Map of life expectancy at birth from Global Education Project.

Wednesday, April 28, 2010

Don Berwick

It has received very little attention in the mass media, but a lot of attention in the circles where I travel, that the president has nominated Donald M. Berwick to direct the Centers for Medicare and Medicaid Services. Apparently Dr. Berwick engaged in lengthy discussions, possibly negotiations, with the administration before agreeing to be nominated. I was initially surprised because I didn't think the CMS director had much of a policy portfolio, that it was essentially an administrative job. That Berwick accepted is a signal that we will see substantial innovation and experimentation in health care financing and organization in Medicare, which the federal government controls directly. CMS can encourage and support the states in redesigning Medicaid, though it has less direct influence.

Berwick, who now runs the Institute for Healthcare Improvement, located in the People's Republic of Cambridge, Massachusetts, is well known as a health care (I still prefer it as two words) visionary and advocate for patients. You can learn his basic schtick here, it's called The Triple Aim. If you've been reading Stayin' Alive, you already know that the goal of universal coverage is inseparable from cost containment. But rather than defining universal coverage per se as part of the triple aim, Berwick allows it to fall out as a consequent, if that. The triple aim is better experience of health care, improving the health of populations, and reducing per capita costs. If universal coverage serves those ends, so be it, but he doesn't try to prove that theorem.

He does argue, however, that the triple aim requires eliminating the fragmentation of our present system, and the misalignment between the incentives of individual institutions and his social goals. This means large scale integration through some sort of authority or another -- a national health service or single payer works, but he's willing to tolerate smaller scale systems -- that is dedicated to these goals, rather than, say, the enrichment of executives or the prestige and market share of an academic medical center. He pretty much concludes that global budgets are necessary, within which resources can be allocated to optimize the first two goals; and that the goal of population health requires redirecting funds away from medical services to more primary public health.

All of this is true, but it means goring many a large and powerful ox. While I believe it is very much pro-liberty, it doesn't sound very libertarian. In fact, some will detect a pinkish hue over the whole thing. I am curious as to how the Confederate Party will approach his confirmation hearing. I hope we'll find out soon.

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