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Dr. Don Berwick — pediatrician, health care improvement guru, Anglophile, Obamacare booster — has a really, really great bedside manner. He leans in; he listens. He's deeply thoughtful about seemingly intractable problems (Medicaid expansion, for instance, or the way doctors get paid) without being alarming. In short, he's the guy you want in the exam room when your kid falls off the jungle gym.
And if you live in Massachusetts, he wants to be your governor.
The last time you probably heard about Berwick, a Democrat, he was being lambasted by certain (Republican) members of the U.S. Senate who vowed to block his confirmation as President Barack Obama's designated Administrator of the Centers for Medicare and Medicaid Services. Berwick served as the head of CMS for 17 months, and then, with regret but little discernible bitterness, he returned home to Newton, Mass., and decided to run for governor. (Before heading CMS Berwick served as the director of the Institute for Healthcare Improvement, a nonprofit in Cambridge.)
We spoke with Berwick mostly about health care on his way to more far-ranging interview on Radio Boston. In a 30-minute discussion, Berwick talked about the "majestic" Affordable Care Act and compared re-inventing health care to throwing a hat over a very tall wall and climbing over to retrieve it. Here, edited, is some of our (very long) interview:
So, overall, how is your campaign going?
I’m thrilled by how things are going. Of course, people are interested in health care, it’s a very big issue for our country and our state. We have to get this right. I keep saying the truth, which is that the eyes of the country are on Massachusetts. We’re, what, five years ahead of the country in broadening coverage. Health care is a human right in the state now, and you can’t say that in any other state, and that’s what began in 2006. So we’re kind of pioneers for the country. Now, in order to make that possible, we have to reform health care.
Health care has to meet people’s needs better, at lower cost, without harming anyone, but by making health care better, that’s the best way to improve, to contain costs. That’s the journey we’re on, since the cost containment enterprise is now started, and everyone’s watching, everyone’s watching.
You know, those opposed to making health care a human right in America would like us to fail. Those who believe in that are rooting for us to succeed, and the stakes are very high here. And it’s hard: We have to take a health care system that’s built around institutions: hospitals, clinics, offices, laboratories, you know, a fragmented system, and make it seamless, so that people can have journeys through their lives instead of these separate encounters with health care. And when we do that, costs will fall and quality will rise, I know that, I’ve seen that for 30 years in the work I’ve done in improvement.
So in Massachusetts right now, we’ve been in a holding pattern, that is, we've achieved almost universal access but haven't yet contained costs. What do you think will be the catalyst to really start seeing those care improvements and cost declines?
Well first, I think we have to look back with pride on Job #1, which was making coverage universal: We are just about at 98% of adults, and 99% of kids. We should be very, very proud. The next part of the journey is making care more affordable, and we’re still not sure — I think the trajectory is good, everywhere in this state. Everywhere you go, professional institutions are talking about how to make care more team-based, more responsive --
There is a lot of talk, I would agree with you --
And progress. There are isolated instances around the state of very progressive work on making health care what it should be. There’s a group of community health centers in Springfield that I just met the leader of last week, and he was telling me of really thrilling work on taking care of people with severe chronic illness. And we have pioneers here, Dr. Robert Master — there’s nobody better in the nation, and we’re seeing in some of our large flagship teaching hospitals, really interesting projects. There’s one at Mass. General that Dr. Tim Ferris has been running, that’s all to the good.
But we need a tectonic change here. We need everything to change, and that is going to be hard. We’re going to have to have leadership from all sectors. Patients, health-care deliverers, institutions, doctors, nurses, and political leaders who are going to stand up and say, “It’s time to make health care both affordable and better in the state,” and that is unfinished work.
What’s the hardest part of making these changes take hold?
Well, you know, a simple way to say it is we built a system in which staying busy is the way you make your money. A hospital makes money by staying full. A CEO that has a hospital whose bed occupancy is falling will be in trouble with her board, or his board. Specialists make their money by seeing more patients, that’s how we built it. They’re not bad people, they’re just doing it the way it was built.
We need to get into a different mind frame, which is, when you think about it, the best hospital bed is an empty bed, not a full one. And the reason is because we attended to health, and helped Mr. Smith stay home instead of bouncing back to a hospital, or maybe never having a heart attack in the first place. And that’s a different business model, and we need to change payment and training and public expectations and systems so that they really can support wellness and health, instead of illness, and that’s a big change. The business models have to change, that’s going to be the hardest part.
