Mr. Quality Goes to Washington

Don Berwick, whose pioneering ideas about quality and safety are all over the healthcare reform bill, was just tapped by President Obama to head the Centers for Medicare and Medicaid Services. His mission is to translate the new law he helped inspire into practice. But with Republicans, industry lobbyists, and his own bureaucracy so invested in the status quo, what are Berwick’s odds for success?
Aug 01, 2010

It's rare for advocates and other political appointees, once in government, to show leadership—let alone courage—by placing ethics above politics, for example. That's a curiosity, because advocacy itself often requires courage.

Our current president, although elected with the largest majority since Reagan, has shown little taste or talent for politics as contact sport—"No drama Obama." Some left-leaning advocates have been recruited into government, but (as is the tradition) mostly for "deputy" positions. Obama's Cabinet appointments have been, with a few exceptions, seasoned politicians. They play the game.

What makes President Obama's recess appointment in July of Don Berwick as head of the Centers of Medicare and Medicaid Services (CMS) so potentially dramatic is that he made his name as a game changer. The Midwestern son of a small-town doctor, Berwick is a pediatrician and former professor at Harvard's medical school who got bitten by the public health bug. He has spent the past two decades putting the movement for quality and safety in healthcare on the global map. At the same time he has managed to earn the respect not only of his fellow doctors but of competing stakeholders in the hospital, insurance, and pharmaceutical industries, whose cooperation is essential to the success of systemic reform.

The new healthcare law, called the Patient Protection and Affordable Care Act, showcases many of Berwick's own ideas—not least of which is his oft-repeated article of faith that the runaway costs and waste in our fee-for-service system can be cut dramatically without causing a decline in quality. Reform's rollout of supposedly cost-effective, better-coordinated, outcomes-based healthcare is balanced, however unlikely, on this single "more for less" credo: that 32 million more Americans can be covered by public or private insurance even as innovations and efficiencies in delivery and payment—and, of course, sheer cuts in federal spending—"bend the curve" on costs by $455 billion over the next decade.

Somewhat astonishingly, Berwick plans to use a weapon that has long been hiding in plain sight: Big Government. In a 2005 interview in Health Affairs, he argued for freeing CMS from its congressional restraints and pressuring payers and providers to assume a greater share of healthcare's economic risk. "As CMS goes, so goes the system," he said. "CMS needs to continue to develop to be the best possible purchaser of care, on behalf of its beneficiaries. To do that through giving more choice to individuals is a very weak lead. To do it as an aggregate purchaser—demanding performance—is a very strong lead."

Whether Berwick can prevail in disrupting the system at a moment when Congress is partisan to the point of dysfunction is an open question. (Berwick's office refused requests from Pharm Exec for an interview.)

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