Sunday, November 14, 2010

What are the plans of Don Berwick's "leaders with plans"?

Dr. Don Berwick,head of the Center for Medicare/Medicaid Services (CMS),has made clear his views on how medical decisions should be made and on what kind of health care system the United states should have.This quote from a book he co-authored with Dr. Troyen Brennan,entitled New Rules leaves little room for ambiguity:

"Today, this isolated relationship[ he is speaking of the physician patient relationship] is no longer tenable or possible… Traditional medical ethics, based on the doctor-patient dyad must be reformulated to fit the new mold of the delivery of health care...Regulation must evolve. Regulating for improved medical care involves designing appropriate rules with authority...Health care is being rationalized through critical pathways and guidelines. The
primary function of regulation in health care, especially as it affects the quality of medical care, is to constrain decentralized individualized decision making.

Berwick in a laudatory address to the British NHS said that we need "leaders with plans" to design and reform the U.S. health care system. He said that"excellent health care is by definition redistribution". See here for a portion of speech praising the British NHS for in which the "redistribution " quote appears.

A likely candidate for such a leader with plans is Dr. Robert A .Berenson.

I first became aware of Berenson's ideas in an important and to my mind- startling at the time- commentary in the Annals of Internal Medicine published in 1998. ( M Hall,and R. Berenson, Ethical Practice in Managed Care.A dose of Realism. Annals Internal Medicine 1998, 395-402.) Here is a quote from that article:

We propose that devotion to the best interests of each individual be replaced with an ethic of devotion to the best interests of the group for which the physician is personally responsible.

Berenson and his law professor co-author were proposing a complete revision of the medical ethics that existed from hundreds of years.This fiduciary duty to the individual patient should be replaced by a nebulous co- duty to the collective to which the individual patient belonged. As outrageous as that appeared to someone trained in the traditional medical ethics, an obligation to serve the greater needs of society and to balance that against the individual patient's welfare has appeared to be widely accepted by various medical organizations. See here the New Professionalism as promulgated by the American College of Physicians.

Dr. Berenson's resume includes considerable work in the area of public policy regarding health care and he has served on a number of policy committees for the American College of Physicians. He served in one capacity or another in the Carter and Clinton administrations and was a member of the transition team for President Obama. He held a position with HCFA (April 1998 to October 2000) and according to his resume posted on the website for the ECRI Institute, see here , he was a vice president at the Lewin Group from 1997 -1998 before joining HCFA.

The Lewin group is part of Ingenix which is a subsidiary of United Health Group.That seems to place him at the Lewin Group in the general time frame of the Annals article publication referenced above. It is of interest that the authors' affiliations listed on the article included only a position at Wake Forest Medical School for both Hall and Berenson. ( I could not determine the exact timing of the article as relates to his time with Lewin so at the time of the publication he may well have not been affiliated with Lewin.)He was appointed as a commissioner for MedPac in July 2009 and in July 2010 became a vice-chairman of that organization. The role of MedPac after the-likely-to- be -very- powerful Independent Payment Advisory Board (IPAB), created by PPACA , becomes operational is unclear.

He is clearly a leader and certainly one with ideas and plans. A recent commentary published in the NEJM gives insight to some of his current ideas. In the Perspective section of the July 8,2010 issue of NEJM he submitted a piece entitled "Implementing Health Care Reform-Why Medicare Matters." ( NEJM,vol 363,no.2,p101-103).

While discussing the issue of medical costs and cost controls he talks about the "growing power of [medical service ] providers" (ask most physicians how much market power they have) and since Medicare price controls, already in place now for almost 20 years, won't control total medicare expenditures " we ought to consider setting all payer-rates for providers." He continues "but the country's antigovernment mood renders such a discussion unlikely,at least for now".

The operative words there are "at least for now".

More on that appears in the next commentary in the same issue. ( "The Independent Payment Advisory Board : by Timothy S. Jost, J.D.) He says in part that as long as the gap in reimbursements between private insurers and CMS continues to grow physicians will increasing abandon Medicare. He closes with this:

"In the long run, Congress may not be able to cap Medicare expenditures without addressing private expenditures as well. If the IPAB opens the door to rate setting for all payers,it may well be the most revolutionary innovation of the ACA".

Price controls for private medical care would do what economics 101 says price controls do generally. There will be shortages, decreased quality and black markets and other methods to evade the restraints. We have seen the first two in the price controls for Medicare/Medicaid.

I wonder which is worse- a medical leader recommending price controls out of ignorance of basic economics or being aware of the likely outcomes and make that recommendation anyway?

4 comments:

drsam said...

Scary People. The ship is going down and the sharks are circling.

Andrew_M_Garland said...

The mandate for the FDA is that drugs must be tested for both safety and effectiveness. It has complete control over drug development, a complete monopoly. The rationale is that even trained doctors might miss some slight negative side effects of a drug, causing unseen thousands of deaths and disabilities. The FDA takes its time and imposes immense costs (say $800 million per drug developed) to avoid this. This delay and cost has been criticized as itself leading to avoidable death. Still, the government plods on, saying "better safe than sorry".

Compare this to the sweeping experiment that Berwick and his friends are imposing on our society. They have no more than theoretical expectations. If their plan doesn't work, or has bad side effects, they will fiddle with it, and fiddle with our lives, until they get it right, someday. They are stepping into the relationships between doctors and their patients worked out over hundreds and thousands of of years. Still, they think they will impose a new and better order.

They are administering their version of a drug to society. By their own rationale, they must be stopped unless and until they have proven safety and effectiveness.

EasyOpinions

Glenn Laffel, MD, PhD said...

It's hard to follow this post, which attempts to link short excerpts, no doubt taken out-of-context, from 3 different people over a 12-year period.

But if the general gist is that doctors owe no fiduciary responsibility to "the commons" and should be free to provide care without regard to its costs, then I completely disagree.

There simply isn't enough money out there to pay for indiscriminate decisions made by physicians or for unproven or non-efficacious technologies.

And if you're argument boils down to a call for "live-free-or-die, physician's version," then my question for you boils down to "who the heck is going to pay for all this individual freedom?"

You,the author perhaps?

james gaulte said...

Dr, Laffel,

Thank you for your comments.

I reject your accusation of my quotes from Drs Berwick and Berenson being "out of context". The general meaning of out of context is that a passage is taken from the surrounding text so as to distort its intended meaning.

I understand you have worked with Dr. Berwick and I would imagine you have more insight into his thinking that I do not.So,I would welcome your submitting other quotes from that book or other published material that would refute what seems to be the obvious meaning of that quote namely that the classic physician-patient relationship must be changed.Without that type of evidence your accusation seems little more than a gratuitous assertion.

Similarly the quote from Dr. Berenson's Annals article accurately captures the essential message of that commentary.If you have reason to believe that was not what he meant I would welcome evidence to that point.

Finally, Berenson's comment regarding setting all payer-rates could seem to mean little else than the obvious.

I imagine we are quite a distant apart in regard our views regarding the relationship between the individual and the collective which is all well and good. However, one purpose of the entry was to call attention to the views of some of the current leaders in government health care policy and I believe I reported that accurately.

James Gaulte