Has the healthcare quality movement become too bogged down in measurement? Has the drive to boost the bottom line cost medicine some of its human touch?
No less an authority than Donald Berwick, MD, MPP, the former CMS administrator, thinks the answer to both questions is “yes.” Berwick, who famously coined the term, the “triple aim” to describe the need for healthcare to pursue improved patient experience, better health of populations, and reduced cost of care, called for a “return to purpose” on Wednesday during an address at the Patient-Centered Summit presented by Horizon Blue Cross Blue Shield of New Jersey, held in New Brunswick.
Those on hand got to hear from Don Berwick the policy master, who put a friend’s emergency room bill on the big screen and picked apart the questionable line items, never faulting the young doctor who cared for his friend, but rather the trap of “a system that’s gone off the deep end.”
And there was Don Berwick the pediatrician, whose tenure at Harvard Community Health Plan allowed him to practice with specialists “down the hall” and extra help from social workers. He shared the story of a young patient named Sean, who first came to him as a teenager deeply troubled by a father’s abuse. At one point, Berwick had Sean hospitalized when he became suicidal, and the teen was not happy. But later, the young man thanked Berwick for his intervention. And many years later, Berwick reconnected with the Sean when he was dying of a brain tumor at age 34; despite his troubled start, Sean finished college and had an exemplary career in the military.
This is what medicine is about, Berwick said. “I do remember lots of moments of technical achievement, but there isn’t another moment that overshadows that.”
Moments like those come close to medicine as it was practiced by Berwick’s father, a family practitioner who took care of everyone in a small Connecticut town. That era of healthcare lasted generations, when doctors judged the quality of their own work. Berwick said his father would have been insulted at the idea of being judged by quality metrics—or not being paid for failing to meet one. That era has passed, but there are elements that physicians miss.
Starting in the 1970s, when it became clear there were “enormous, unexplained variations” in both the quality of care and costs, Berwick said, the pendulum began to swing toward measuring all kinds of things. Before the quality care movement, there were glaring inequities based on where patients lived, their social class, or race. Studies of these disparities found that “Injuries and deaths from errors in healthcare made healthcare nothing less than a public health menace,” he said.
In the current era, there have been financial rewards for those who can show progress at things like lowering blood pressure and cholesterol for a group of patients, trimming readmission rates, or cutting back on the number of hospital-acquired infections. If the first era of medicine was about “trusted professionalism,” Berwick said, “Era 2 is about accountability, and scrutiny, and measurement, and incentive, and doubt.”
While the shift has made a difference, “the currency is clear: it’s metrics and money,” he said.
This system of “carrots and sticks,” as Berwick called it, has become too complex. “Measurement should be a servant, not a master,” he said. While reining in healthcare costs is important, “the best strategy for savings money isn’t to work on saving money; it’s to improve the match between the work you do and the need you’re trying to meet,” he said.
The current era has brought medicine from quality control—just fixing what’s broken—to quality improvement, which creates systems for ongoing change. But reaching the stage of quality planning—which calls for innovative leaps—requires radical change, and it doesn’t happen on its own. Quality requires investment, Berwick said, and “a healthy dose of innovation.”
The triple aim, he said, can’t be built on the current system. “You’ve got to have some new stuff.”
Which brings healthcare to what Berwick sees as a coming era, one that combines the professional pride of his father’s generation with the transparency and accountability of more recent times. Berwick calls it the era “of return to purpose.” He spelled out 9 elements:
Avoid excess measurement. Accountability is good, but “this country has gone mad with measurement.”
Abandon “complex incentives.” This is especially important for individual practitioners; Berwick said such programs were not only impractical, but they did not “respect” the physician. This requires trust, he said. “If you trust the motivation of the work force, you can put your carrots and sticks back where they belong,” he said.
Get of the billing “treadmill.” “We’ve got to stop focusing so much on the money,” he said. This will require innovative payment models and greater movement away from fee-for-service. Berwick, who has estimated that up to 30% of healthcare is waste, blasted the use of consultants to “squeeze” every dollar from patients and insurers.
Be part of a team. Berwick said physicians must learn to “give up professional prerogatives at the expense of the whole,” which does not invite disrespect but recognizes that no one today can practice in isolation.
Commit to quality science. This includes embracing healthcare redesign principles. “For modern quality methods to work, you have to use them,” he said.
Promote transparency. Berwick called this “the opposite of secrecy.”
Protect civility. “Everything that is possible begins with civility,” he said.
Believe in the power of the patient. This, he said, is what the term “patient-centered” is about: the transfer of control of care to the people being care for, which Berwick said is distinctly different from giving patients a bigger share of the bill.
Reject greed. Berwick spared no one here—not pharmaceutical companies, not hospitals that he said, “jack up” prices after consolidations, not consultants who promote excessive use of codes to collect extra revenue.
These are challenging times, Berwick said, citing research that shows about half of today’s doctors would not advise a young person to enter the profession. “The pressures are enormous,” and are not helped by the current political climate, he said. “More and more you feel like you’re in a gerbil cage.”
But there are reasons to be optimistic. In a separate interview with The American Journal of Managed Care®,
he discussed how young healthcare professionals are embracing the quality movement through online learning, and how many good examples of healthcare delivery systems exist. “You’ll find gems everywhere,” he said.