I had the good fortune to flip the radio dial to C-SPAN this morning and hear Dr. Donald Berwick talk about his job as director of the Center for Medicare and Medicaid Services (CMS). Berwick probably won't be confirmed by a Republican Congress, but he is working day by day, and seems to be enjoying every minute of it. He busies himself, re-organizing CMS around three major goals: better care, better health, and lower cost.
Berwick is an optimist. He has 100 percent confidence in the ability of health care reform to achieve success, he feels things are really on track right now in CMS, and he just wants to go faster, get more done before Congress drives him out. He says he's been pleasantly surprised by the competence of the federal work force, its commitment, and its willingness to do new things.
According to Berwick, who began his career as a pediatrician, there are two ways to preserve Medicare and Medicaid. The first, the Paul Ryan way, is to cut services or send individuals out into the market with vouchers.
However, individuals who aren't equipped with either the expertise or the bargaining power of the federal government are likely to find themselves in an inferior position in the insurance market: Berwick estimates that the value of a voucher, over time, might buy as little as 35 percent of the care a senior might need. Some seniors, arguably the most needy, wouldn't be able to afford insurance at all.
Also built into the Ryan plan are gigantic cuts for doctors. Berwick believes most providers want to do the right thing, and holding the sword of Damocles over the heads of physicians doesn't contribute to better care. He'd like to see this fixed once and for all.
Berwick has chosen a different road to saving money: lowering costs by delivering better care. Better care means more emphasis on prevention, fewer hospital infections, fewer re-admissions, and less unnecessary testing.
Berwick contends that as a nation, we face a choice about whether we are willing to improve the entire system or not. We know what to do, but we have to bring excellence to scale. And that is true not only in CMS, but in the private market as well.
We have to improve care so it doesn't keep using scarce resources. When a hospital is able to reduce central venous line infections to zero, as some already have, that's a big saving. The entire health care system can be trained to produce such measurable results.
Hospital-caused infections are expensive to treat and unnecessary. But until now, when those infections went away, the savings didn't go to the hospital.
The Affordable Care Act has medical homes and bundled payments that will allow people who give better care to share in the savings, which Berwick believes can incentivize excellence.
Positive thinker that he is, Berwick was still shocked by the fraud and abuse numbers he confronted once he got inside the agency. An important minority of providers, he admits, cause tens of billions of dollars in losses, by essentially stealing money from taxpayers.
The good news, he says, is that we now know what to do. Once again, it comes down to prevention: screening providers in high risk areas.
What will happen to Medicaid in this time of crisis? Berwick says if Congress leaves Medicare untouched, Medicaid must be cut. The states are partially responsible for Medicaid payments, and most are under terrible budgetary pressure.
The same improvements are needed in Medicaid as in Medicare: stress prevention, reduce infections, cut down on hospital readmissions. And 40 percent of Medicaid's budget goes to people who are dual eligibles: people with chronic conditions and behavioral health issues who receive benefits from both Medicaid and Medicare.
Here again, Berwick is looking for efficiencies that will allow costs to fall. Although he's a realist, he looks at health care from the perspective of the beneficiaries and their needs, rather than from the payer's vantage point. That puts him at odds with both Congress and the states, both of whom are eying their budgets with despair and desperation, and have focused on CMS as the battleground on which the budget war will be fought.
Berwick, already mortally wounded by the refusal of the Senate to confirm him, operating day by day on a recess appointment, can only hope he gets enough done to prove his point before he's expelled by the toxic politics of Washington.