Donald M. Berwick, MD, MPP, president emeritus and senior fellow of the Institute for Healthcare Improvement, served as the guest editor for The American Journal of Managed Care's supplement on research emerging from the Aligning Forces for Quality (AF4Q) initiative. In a series of video interviews, he discussed the lessons of AF4Q regarding alignment in the United States healthcare system, consumer engagement in healthcare, and evaluating social experiments on improving healthcare, among other topics.
Transcript (slightly modified) A central problem with the US healthcare system is misalignment: we reward individual acts and not overall acts of wellness. What have we learned about fixing this problem from AF4Q?
We built a healthcare system in fragments, and the fragments are not aligned for what the Institute for Healthcare Improvement calls the triple aim—better care, better health, lower costs.
For example, it makes a lot of sense in society to put efforts into preventing illness, and yet the reward systems for hospitals reward being full. We say we value primary care as a foundation for keeping people healthy and thriving, but money shifts to technocratic care. We say we value mental health, but we don’t support mental health.
And it is very difficult to manage toward health and well-being when things aren’t aligned. That’s the brilliance of Aligning Forces for Quality. It took a number of levers, and it said, “Let’s get all these levers lined up, so that healthcare providers and communities can really work together toward a common aim with that kind of alignment.”
What we learned from Aligning Forces for Quality is that it’s hard—it’s very hard.
Some of what the premises were behind Aligning Forces for Quality, like the importance of transparency, turned out to be hard to execute. We can say we want to be transparent, but that requires consumers and healthcare providers to truly be interested in that. One of the lessons learned is that it’s hard to maintain their attention, and a real commitment.
It was a great effort, to try to get the signals aligned. It taught us how hard it’s going to be get all the forces working in the same direction.
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.
Transcript (slightly modified) What can be done to bring the lessons of AF4Q into the broader debate this election season?
The lessons of AF4Q, they're technically complicated lessons. The papers that are being assembled in this special issue that's reporting out of this, they're brilliant papers. They're going to be landmarks. But they're really specialty oriented.
We really still need a way to help busy laypeople, who have a stake in their communities but have many, many things on their minds, to be able to grasp what it means to align for health. What their responsibility is, how to act cooperatively. That's unsolved. And, indeed, one of the lessons learned in AF4Q is how difficult that is.
The attention of the public is a very limited resource and I'd say the challenge in an election year, and any year, is to bridge between the technical understandings of how we can really achieve better health and the day-to-day mentality of a very busy public. That's unsolved. We're not there yet.
Transcript (slightly modified) AF4Q asked stakeholders to collaborate on solutions, even as some of them—payers—compete within markets. Is it unrealistic to expect certain parts of the system to act more for the public good, especially if they are publicly traded companies?
Fragmentation is our enemy, and we have built a system which rewards individual heroism, particulate organizational success, local profit—whether you’re for-profit or not-for-profit—still making a margin, and it produces uncooperative behaviors.
The biggest challenge in improving American healthcare may be to forge cooperation.
I personally think the emphasis on competition as a tool is in our way. The health of the community is a community good. It’s an asset that we need to understand and work on all together. Is it unrealistic to expect cooperation? Yes, if we’re paying for fragmentation. If our incentives say, in order for you to win someone else has to lose.
But I don’t think that’s inevitable. I think we can, with proper leadership move into a communitarian view that says healthcare can be a win-win in which I don’t have to defeat someone else to be a good contributor to the health of the communities.
I hope we move that way. It’s going to take some policy changes. And probably beyond what AF4Q itself tried to tackle.
Transcript (slightly modified) Is there an upper limit on what we should spend on healthcare to ensure the system remains affordable to most people? If limits are a solution, then who should set them?
We don't really have, that I know of, a pedigree to calculate what the right amount to spend on healthcare is. We know a couple of things. One is that the American healthcare spend is way out of line with other developed nations. I mean frankly, just about double what OECD (Organisation for Economic Co-operation and Development) countries are spending on healthcare without anything like better results. In fact, we're ranked pretty low in outcomes and longevity in the satisfaction of our public with its healthcare.
