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Dr Don Berwick Highlights the Lessons From AF4Q
In a series of video interviews, Donald M. Berwick, MD, MPP, president emeritus and senior fellow of the Institute for Healthcare Improvement, discussed the lessons learned from the Aligning Forces for Quality initiative.
Transcript (slightly modified)
This presidential election season, there have been calls to unravel the Affordable Care Act, or at least parts of it. As with the phrase "all politics is local," are we learning that "all healthcare is local"? What did AF4Q teach about the importance of local dynamics that will allow us to adjust the ACA moving forward?
The Affordable Care Act, which I had a hand in implementing as the head of Medicare and Medicaid, happened in the middle of Aligning Forces for Quality. It was the new game in town.
I personally regard the Affordable Care Act as an immense American achievement. We have 20 million people who have coverage who didn’t have it before. The Affordable Care Act gave us a lot of tools for clarifying purpose in healthcare—moving us toward value-based payment, moving us toward transparency, moving us toward quality as a focus.
It’s a very good step, but as Aligning Forces for Quality discovered, changing the mindset and the investments of a $3 trillion industry is really hard. I personally think Aligning Forces for Quality had the right theory, which is this is more likely to happen at the local level than at the national level.
The national statutory and regulatory environment sets the stage—it’s very important how CMS pays for care. But unless the agenda—better health, better care, lower costs—unless the agenda is owned by communities, variously defined, but owned by relatively self-contained populations who know each other, who have a common stake, it’s really hard to get the changes made.
And it’s hard to make them customized. Federal policy is a very blunt tool. And the way we need to work on, say, mental health services, or risks for children, or integrating healthcare with housing—all of which are crucial—that’s going to look very different in downtown Boston, in rural Alabama, or on the coast of Oregon. I trust local initiatives.
The work of Elinor Ostrom, which I became a student of, is very key here. Professor Ostrom was the first woman to win the Nobel Prize in Economics. Her work was on managing the commons. The commons means the resource we all have access to—a fishery, a forest maybe—but that we can destroy if we each act in our individual self-interest. Until her work, it was taken as inevitable that there was a tragedy of the commons—that everyone would take everything they could get, and the commons would get destroyed, no more fish, nor more forest.
What Ostrom discovered is that’s not true. There are many communities that have something in common that they manage well. They do it with a series of sociologic circumstances, rules, habits, structures, that allow them to act as a cooperative force in their own self-interest. We need that in healthcare. Healthcare uses the commons. It’s the commons of the resources we pool … that are taken from somewhere else. It’s really hard to get that consciousness of what we share, at a national level, in a nation of 320 million people.
But when you go to a town or a city and say, “We are in this together. What healthcare takes, schools don’t get. Your health affects my well-being.” We get a chance of acting together—at aligning. That pushes me much more toward local activity, as AF4Q tried to do.