In our last post, we looked at a hearing (his very first given granted to any branch of Congress) that Dr. Don Berwick gave before the Senate Finance Committee. As most of you will know, Dr. Berwick is the head of the Center for Medicare and Medicaid Services (CMS). He was given a recess appointment by President Obama, and had never had to undergo any sort of questioning from Congress previously. In our previous post we examined just two questions from Senator Chuck Grassley (and the answers from Dr. Berwick) that seemed to be representative of level of detail and candor that characterized the entire hearing. However there is one more question that we really should have included in our write-up. This has to do with a question that Senator Ron Wyden (D-OR) asked about rationing healthcare goods and services and the provision of curative treatment to hospice patients:
Wyden: “Dr. Berwick, you cannot find a more important issue in healthcare than end-of-life care. And the approach that I’ve supported is the opposite of rationing. For example, right now, traditionally, patients have had to give up the prospect of curative care in order to get the hospice benefit. I don’t think that’s right. I think that they ought to have all of the choices. And I wrote a provision that’s in the bill that begins the program that for the first time would give patients the right to get both the hospice program and curative care. So we start two principles: empowering patients to make choices and making sure they have all the options. Hospice care. Curative care. All of the options. Are those the kinds of principles that you believe would really enhance quality of life in this area of end-of-life healthcare?”
Berwick: “First thanks for your leadership on that Senator Wyden and some of the other important issues – I’m very grateful for it. My principle is that every person in America, certainly every beneficiary of Medicare and Medicaid should be able to get all the care they want and need, when and how they want and need it. If someone in hospice care also needs and wants curative care at the same time, I’m completely in agreement with you. As a physician I am. When I saw patients my question always was what care does that patient want and need and how will I get if for them? And in this particular case of being able to offer curative therapy to patients who are in hospice care, that sounds totally consistent with that idea.”
This answer is, or at least should be, troubling on many levels.
Level number one. If this really is the principle by which Dr. Berwick expects to govern Medicare and Medicaid, then the good doctor is either delusional or he has not the slightest grasp of economics. In the real world, resources are limited, while the wants and desires of people are infinite. It is therefore economically impossible for Medicare, Medicaid or any other health insurer to provide all of the care anyone might want or need whenever they might want to need it.
One might as well govern based upon the principles of world harmony, universal kindness and perfect justice, knowing that if we would just accomplish these three things everything will work out just fine.
Of course no reasonable person really supposes that Dr. Berwick is delusional or an economic ignoramus. It is quite clear that the current head of CMS has a well-developed appreciation for our inability to provide everything for everyone. How do we know? He’s said so in this June 2009 interview:
Reporter: “Critics of [comparative effectiveness research] have said that it will lead to the rationing of healthcare.”
Dr. Berwick: “We can make a sensible social decision and say, “Well, at this point, to have access to a particular additional benefit [new drug or medical intervention] is so expensive that our taxpayers have better use for those funds.” We make those decisions all the time. The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open. And right now, we are doing it blindly.”
Which leads us to a second level of concern about Dr. Berwick’s comments to Senator Wyden. If he’s not stupid or delusional, then is he, for lack of a more honest word, a liar?
Now don’t get us wrong. There are many people who lie in public life, and many of them are otherwise perfectly good people. But Dr. Berwick is a special case. He now controls roughly 21% of the federal budget – a whopping $753 billion in 2010. That’s more than we spend on defense (about $715 billion), Social Security ($708 billion), or interest on the national debt ($209 billion). Our healthcare system is in serious trouble – in large part because our political leaders have previously been ignorant, dishonest or both. It is, for example, disingenuous to claim that more government regulation and price controls will lead to an efficient healthcare system when they have failed to do so over the past 40 years. Yet this is what the American people have been told time and again, beginning with government price controls in the 1970s, through the development and implementation of the RBRVS payment system in the 1980s, through the HMO fad of the 1990s and right up through the present day. In a country with serious and unsustainable financial problems, the baby boomers growing up and serious problems in the way in which our healthcare system delivers and pays for care, we can no longer afford to place liars in charge. Let’s be clear – when it comes to medical care of any ilk, lying can and does routinely kill people – directly and indirectly. Lie to someone about a lab results, and patients can easily die. Lie about the benefits of a drug, and patients can easily die. Lie about the ways in which healthcare dollars can or should be used most efficiently, and people will die. If Dr. Berwick is, in fact, either a liar or in the habit of deceiving himself and/or others, then he doesn’t belong in the position to which he’s been appointed. It’s a serious matter. The stakes are simply too high.
But maybe Dr. Berwick isn’t ignorant or a liar. Maybe there is a third possibility. Perhaps Dr. Berwick does know that rationing of some type is needed, and it is just his personal principle that every person in America should all of the care that they need and want when they need and want it. In other words, maybe he doesn’t really intend to apply his own principles when it comes to managing Medicare, Medicaid and the rest of America’s healthcare system. Maybe he’ll just check his principles at the door when it comes to tough decisions. How might that work? A rationing decision arises. Despite his own misgivings, Dr. Berwick weighs the competing needs of taxpayers, patients, providers and the government and makes the decision that somehow, in some fashion, rations care in such as way as to maximize human, medical and economic benefit. He knows that everyone in America is depending upon Medicare as the healthcare insurance that they will use in their old age. He himself will depend upon Medicare to keep himself healthy and fit in his twilight years. And if he must sacrifice his own personal principles to ensure its solvency and effectiveness, then that’s what he’ll do. Thank goodness all of his own incentives are aligned in the right direction.
Except that Dr. Berwick will apparently never, ever, use Medicare or Medicaid himself. He will be exempted from the decisions that he makes, the rationing that he implements and the payment mechanisms that he sets in place. As has been reported elsewhere:
“Which brings us back to the good doctor’s personal coverage. Before Obama picked him to be our new Medicare czar, Berwick was the chief executive officer of an outfit he founded called the Institute for Health Care Improvement (IHI). IHI bills itself as a nonprofit charity, but it seems to do an awful lot of work on behalf of for-profit entities. As CEO of this enterprise, Dr. Berwick earned a cool $2.3 million in 2008. But, more to the point, IHI will provide him with private health care coverage during his declining years: “The Institute created a postretirement health benefit plan for its chief executive officer (CEO). It provides the CEO and his spouse medical insurance from retirement until death.”
In other words, Dr. Berwick has made sure that he and his wife will never be subjected to the tender mercies of Medicare, the health care program for seniors over which he now has control. Thus, even after he has implemented rationing programs modeled after those of NICE, he won’t have to worry about his wife suffering for lack of drugs deemed too pricey by some obscure comparative effectiveness calculation. You and I, on the other hand, won’t be so lucky once we’re on Medicare. If we contract deadly diseases requiring treatment that costs more than our lives are “worth,” we’re toast. “
When you come right down to it, there is really no charitable, yet logical interpretation that can be placed upon Dr. Berwick’s answer to Senator Wyden; only explanations that hint of ignorance, dishonesty or an abandonment of higher principles. That’s a damned shame. America’s healthcare system needs all of the honesty, integrity and competence it can get right now.