He believes a greater focus on individuals will take the health-care system to a more sustainable place. In general, liberals have opposed consumer-driven medicine, thinking it a way to simply ration by income. Berwick is attempting to rescue it, presenting it instead as a way to create a more humane health-care system.

Instead, Republicans are using Berwick’s nomination as an opportunity to score political points against President Obama:

‘This is not really about Don Berwick,’ John Rother, executive vice president for policy and strategy at the AARP told McClatchy Newspapers. ‘In ordinary times, the nomination of somebody with Don’s record and standing in the field would not be controversial.’ Thomas Scully, who led the CMS under President George W. Bush agrees: ‘He’s universally regarded and a thoughtful guy who is not partisan. I think it’s more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now.’

But the Republicans’ opposition to such an obviously qualified candidate could have consequences beyond this one nomination. Writing for Kaiser Health News, two doctors worry that the attacks on Berwick will keep other qualified people from taking positions in government:

Our worst fear is that the people best-equipped to do these jobs will view Berwick’s predicament and decide: It just isn’t worth it. After all, people at Berwick’s or McClellan’s level can pursue many other lucrative and challenging opportunities that bring a lot less trouble and stress. For government to succeed, we need such experts who can do their work at least somewhat shielded from the immediate partisan fray.

Possibly hoping to avoid that type of outcome, the White House has said that they will not withdraw Berwick’s nomination. He’ll need 60 votes to be confirmed, which means that two of the Republican Senators that signed the letter will have to change their minds. If you feel compelled to help that happen, Maggie Mahar author of Money Driven Medicine, has the list:

Lamar Alexander (R-Tenn.), Kelly Ayotte (R-N.H.), John Barrasso (R-Wyo.), Roy Blunt (R-Mo.), John Boozman (R-Ark.), Richard Burr (R-N.C.), Saxby Chambliss (R-Ga.), Dan Coats (R-Ind.), Tom Coburn (R-Okla.), Thad Cochran (R-Miss.), Bob Corker (R-Tenn.), John Cornyn (R-Texas), Mike Crapo (R-Idaho), Jim DeMint (R-S.C.), John Ensign (R-Nev.), Lindsey Graham (R-S.C.), Chuck Grassley (R-Iowa), John Hoeven (R-N.D.), Kay Bailey Hutchison (R-Texas), Jim Inhofe (R-Okla.), Johnny Isakson (R-Ga), Mike Johanns (R-Neb.), Ron Johnson (R-Wis.), Mark Kirk (R-Ill.), Jon Kyl (R-Ariz.), Mike Lee (R-Utah), Dick Lugar (R-Ind.), John McCain (R-Ariz.), Mitch McConnell (R-Ky.), Jim Moran (R-Kan.), Ron Paul (R-Ky), John Risch (R-Idaho), Pat Roberts (R-Kan.), Marco Rubio (R-Fla.), Jeff Sessions (R-Ala.), Richard Shelby (R-Ala.), John Thune (R-S.D.), Pat Toomey (R-Pa.), David Vitter (R-La.), and Roger Wicker (R-Miss.).

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