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Where Have President Obama and Dr. Berwick Gone Wrong?

Stanley Feld M.D.,FACP,MACE

Director of CMS, Dr. Don Berwick, has the same central government control philosophy as President Obama. They have different reasons for central control.

Dr. Berwick is going to feel disappointed and deceived when he fails to effect meaningful change or reduce medical costs. President Obama’s healthcare reform law is going to increase the cost of Medicare and Medicaid, restrict access to care and result in rationing of care.

President Obama wants to increase quality and decrease cost of healthcare with more efficiency. Everyone has the same goal. President Obama is going about it the wrong way

Dr. Berwick has stated that he loves the British National Healthcare System. He was hired as a consultant to that system by Tony Blair. The goal was to modernize Britian’s centralized system. He failed to reduce their costs. Britain is now decentralizing its healthcare system.

Dr. Berwick thinks in systems terms using the concepts of Fredrick Taylor. In a 2009 speech Dr. Berwick said,

“The idea of a system is neither a frill nor a fine point if we are to get reform right,” “System of healthcare lies at the very center of the scientific and political challenges that stand between us and the care we seek. With a proper understanding of systems, authentic health care redesign is feasible and socially productive. Without that understanding, ‘reform’ will likely do more harm than good.”

Our healthcare system does not coordinate care using teams. If they did the patient must be at the center of the team not the government.

All the stakeholders must be members of the team. They all must be accountable to each other. Members include patients, physicians, hospitals, healthcare insurers, and the government. Dr. Berwick is only considering physicians and other healthcare providers. He is giving the healthcare insurance industry a pass. The healthcare insurance industry is the biggest villain in our dysfunctional healthcare system..

Patients and physicians are the most important members of the team. Physicians are the managers, patient are the workers.

In order for a system to work, team members first have to know the elements of the system. The team members should then be provided with incentives so they are motivated to make the system work.

Dr. Berwick is not considering incentives for patients and physicians. He does not believe in the value of the free market. I believe his attitude will be a huge problem in his attempt to convert medical care to Taylor’s principles of scientific management..

I do not doubt his ability to create systems of care. I disagree with his punitive system of fulfilling systems of care. It will not work.

“Health care reform without attention to the nature and nurture of health care as a system is doomed,” Berwick said. “It will at best simply feed the beast, pouring precious resources into the overdevelopment of parts and never attending to the whole — that is care as our patients, their families and their communities .”

Dr. Berwick has criticized physicians care. He does not criticize patients lack of adherence to recommended care or their lack of compliance to healthy lifestyles. There has been little discussion on where money is wasted in the healthcare system. The healthcare insurance industry, hospitals’ or government’s role in the dysfunction of the healthcare system is not being discussed.

His has focused on waste created by the deficiencies in safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. There is no doubt the healthcare system’s needs the scientific management approach in each area. However, this is not where the bulk of the waste is.

“The improvement of health and health care depends on systems thinking and systems redesign,” Berwick said. “ ‘Reform’ without systems thinking isn’t reform at all.”

I agree we need systems of care. This philosophy is expressed in AACE’s System of Intensive Self-Management for Type 2 Diabetes Mellitus. I was the chairman of the task force for these guidelines. I ask develop of system of care for the diagnosis and treatment of osteoporosis.

President Obama favors a single-payer system with central control. Central control does not increase efficiency.

Dr. Don Berwick believes that the only efficient way to develop a process of scientific management in healthcare is central control with a single-payer system.

There are multiple defects in his notion.

1. Medical care should not be a set of algorithms that are centrally dictated. Algorithms should be a guide to care. Physicians must use clinical judgment.

2. The patient physician relationship must be nurtured. A large part of the therapeutic effect is that relationship. Medical care is not a commodity.

3. Clinical judgment is vital to successful patient outcomes.

4. Systems of care, with an interdisciplinary team approach, should be taught in medical schools and post graduate courses.. Presently, all disciplines are taught in isolation. When physicians go into practice, they realize the importance of interdisciplinary relationships. Models for interdisciplinary treatment approaches must be promoted and incentivized.

5. Dr. Berwick’s approach assumes that politicians and politics do not play a role in forming healthcare policy. Few believe this notion. Politics plays a big role in dictating agency policies.

6. In 1945, Friedrich Hayek pointed out that the command approach to dictating work flow is doomed to failure. Commanders do not receive accurate information about what is happening on the ground. This results in faulty central decisions.

7. Technocrats, like Dr. Berwick, may believe they can marshal statistics to optimize the health-care system. Statistics on outcomes and treatment plans have been misleading..

8. Statistical analyses rely on too many assumptions and too much unreliable data. These are the reasons government programs often result in colossal amounts of waste, fraud, and abuse.

9. The interaction of all the stakeholders must be considered. If the abuses of all the stakeholders are not considered and eliminated, the decision reached by the technocrats could be incorrect.

President Obama believes technocrats (Dr. Berwick) can solve the problems in the healthcare system. Dr. Berwick sees the problems in the healthcare system from 30,000 feet.

Our healthcare problems will only be solved by consumers at ground level along with disintermediation of the middlemen in favor of consumers.

Repair of the healthcare system can be achieved with consumer driven healthcare and ideal medical saving accounts. Consumers must be empowered by the government to take care of their health and their medical care individually with the appropriate incentive.

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone.

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