There is a moon shot here: Don Berwick's exit from CMS & the irrationing of healthcare

In my blog post yesterday, I mentioned the sometimes ridiculously high cost of healthcare, and the resulting lack of coverage for many people.

No one wants rationing of healthcare; rationing connotes a period of barely adequate consumption in a time of war. Yet coming from the same root as "rational," rationing is the product from a conscious effort to equally and fairly share a limited resource.

Our high prices create "irrationing." Think of the harm to Deamonte Driver, a boy with a gap in his Medicaid coverage, who eventually died from an untreated toothache, to Nikki White, a young woman with cancer who was denied benefits by her insurer for her pre-existing condition of lupus, and to Natoma Canfield, an uninsured woman whose cancer was detected far too late, among far too many others. That's irrationing; irrational, needlessly cruel and jarringly wrong for the richest and greatest country on earth.

In 2009, Dr. Don Berwick told a biotechnology journal, "The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open."

Now, as he exited his leadership role over the Medicaid and Medicare programs, Dr. Berwick said, just as Americans supported manned missions to the moon without knowing the details of rocket science, they ought to support the universal health insurance law because of its ultimate destination. "We are a nation headed for justice, for fairness and justice in access to care," Dr. Berwick said. "We are a nation headed for much more healing and much safer care. There is a moon shot here."

Thanks to Robert Pear for his interview in today's New York Times.

A smoke-making machine: My Don Berwick & his CMS Nomination

Twenty years ago, when my son was a toddler, my wife and I brought him with us to the National Forum of the Institute for Healthcare Improvement (IHI). He had a cold at the time, but was otherwise fine. As we checked into our hotel room, we saw Dr. Don Berwick, who was entering his own room next door. He said we could call him, even in the middle of the night, if needed, to come and take a look at our son. The gesture was doubly generous because no doctor can cure a cold; the visit would be for the purpose of reassuring us young parents. My son slept peacefully, so we didn't need to take up the offer of this internationally known pediatrician to make an unpaid house call.

Senators Orrin Hatch, Mike Enzi and 40 other Republican U.S. senators sent a letter to President Obama on March 3, asking the president to withdraw the nomination of Dr. Don Berwick as head of the Center for Medicare and Medicaid Services (CMS).

The letter cites four reasons. One is Don’s "lack of experience managing an organization as large and complex as CMS." CMS is the largest organization in the world, so only people who have already led CMS could have that prior experience.

The letter criticizes the President's nomination as "abrupt and unilateral." The Republican legislators' recent habit, of refusing to even formally debate many congressional matters via the filibuster, makes "unilateral" an example of the pot calling the kettle black.

Third, the letter cites Don's past record of "controversial statements." The most loudly voiced (though utterly ungrounded) Republican concern has been to "death panels." Don's father, himself a doctor, died in a nursing home. Don has long pushed hard to make treatment at the end of life – which some call "death by intensive care" – far more humane, via his leadership of the nonprofit Institute for Healthcare Improvement. Don has certainly made controversial statements over his long career in the midst of efforts to greatly change our healthcare system.

The final stated reason in the letter is Don's "lack of experience in the areas of health plan operations and insurance regulation." Before founding IHI, Don led a unit in a large pioneering health maintenance organization (HMO) that was really about health maintenance: Harvard Community Health Plan. (I'm proud to have worked in a sister unit there at the time.) Perhaps Don does not have experience in insurance regulation; I don't know.

Thus, these senators seem to be asking the President to bilaterally nominate someone who led CMS in the past, who has not made controversial statements. No such person exists, of course.

We have to assume that the senators made as compelling a case as they could. But there's no smoking gun here. There is smoke, however: the fact that so many senators agree is itself newsworthy. Well, where there's smoke, as they say, there's a smoke-making machine.

That machine has been quite busy lately. I hope that the President will use his training as a law professor to see the true crux of the senators' objections. Since the stated reasons in the letter aren't genuine, there must be some other reasons. My hunch is that these senators think Don has been, or will be, too effective. And that they must win at all costs, even at the costs of logic, and at the cost of depriving more than 30 million Americans of health insurance.

Read a story about President Obama's personal commitment to health care reform.

Donald Berwick as head of CMS

Pres. Obama has just nominated Dr. Donald Berwick to lead CMS, the Federal government agency that runs the Medicaid and Medicare programs. Don has stellar qualifications. Equally important are his experiences as an advocate during his father's period of declining health, and his own experiences as a patient with a botched knee operation. Years ago, at his speech to the Institute of Healthcare Improvement's National Forum, he movingly described his frustration and inability to get the proper treatment, and an appropriate wheelchair, for his father, himself a doctor. At the most recent December Forum, he described his definition and vision of his own health, and showed the large gulf separating that from the absence of illness, as doctors usually define good health in practice. He did this by encouraging people to ask, What do you really want? Then to ask again, What do you really, really want? And to ask a third time, which elicits the true vision of one's ideal health.

What do I really, really, really want? For the Senate to confirm my friend and colleague Don, and give him the keys.