Must Reading: Berwick's Reply
In a talk at the Institute for Healthcare Improvement annual forum this week, Don Berwick encapsulated his wisdom of how health care change can happen, his rage at the politics and cynicism that accompanied his work at CMS, and his optimism for a more humane and efficient health care system. I'd strongly urge everyone to read the entire speech.
It's so hard to pick out the highlights, but here are some excerpts:
Inscribed on the wall of the great hall at the entrance to the Hubert Humphrey Building, the HHS Headquarters in Washington where my office was, is a quotation from Senator Humphrey at the building’s dedication ceremony on November 4, 1977. It says: "The moral test of government is how it treats those who are in the dawn of life, the children; those who are in the twilight of life, the aged; and those in the shadows of life, the sick, the needy and the handicapped." I believe that. Indeed, I think that Senator Humphrey described the moral test, not just of government, but of a nation. This is a time of great strain in America; uncertainty abounds. With uncertainty comes fear, and with fear comes withdrawal. We can climb into our bunkers, each separately, and bar the door. But, remember, millions of Americans don’t have a bunker to climb into – they have no place to hide. For many of them, indeed, the crisis of economic security that we all dread now is no crisis at all – it is their status quo. The Great Recession is just their normal life.
Cynicism diverts energy from the great moral test. It toys with deception, and deception destroys. Let me give you an example: the outrageous rhetoric about “death panels” – the claim, nonsense, fabricated out of nothing but fear and lies, that some plot is afoot to, literally, kill patients under the guise of end-of-life care. That is hogwash. It is purveyed by cynics; it employs deception; and it destroys hope. It is beyond cruelty to have subjected our elders, especially, to groundless fear in the pure service of political agendas.
If you really want to talk about “death panels,” let’s think about what happens if we cut back programs of needed, life-saving care for Medicaid beneficiaries and other poor people in America.
What happens in a nation willing to say a senior citizen of marginal income, “I am sorry you cannot afford your medicines, but you are on your own?” What happens if we choose to defund our nation’s investments in preventive medicine and community health, condemning a generation to avoidable risks and unseen toxins? Maybe a real death panel is a group of people who tell health care insurers that is it OK to take insurance away from people because they are sick or are at risk for becoming sick.
Enough of “death panels”! How about all of us – all of us in America – becoming a life panel, unwilling to rest easy, in what is still the wealthiest nation on earth, while a single person within our borders lacks access to the health care they need as a basic human right? Now, that is a conversation worth having.
And, while we are at it, what about “rationing?” The distorted and demagogic use of that term is another travesty in our public debate. In some way, the whole idea of improvement – the whole, wonderful idea that brings us –thousands – together this very afternoon – is that rationing – denying care to anyone who needs it is not necessary. That is, it is not necessary if, and only if, we work tirelessly and always to improve the way we try to meet that need.
The true rationers are those who impede improvement, who stand in the way of change, and who thereby force choices that we can avoid through better care. It boggles my mind that the same people who cry “foul” about rationing an instant later argue to reduce health care benefits for the needy, to defund crucial programs of care and prevention, and to shift thousands of dollars of annual costs to people – elders, the poor, the disabled – who are least able to bear them. When the 17 million American children who live in poverty cannot get the immunizations and blood tests they need, that is rationing. When disabled Americans lack the help to keep them out of institutions and in their homes and living independently, that is rationing. When tens of thousands of Medicaid beneficiaries are thrown out of coverage, and when millions of Seniors are threatened with the withdrawal of preventive care or cannot afford their medications, and when every single one of us lives under the sword of Damocles that, if we get sick, we lose health insurance, that is rationing. And it is beneath us as a great nation to allow that to happen.
And that brings me to the opportunity we now have and a duty. A moral duty: to rescue American health care the only way it can be rescued – by improving it.
I have never seen, nor had I dared hope to see, an era in American health care when that is more possible than this very moment. The signs are everywhere. In the past two years, major hospital systems are asking at last how they can coordinate care. Specialty societies are coalescing around plans for more evidence-based care, the use of clinical registries, serious recertification, and reduction of overuse of unhelpful care. The patient safety movement is maturing, with numerous national efforts to bring excellence to scale, including the billion-dollar Partnership for Patients that we launched in HHS. Insurers are experimenting with much more integrated payment models, of which Accountable Care Organizations are only one breed. Transparency is, I believe and hope, about to leap forward. Patients’ and consumers’ groups are more active and more sophisticated, and they are gaining the footholds they need in governance. Employer groups and labor unions are uniting in their demands. And states are on the move – states like Oregon, Arkansas, and Massachusetts – where courageous and visionary governors – like John Kitzhaber, Mike Beebe, and Deval Patrick – are catalyzing transformation.
I apologize for the length of the excerpt, but this extract actually leaves out some of the best stuff. Read the speech.