In a previous issue of our journal, we interviewed Don Berwick, former Administrator of the Centers for Medicare and Medicaid Services (2010-2011). We have chosen to reproduce this interview as it holds important messages for all health care professionals who are interested in improving health care delivery. A link to the interview published in our journal can be found here.
Khin-Kyemon Aung: What types of challenges do you anticipate will emerge in the coming years as the Affordable Care Act is implemented, and what do you think leaders in the field should do to plan for these challenges?
Don Berwick: The ACA is just one component of the larger social enterprise to make American health care both universal and sustainable. The legislation brings new frameworks in payment, insurance, medical regulation, innovation, service delivery, and quality improvement. It encompasses a collection of useful changes to support health care delivery. But because these frameworks are new, health care delivery as we know it will have to change radically. Many of the business models health care has been using for half a century that reward high volume care—how much you do rather than how well you do—will have to be modified. This is one major challenge in adopting health care reform. To deliver patient-centered care, to realize that often doing less rather than more may be better for the patient, the infrastructure of health care and the practice culture will both need to change. We can do it, but it will be a difficult transition.
These challenges will demand the best from leaders. Leaders need to explain best practices, to support the search for better ideas, and to help the workforce transition from old models to the new. Health care reform is encumbered at this particular time by a lot of distance and even rancor across political divides. People who in the past would have been able to work out agreements lack formats for dialog. This divide is very costly. It leads to misinformation and confusion in the public and a sense of inconsistency and lack of direction. We need leaders who resist that negative culture and have the courage and conviction to be part of the solution. Leaders always have the job of helping the workforce change its work. They must have a clearheaded understanding of the problems of today and the solutions for tomorrow.
KKA: Throughout your career, you have continually defended the importance of comparative effectiveness research (CER) and evidence-based medicine. First, why do you think CER and evidence-based medicine are so valuable? How satisfied are you with the way CER is being integrated into health care delivery?
DB: Our main job in health care is to do what helps the patient. It is important that we both assure that people get all the care that can help them, and assure them that they are not subjected to the risks and costs of things that don’t help them. In order for this to work, we need to have the data that tells us what does help a patient and what does not. CER is valuable because it helps us make these determinations.
Right now the whole field is mired too much in political drama, in which people would rather use rhetoric than logic, misleading themselves and the public to think that basing care in science is harmful. This is unfortunate, but I think change is coming. Integration of CER into health care delivery is surely better than it was, but large information gaps remain about how to best provide quality care than volume of care.
THE IHI & IMPROVING HEALTH CARE
KKA: The Institute for Healthcare Improvement (IHI) is spearheading efforts to optimize health system performance and provide better health and better healthcare at lower costs through the IHI Triple Aim Initiative. How close do you think the United States is to achieving the Triple Aim?
DB: First I want to say that IHI has been doing a great job and I am very proud of the organization – IHI is a valuable force for improvement, one of the best in the world, and IHI deserves credit for a lot of helpful changes. The Triple Aim is especially ambitious. Right now, the good news is that we have people who believe in it and are talking about it. People are starting to believe that it is possible to improve health and health care while simultaneously lowering costs. Unfortunately, we still have a very long way to go. We are still moving very slowly but I think we are headed in the right direction.
KKA: Currently, the health care system is in a state of great flux as the country moves towards payment reform, health IT adoption, patient-centered care, and improved quality and access to affordable care. Which efforts do you think should be prioritized to most effectively improve health care?
DB: It is difficult to think of prioritizing just one effort. The best changes are synergistic; each is a piece of the greater whole, aimed at integrated, patient-centered care.
Let me highlight two pieces. First, we need to keep the needs of the patient firmly in the foreground. Sometimes that clarity is hard to maintain. One way to do that is to give more power and voice to patients and their loved ones. They ought to have control over their own care. They will help us stay aimed in the right direction.
Second, we need to improve professional education so that young people are prepared to engage in the changing health care system. Currently, we train young people entering the health care profession separately in their disciplines, and we don’t help them enough to know how best to work together across boundaries. In professional schools, we need to focus on topics like quality improvement, measurement, patient-centeredness, coordination, teamwork, and an understanding of waste. If we had a health care workforce better attuned to these principles, our system that would be more effective. Currently there are some efforts underway to achieve this. The most thrilling to me IHI’s Open School for Health Professions, which has over 135,000 students and 550 chapters in almost 60 nations across the world studying, working, and learning together. Even if schools are not ready to offer integrated curricula, I think the students are ready to collaborate. The students give me hope; the potential is amazing. We could use even more momentum on this front.
Donald M. Berwick is a leading advocate for high-quality, affordable health care in the United States and, for nearly 20 years, was President and CEO of the Institute for Healthcare Improvement. He has also served as the Administrator of the Centers for Medicare & Medicaid Services, Clinical Professor of Pediatrics and Health Care Policy at Harvard Medical School, and Professor in the Department of Health Policy and Management at the Harvard School of Public Health. He received his undergraduate, medical and public policy degrees at Harvard University and completed his residency training in pediatrics at Children’s Hospital Boston.