(L-R) Senator Bill Frist and CMS Administrator Donald Berwick discuss transforming the nation's healthcare system. Each has the dual perspective of being a physician and public health policy expert.
Former U.S. Senate Majority Leader, CMS Chief Talk Healthcare Reform
Last month, former U.S. Senate Majority Leader Bill Frist, MD, and Centers for Medicare & Medicaid Services Administrator Donald Berwick, MD, MPP, sat down to discuss the way forward for the nation's healthcare system. Approximately 500 Nashville industry executives were invited to eavesdrop on the 'intimate' conversation as part of the Nashville Health Care Council's ongoing efforts to share information on health policy and reform. (See related story below.)
Two chairs and side tables and a simple blue curtain backdrop emphasized the conversational tone as the pair of renowned physicians and policy experts shared insights into fundamentally changing the way healthcare is delivered in America.
When Senator Frist asked Berwick what prompted him to leave the private sector and take on the huge role in Washington, D.C., Berwick gave a two-part explanation. "The easy answer is the president asked me," he stated. "I think the other side is the potential here."
Through his work with quality initiatives (see box), Berwick said he had seen a number of innovations and clinical breakthroughs emerging. "We have hospitals in this country that have completely eliminated forms of infection that I thought were inevitable." He added that he had witnessed real strides in patient-centered care and innovative systems that redesigned modern care while reducing costs. "It's just as true in healthcare as anywhere else ... if you do it right, it's less expensive than doing it wrong ... that is the bottom line. But the problem is it doesn't spread. There are pockets of excellence but not a habit of excellence. We don't have this commitment that if it can be done somewhere, it will be done everywhere."
Berwick said through his role at CMS, he hoped to help take excellence to scale. Frist asked what the tipping point was that made now the optimal time to do this. Berwick responded the building blocks are all in place — today we have a broader body of scientific and clinical knowledge and concrete examples exist to show how integrated quality could effectively work; we live in a consumerist age where knowledge has been democratized so there is traction for change among Americans; we have a new urgency as the country can't afford healthcare at the current level so the social tension for change has risen; and the modern information architecture allows for the easy transference of data and knowledge.
While Frist and Berwick might have some variance in perspectives regarding the best path to achieve national reform, both made it clear that the time is at hand to tackle the nation's health crisis and that partnerships and alignment would play a central role in optimizing value and quality.
"I am more and more convinced that we are in this together," said Berwick. "We have a national crisis about making healthcare become what it really needs to be for our country ... better care, better health, lower cost." He added the key lesson of reform so far is the need to reach across silos and ideologies to build a national will for improvement. "I want to build a sense of connection."
However, he added, the way those connections and partnerships are formed might differ across the country. Nashville, he said, is highly entrepreneurial with a strong belief in the business ethic and a sense of doing well by doing good. "I actually think the regional idea — the idea that region by region, community by community — that's where the solution is. You can redesign the care you want to give and get."
Berwick said high quality and lower costs are not mutually exclusive. "It looks obvious that cutting things is the way to get lower costs. It just happens to be wrong. We can have all the care we want and need exactly how we want and need it for less money than we're spending ... if we redesign," he stressed, adding that improvement is the mainstay of successful businesses. Unfortunately, he added, the current system was built in a fragmented manner so each piece continually wants to be a bigger piece. But, he warned, "You don't get sustainability by sub-optimizing the fragments."
Frist said over the past few years that the most powerful lesson clearly has been the need for alignment of incentives "all to come around this issue of value, of quality ... of controlling costs but at the same time doing it in a way where everybody benefits, all focused on the patient."
Simultaneous to enhancing efficiency, addressing fraud and abuse could also lower healthcare costs, Berwick said. "Don't tolerate it. It doesn't help anybody, it just causes us to pass rules." Frist asked Berwick if there was more or less fraud and abuse than he expected when accepting the CMS position. "A ton more," Berwick quickly replied. "I was really naïve about it." He added that partnerships on both a federal and local level were modernizing the approach to fraud. In the past few months, CMS has invested in predictive modeling to seek out patterns of fraud and abuse. "What happens when there is fraud is two bad things. Money gets stolen, and the second is we have to up surveillance on everybody so we make your life harder."
Frist interjected that for many healthcare providers and entrepreneurs that surveillance is seen as a 'heavy hammer coming down' on efficiency and incentives through more regulation, more paperwork, more scrutiny. Frist added that he is hopeful that the investigative process will indeed become more sophisticated.
Berwick turned back to a question Senator Frist had asked earlier regarding the private sector's role in the national dialogue when it comes to transformation through innovation. Berwick readily acknowledged it was a tough question but added the government had to find a way to be more supportive of and responsive to real innovation.
"We need you, as inventive entrepreneurs, to come in with the ideas that get us to better care, better health and lower costs," he stated. "If you've got answers, we need them." He added that he does see better approaches as he travels around the country. Berwick pointed to programs such as Meharry's CenteringPregnancy initiative, which enhances efficiency and improves outcomes through group provider visits, as an example of an innovative solution.
Berwick said the government is also doing its part to tap into novel ideas through the new CMS Innovation Center. "It's one of the jewels of the Affordable Care Act. It's a $10 billion allocation by Congress over a 10 year period to foster new ways to pay for care and new ways to deliver care that have the effect of reducing costs and improving quality at the same time." He added that it has already launched a number of projects and announced more to come including a pilot project for Accountable Care Organizations.
As for the bigger ACA picture, Frist pointed out the favorability of the American people toward the act was eroding and wondered about the implications of that downward trend. Berwick countered that he believed the trend lines would change over time as people began to see all the good things that come out of ACA. Bottom line, Berwick said, "We have to deliver the goods.
The Men Behind the Meeting
Donald M. Berwick, MD, MPP: Prior to assuming his current role leading the Centers for Medicare and Medicaid Services, Berwick was president and CEO of the Institute for Healthcare Improvement. He also served as clinical professor of Pediatrics and Health Care Policy at Harvard Medical School and a professor of Health Policy and Management at Harvard School of Public Health. He received his undergraduate and medical degrees from Harvard and his Master in Public Policy from the John F. Kennedy School of Government. As CMS Administrator, Berwick oversees Medicare, Medicaid and the Children's Health Insurance Program (CHIP). In total, these programs provide care to nearly one-third of the country.
William H. Frist, MD: Currently a partner of Cressey & Company, LP, Frist served 12 years in the United States Senate representing Tennessee and was ultimately elected Senate Majority Leader. Since completing his second term in office, the renowned cardiac surgeon has turned his attention to policy issues and efforts to reform healthcare and education. He holds leadership positions in a number of organizations targeting these issues. On a national level, he is co-chair of both First Lady Michelle Obama's Partnership for a Healthier America, which seeks to eliminate childhood obesity, and the Bipartisan Policy Center Health Project. He also serves as an adjunct professor of Surgery at Vanderbilt University School of Medicine and a clinical professor of Surgery at Meharry Medical College. Frist majored in health policy at Princeton University and received his medical degree from Harvard.