So we're spending too much in America, I'm pretty convinced. I've personally put a stake in the ground here that we're at 18% of our gross domestic product—I see no reason at all that we couldn't have all the healthcare we want and need without a hint of rationing at, say, 15% of gross domestic product. That's still 3% more than probably the next most expensive nation. That's been my target
There's one other really important idea here, which is relevant to AF4Q—and, by the way, relevant to Robert Wood Johnson's successor focus on a Culture of Health—which is, if you look nation by nation, not just at healthcare spend where we are really excessive, but at the total spend on healthcare and social supports and the investments in affecting determinants of health (housing, transportation, child support, education), if you look at the total spend of health and social services, we're about the same across the developed democracies. The difference in the United States is not that we're spending more total, it's that of the total, so much more is healthcare and so much less is working on determinants of health. And I personally think Robert Wood Johnson Foundation has gone exactly where it needs to go now, focusing on that, saying, "it's a rebalancing job."
So there's Aligning Forces for Quality but there's also rebalancing investments for health. And I think that's really where the action needs to be.
Transcript (slightly modified) AF4Q addressed quality improvement, transparency, and consumer engagement. As you wrote in your editorial, consumer engagement proved more difficult than imagined. What have we learned about the best ways to get consumers to become active participants in their own healthcare?
There are people better than me to opine on what we now know about how to get consumers engaged. I think the findings in AF4Q were pretty consistent, which was: it's really tough.
You know what, as a human being, as a citizen of America, as a busy person, I know what that means. You can tell me to worry about my health and healthcare, but I've got other things to worry about, too, you know, like my kids' well-being and our investments in our future in other domains. I don't have that much of an attention budget for healthcare.
So healthcare is not going to get better by screaming louder than other social enterprises for the attention of the public. It isn't going to work. AF4Q rediscovered that, and I'll tell you, it was really hard as I read these reports to maintain that connection to consumers.
By the way, that was reflected in the work of the healthcare delivery systems. Because of lot of them lost interest in this. They were talking about transparency and engagement and over time, it kind of eroded.
There must be a way to have mature conversations in communities about how to seek community well-being, imagining the kind of place we want to be. I do think with proper leadership we can get there.
But just yelling louder than other sectors and saying, "Hey, everybody, worry about your healthcare, read this report, be active"—we're fooling ourselves.
Transcript (slightly modified) When we evaluate drugs, devices, therapies, we use the randomized controlled trial; but when we evaluate social experiments, like AF4Q and the Center for Medicare and Medicaid Innovation, things are never randomized and there are often changing variables. What do you think is the best way to handle this?
The issue of what constitutes evidence in complex social experiments like AF4Q is a very sticky one and I've been in that arena for a very long time. I have a very strong opinion of this and unfortunately, I think it's not that thoroughly embraced. It's that in the pursuit of understanding of how to get better complex social policies and interactions like AF4Q, the randomized trial has virtually no role whatsoever.
That is a way for learning in very pure environments where there's a pill A and pill B and randomization of the patients to the pills teaches us exactly what we want. That's not how the world works. The world is very complex. Every single site in AF4Q was very different from every other site, and in that complexity lies a tremendous amount of learning and when you treat the randomized controlled trial as the only way to learn, you basically put a blindfold on. And it's time to stop.
The problem is that the randomized trial in its usual form of evaluating, say, clinical procedures, it was a big leap forward. But we over-learned, and I think the evaluation of community became much, much too bonded to that design.
On the happy side, there are methods of learning over time, with measurement, in complex environments that are very instructive—realistic evaluation, in real-time environments. The AF4Q team, by the way, knew that. I think one of the strengths of AF4Q is how open-minded and yet highly disciplined in ethnography and anthropology and time-series measurement that that program was.
My brief is really clear: let's not tie our hands to a single method of evaluation and call it the prince of all methods. It isn't. It's the wrong tool in the complex environments that we need to learn about to make healthcare in communities better.