Wednesday, July 28, 2010

Unraveling the enigma of Donald Berwick

In several earlier posts I said that Berwick's detractors as well as his supporters take a simplistic approach about his positions. A nuanced view of Berwick would be that his statements on health care are,at least on the surface, incoherent. How, for example, does he reconcile his contradictory positions, favoring rationing and central control on the one hand while at the same time espousing individual patient choice and consumerism?

A recent post at the Drug Wonks blog points to a primary source that may offer some insight. It's a document from the IHI entitled Best Health Care Results for Populations: The “Triple Aim.” The document isn't signed by Berwick but it is Berwickian. Berwick was head of the IHI and the document contains the substance of remarks he made in his keynote address at HM 2008. The subtitle lists the three incompatible aims and hints at Berwick's incoherency: Achieving the optimal balance of good health, positive patient experience of care, and low per capita cost for a population. So, if the document could explain away the incompatibility of these goals it could reconcile the inconsistency of Berwick's statements.

After the usual claims that the U.S. has the most expensive health care in the world with anything but the best quality the reader is offered this:

“Health care systems have evolved around the concept of infectious disease, and they perform best when addressing patients’ episodic and urgent concerns. However, the acute care paradigm is no longer adequate for the changing health problems in today’s world. Both high- and low-income countries spend billions of dollars on unnecessary hospital admissions, expensive technologies, and the collection of useless clinical information. As long as the acute care model dominates health care systems, health care expenditures will continue to escalate, but improvements in populations’ health status will not.”3

Is what's hinted here that we'll have to slash billions for hospital admissions, technology and diagnostic tests, but that's OK because we'll make it up in savings resulting from more basic care and prevention? Could this be the magical thinking that reconciles Berwick's positions?

A little later on in the document:

The recent Dartmouth Atlas work reveals waste in resources for care at the end of life, but the financial incentives are misaligned to produce change. Per capita US health care costs continue to rise, spurred by increasing use of technology as well as increasing prevalence of various medical conditions.5

No doubt referring to those conditions prevalent at the end of life. I guess there's a sense here in which reduced care for the “episodic and urgent concerns” of the very ill and the very old, and improvement in the population's health, are compatible. If you know what I mean.

For the positive patient experience aim the IHI model would include a measure such as “They give me exactly the help I want and need exactly when I want and need it.” (Likert Scale: strongly disagree to strongly agree) . There's Berwick's extreme consumerism. Left unanswered is how that aim would be accomplished alongside central control and slashing services to the very ill and very old.

Another measure in the IHI triple aim model is how many people have a BMI of over 30. Think of the money we could save if we could solve problem! After all most of our health care expenditures arise from diseases of choice, not chance. So does Berwick intend to appoint an obesity czar equipped with all the legal muscle he can squeeze out of the Constitution? Would it work? If the grand experiment in my home state of Arkansas is any indication, no. Former Arkansas Governor Mike Huckabee was an obesity czar. After an epiphany concerning his own obesity he put the entire state on a diet. But despite being in the top two states for anti-obesity public initiatives Arkansas remains among the most obese states in the U.S.

The ultimate solution to reconciling these conflicting aims, according to the report, lies in the integrator. In its pure notion the integrator could consist of just about anything---a health care system, an insurance company, a group of leaders. Berwick even suggested at SHM 2008 that it could be the hospitalist movement (go figure). Ultimately, though, the discussion focuses on the British National Health Service and its Primary Care Trusts as the best model for the grand integrator:

Primary Care Trusts are the center of the National Health Service (NHS) in England and control over 80 percent of the NHS budget. There are over 100 Primary Care Trusts in England, each of which is responsible for the health of the population they serve. Each Primary Care Trust serves approximately 600,000 individuals. Trusts receive funding through the NHS based on a weighted capitation scheme that corrects for deprivation, age, and market forces.

How would it all work? The grand integrator would be given lots of power and charged with lofty goals. For example:

Identify the needs of the population.

Manage a population-based budget for the health care needs of a defined

Help align the financial payment structure so that population health outcome is
rewarded. ..

Design standards for primary and acute care services.

Evaluate the effectiveness of new technologies and treatments.

Provide a mechanism for “remembering” each patient (could be an integrated
medical record). ..

Measure performance in new ways, including developing assessments that
measure health experience down to the patient level. ..

Connect individual health with public health.

Form partnerships with local communities.

Grandiose, nebulous and intrusive are adjectives that come to mind.

So that's Berwick's thinking. You can decide whether it's merely outside the box or beyond the pale. Whatever IHI's Triple Aim document may tell us about Berwick's thinking it fails to articulate a coherent stance on effective health care. Only the credulous among us would be convinced that it does.

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