So what would you do as governor? The cost-containment law that passed in 2011 is very judicious to the point that it can seem toothless. It was so careful not to hurt stake-holders that it ends up seeming somewhat impotent. So as governor....?
You're talking about chapter 224, the cost containment law of 2011 that followed on the 2006 reform law. I once said that, I quoted an Irish adage that I love, which says, “When you come to a wall that’s too big to climb, you throw your hat over the wall and then go get your hat.” And that’s what we did.
We threw our hat over the wall, and said we’re going to be universal; now we’re going to get the hat by making it affordable.
As governor, I think we need an uncompromising commitment across all stake-holder groups to reduce the cost of care in the state to something that’s affordable by average workers; that isn’t taking money from their pockets every single day, and denying laborers the benefits of wage increases. There have been no wage increases in ten years in this country, not in real terms. All the money’s gone to health care...
We’re going to need a governor, whether it’s me or anyone, who’s going to go to the health-care delivery system and say, 'The old system, it’s gone, it’s over...What I want to help you do is migrate to the system of the future,” which is home-based, patient-centered, health-oriented, and frankly trying to empty the hospitals.'
I think one key there is to get away from fee-for-service payment as fast as this state can. The more we go to pay health-care providers globally to take care of populations, and reward them with populations that are healthier, the more they’ll change their model, and we need hospitals to try to be empty, that’s kind of the way to think about it.
So what do you do, pay all those heart specialists a fixed salary?
I personally think salaried practice, which is the only way I ever saw children, I always was on salary, was ideal, for me; I never got paid more to do more, I never got paid less to do less. All I had to do was think about that child in front of me, and what that kid needed, and do it for him or her. End of story. Money was disassociated from the clinical judgment. I think that’s a better system.
Maybe we want to stay with fee-for-service, but what I would have to say as governor, and we all as leaders in the state, is that we need your help to change, and we can do it now under the gentle prodding of 224 and the call to arms that the state has engaged in, it’s how we got universal coverage passed, that didn’t have a lot of teeth, that was a good agreement that we were going to be a state that made health care a human right.
We’re trying it with agreement now, you’re absolutely right, everyone’s come to the table and said, “We’ll do this, we’ll get it done.” Your governor is going to have to say, “Now you get it done.” And if not, frankly, go back to the legislature and say it didn’t work on a voluntary basis, we need teeth and consequences now, and work with the legislature to understand the new legislation we would need.
The consequences are too big to let time just pass, we can’t do that anymore. This is taking money from our schools, and our roads, and our museums, and our poverty programs, and from workers and businesses, small and large businesses, and it isn’t sustainable.
And how much time do you give them to do this voluntarily, before you lay down the law?
If I didn’t see a beginning to real change, a trajectory in accord with the goals of chapter 224 — and my goals would have actually been bolder than 224, but I’ll accept those — within the next two years, year-and-a-half, if we don’t start to see costs get to gross state product growth, I think it’s got to be a new game. There’s just — these aren’t bad people, but they’re responding to the signals and if they can’t respond to the signal that says “it’s time,” we have to make the signal stronger.
And to this ongoing issue of market clout, and the Partners hospitals riding on their reputation to inflate costs, how do you deal with that? We know there's a problem, the attorney general keeps telling us it’s a problem, and yet, it doesn’t really change.
It’s the same answer. We have to change the game to make the smart game the one that meets the social need. I refer to it as the triple aim: better care, better health, and lower costs, and that’s what we need to orient toward. Remember that they’re hitting the pitch we throw, to use an apt baseball analogy right now. If we want a different swing, we need a different pitch. And the pitch here has to be, “No, your payment will be global, not piece-by-piece, you get rewarded for health, not just doing things, and we need you to attend to the social goal here, which is better care at lower cost.”
When I ran Medicare and Medicaid for President Obama, I thought hard before the implementation of Obamacare, and part of that was to give healthcare deliverers and markets the chance to cooperate. We need more cooperation. We need doctors to work better with hospitals, specialists to work better with primary care nurses to work better with doctors. So cooperation to me is the core of good care, it’s teamwork.
