Dr. Donald Berwick is a natural to help lead American health care reform. In addition, his appointment by President Obama to be the administrator of the Centers for Medicare & Medicaid Services signals a new role for doctors. Dr. Berwick is president of the Institute for Health Care Improvement (IHI) and is renowned for his experience in changing health care practices for the better. He is a champion of health care improvement based on changes by professionals who have the knowledge to make it happen. CMS is the agency responsible for Medicare, and he is exactly the leader we need to rescue Medicare. But as a doctor, I believe the opportunity now for doctors to help with reform goes beyond that.
Incomplete but promising, the Patient Protection and Affordable Care Act (ACA) sets the stage for important health care reform. And it does so with a flexible structure that is perhaps unprecedented in U.S. law. It is "unprescriptive," leaving details open to be decided by doctors. In this, Congress has said just the right thing to American Medicine: figure it out and get going with it.
Quality is the key. We need to focus on quality care based on clinical criteria, not based on insurance "market" forces. This is important for every patient, rich or poor. But improved quality also makes all other aspects of reform possible. Improved quality decreases costs. Cost control removes the biggest objection against expanding coverage.
Although we often offer excellent quality of care in the U.S., it is side-by-side with confusion and mistakes based on a profusion of jumbled guidelines. Misaligned incentives support unnecessary care, which is increasing the risks of care and costing us dearly. Too often, ineffective hospitalization and faulty communication result in unneeded, costly readmission. We are left guessing about what is happening in a hospital or a doctors' office that could be improved with authoritative input. Much of this is no mystery. Doctors try to maintain their dedication to excellence but we are only human. The system has overwhelmed us with red tape and misaligned incentives. The remedy is to put doctors in charge of national treatment standards.
Under Dr. Berwick's leadership, CMS can organize doctors, nurses, and hospitals to address our health care cost and quality problems. His Institute has shown that teams of collaborating professionals using repeated 'Plan, Do, Study, Act' cycles and frequent exchanges of findings can quickly make health care better. We can improve patient care and control costs through improved communications, authoritative guidelines, and teams to extend and support the doctors' work.
An example is electronic health records. Rapid deployment of a user-friendly (doctor-friendly) seamless national record system that sends current data on diagnosis and treatment to CMS, and provides protocols to caregivers about common well-established routines, will support practice and revolutionize communications among your doctors. It will allow CMS to monitor care and reimbursement more accurately – and with far less paperwork. How about unnecessary care? The law provides for defining what not to do as part of best practices for patient care. And Dr. Berwick's IHI method can help with counseling patients about the benefits of avoiding harmful overutilization.
Does the recess appointment cloud the promise? Don't worry. Medicare has lacked an administrator for four years and is not stable for long. Congress needs his help there. He loves the British NHS? Well, unlike in Britain, the law does not authorize him to cap U.S. health care costs. Importantly, he stands for medical, not government, solutions. He loves affordable quality care for everyone. This is his vision for fixing Medicare. How could Congress have voted against any of that and face their constituents?
Can anyone, even Dr. Berwick, an eminent pediatrician and professor of medicine, get American doctors behind these goals? Of course. He says, "There is so much pent-up need in the health care work-force … to really do better. It's so easy to get there once you decide to." He has proven that hundreds of times.
Yes, the new law leaves reform incomplete. It leaves us relying on insufficiently tamed private health insurance. Coverage to provide health care for all Americans will continue to be sacrificed to the excess administrative costs and profits of the health insurance industry. But it is a start. The ACA will allow us to narrow the gap by improving coverage and quality of care for millions.
Best of all, the dream is now bright on the horizon: a doctor for every family. If doctors get behind effective reform Americans can finally expect this promise to be kept.
James F. Burdick, MD, St. Michaels
The writer is professor of surgery at Johns Hopkins University School of Medicine. He worked as a transplant surgeon and served in the Department of Health and Human Services as director of the Division of Transplantation. He is writing a book detailing his doctors' plan for health reform.