Tuesday, July 30, 2013

Opinionated Predictions about Berwick’s Eleven Monsters
What a chimera is man! What a monster, what a chaos, what a contradiction, what a progidy! Judge of all things, feeble earthworm, depository of truth, of uncertainty and errors, the glory and shame of the universe.
Blaise Pascal (1623-1662), Lettres Provincciales (1656-1657)

Have you noticed is one man's "achievement, " is  another man’s “monstrosity” or “monster”? Such is the case with Obamacare,  its proponents and opponents.   

In one of my blog posts,  I characterized Obamacare as a cookie monster.  I closed with this paragraph;
“What a cookie monster is health reform! It is like a big baby- an alimentary canal with a huge and growing appetite at one end and no end in sight at the other. It keeps saying ,”Me want cookies!” The trouble is: its cookies are your cookies too.”
Donald Berwick, MD,  Obama’s first CMS Administrator,   founder of Institute for Healthcare Improvement,  now candidate for Massachusetts Governor,  and sweet voice of reason for top-down government reform and patient safety,  has his own set of 11 "monsters" facing the hospital industry.

He says these monsters can be conquered and brought into the hospital corral.

Here’s how to bring these monsters to bay.

1.      Instill confidence in science as a basis for action. Doctors and hospitals have triumphed in connecting medical decisions to science, and treat patients "according to facts, not according to myths or habits…But it's an incomplete triumph because we don't do it…We continue to allow quite senseless unscientific variation in practice to masquerade as autonomy."

Prediction – This isn’t going to happen on grand scale.  Patients have more confidence in their own judgment and that of their physician than in science, as set forth in government guidelines.

2. Use our global brains. While at CMS, Berwick says, he was told to never mention another country. "If you do, you'll take a cheap, demagogic shot from someone who questions your loyalty or says you're a socialist"

Prediction -   Americans are more likely to listen to their own healers and to adopt their own solutions, rather than mimic other country’s systems and solutions. Policy makers may think “global’ but they act “local.”

3.      Learn from large systems. Somehow, American healthcare's thought leaders must learn how to improve care by experimenting with change in real time clinical environments, not by researching or adopting what happened in the past. But they haven't sufficiently developed, nor have they widely accepted, new investigatory approaches and they will have to get over that.

Prediction - We would be wise to learn from successful clinical experiments from large organizations  But ie hasn’t happened yet, and it may not because, to paraphrase Tip O’Neil, “All health  care is local.”

4.      Name the excess. America spends 40% more on healthcare than it needs to. And that has been pushed by the argument that patients need more. "These claims are goodhearted…But it has been nearly impossible to claim what in our nation has become true, which is enough is enough. The particular monster here is very big and very scary. It's the scariest one."

Prediction -  When you or your relative is  sick, enough is never enough.  The best way to rein this monster is malpractice reform, including loser pays. Unless this is acknowledged by Berwick and Obama, not much will change.

5.      Distinguish profit versus greed. The American healthcare marketplace generates "energizing entrepreneurship and what I'll call proper competition," Berwick said. "But on the other hand, it has cynical, calculating greed in it. And we do not have methods in public policy or in private to tell the difference between entrepreneurship and greed and act on it."

Prediction -  As long as Obama and people like Berwick preach the gospel of entrepreneurship as equivalent to greed,  innovation will be stunted because “profit” is necessary for disruptive  innovations to occur.

6.. Resist innovations that don't help. At a major convention last year, Berwick was escorted through an exhibit hall with 6,000 vendors, one for each of the 6,000 participants. "There was fiber optic this and robotic that, ceramic this, and disposable everything. And I am absolutely sure that somewhere in the acreage of innovation there was something that could help patients that was definitely worth the money.

Prediction -  This is not helpful.  How do you know something will help unless you try it and it fails.   I predict government will be unable to stifle innovation through punitive regulations, as abandonment of the he medical device tax will show.

7. Expand roles and scopes of practice for non-physicians. "We need to support new models of care that provide expanded roles for non-physicians." However, he says, the legacy payment systems don't encourage these changes. We need help from the (professional) guilds, not their opposition," but he said, many "are fighting the change."

Prediction:  This is already happening , but it is a state-by-state process.   It depends not only on physician acceptance but public acceptance.

8. Defend the poor. This monster, Berwick said, is causing him to lose sleep because the nation fails to regard healthcare as a human right. "The social safety net is vulnerable and the will to protect" social services for the poor "needs constant reinforcement that government can't provide without hospitals' support.

Prediction – This is classic liberal position that somehow the rest of us are against the poor.  In the case of Medicaid, the truth is that the states say they handle Medicaid  better than the feds without going broke.

9. Palliative and end of life care. Berwick blasted what he called "cruel rhetoric" that equated sensible discussion of advance directives and preferences with "death panels." "But the rule in Washington favors never ever mentioning end-of-life or palliative care, or advance directives. Not in government. That is a tragic silence and it has to stop."

Prediction – This is overstated.   The hospice movement will continue to grow, and so will palliative care.  To say otherwise is its own form of “cruel rhetoric.”    No one has a monopoly on compassion.

10. Create Authentic Prevention "Hospitals cure disease but they do not prevent it. And they can not prevent it," because they aren't set up to do that today. "Prevention doesn't have any cathedrals. The result is continuing misallocation of effort.”

Prevention -  Berwick is entitled to his opinion.  Due in no small part to his efforts,  hospitals are organizing to prevent infections, falls, and drug mishaps,

11. Creating Transition Models Berwick referred to Alaska's Southcentral Foundation "Nuka System of Care," a project that won the Baldridge award for its success in emptying hospitals and decreasing the need for specialty care, as a care transition model monster that is scaring hospitals.

Prediction -  I am all for creating “Transitional Models”.  Nuka is a model that  may work in the wilds of specialty-short Alaska, but  will fall short in urban and suburban continental America.

Berwick’s monsters are hardly monsters.   His monsters are  human beings under sickness and economic stress.  Hospitals and doctors are like most of us:  They want to pay their bills and creditors while doing the best they can under present medical-legal, financial, and regulatory circumstances. 

 Here is one’s reader comment on the 11 monsters,

Dr. Berwick somehow forgot the number one monster that is threatening our healthcare system. That is a bloated, overreaching, hyper-political Federal government, populated by holier-than-thou political apparatchiks like himself…. Dr. Berwick sees everything through the eyes of government. In one breath, he says we must "defend the poor" by which I assume he means bankrupting the taxpayers through ever higher Medicaid expenditures, but in the next breath he decries end-of-life care, because it costs the government too much.”

Tweet:   Dr. Donald Berwick has identified 11 “monsters” bedeviling American hospitals, but they may be  more likely creatures of human nature.

Source:  Cheryl Clark,  “Berwick Names 11 Monsters Facing Hospital Industry,” Healtheaders Media,  July 29, 2013

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