In the regulators department, Department of Justice, FDIC, the federal anti-trust architecture, the inspector general, they were all very nervous. They said, “You know if we give these places an opportunity to cooperate, well, you watch, they’ll collude and we’ll see prices go up, not down.” And I said, “Well, we’ve got to give ‘em a chance. We can’t get to seamless care the way we are.” I won that argument, but now it’s a trust issue. Now the large organizations, which have market clout, have got to show that they are just as committed to reduction of costs as our society needs them to be.
So, you’re talking about health-care delivery a lot, but there’s also this problem of prices just simply being too high. And the best explanation for that is that health-care in the United States is a business. Not that we even usually know what the prices are.
You’re right, and your comments are related. We have serious pricing problems; if you compare us internationally, you know, a lot of our procedures cost three, four, five, 10 times as much as they would in another country with just as good health care. And beyond that, the opacity, the inability to see the costs is really harming us greatly.
Sometimes I get asked, if I could make one policy change in healthcare — and by the way, I think this might apply in other sectors than health care — what [would it be]? It is transparency, we just need to turn the lights on, and people need to see what these costs are, they need to be publicly accessible, we have to allow comparisons to occur, and we need some people to be able to be proud that they’re holding their prices down, and others to be embarrassed that they’re not, and then I think we need the competitive landscape which allows judicious consumers, you know, understanding that the price doesn’t always reflect value, to make some choices. But to do that, the lights have to be on. And I favor strong levels of transparency.
Mmm. And quality.
Same, you would — you can’t just have price information, it isn’t enough. You have to know how good is what I’m buying, of course. You know, a fancy automobile costs more than a simple one, but transparency will help on both quality and cost grounds...
The public isn’t currently getting the information they probably ought to have, but we know how to do that. We know how to change, how to measure a lot of quality. You know, a lot of my career has been measuring quality in health care and other industries, and we could do a lot; it’s a matter of will. And it’s a matter of commitment to sharing data, that’s the other piece here. Insurance companies would want to keep their data to themselves, hospitals want to keep their prices to themselves, doctors are reluctant to have too much measuring going on, and too much is bad, but we need to change culture here so that people understand that there’s an accountability here.
So how do you solve the problem of...“But I really want go to that fancy doctor at MGH for my lower back pain, even though I live out in the suburbs and I could easily go to my community hospital?” That’s so entrenched.
It is, and I’m for choice. I have this very strong belief that, as in any other industry, the right thing in dealing with the people who use our services, consumers of care, in this case, is to give them choices, not take them away, and then do it in a system in which they can see the consequences and study what they do. Is it really worth it? Is it really worth it to drive that distance and go into a place that doesn’t really know you?
Well, if I’m not paying for it, it surely is worth it. I have great insurance...
You are paying for it, of course, and that’s another part of the enterprise is to understand that is it all our money. There is only one source of money for health care; that is the wages of workers. There’s no other place that the money comes from, it goes out of pocket or through taxes, or through employer contributions to premiums, which then are not available to labor... labor unions know that, workers know that, and so it is your money, and begin to get that sense in the public and have leaders who stand up and say, “You know, health care is taking things from us.”
You know that in the Massachusetts state budget, things I care deeply about have been cut steadily over ten years. Local aid, aid to higher education in the state down 20, 30%, aid to Parks and Recreation down 25%, item by item; there really is no item in the state budget, really, that has gone up in ten years, except one. And that’s health care. And that’s gone up 59% in ten years. And I know from 30 years of work on improvement that we can make health care costs go down while improving care.
As a candidate for governor, there are lots of agendas I have: I want to emphasize early childhood education, it’s key — school preparedness is absolutely key to success in school, which is key to successful entry into the job market. I want to invest in our elementary and secondary schools and get much better relationships with businesses and communities. I’d love to make our community colleges the envy of the country. I think the community college system is absolutely key to social mobility. I care deeply about the problems of transportation in this state. You don’t have to visit many towns before getting the signal here that our transportation system is very rocky. It’s not meeting people’s needs, just on basic maintenance, let alone the development of new quarters of service.
Well, this takes money, and so, people ask me, on the campaign trail, “Where will you find the money?” And my answer is, “Well, we’re going to have to think about giving an opportunity for wealthier people to contribute more to government and people of limited means protected against it, but you know, a place to go for the money is health care. You look at the state budget figures, and you see what would happen if we actually could have health care in Massachusetts that was at the world class for continuity and coordination and health-orientation? Oh, we’d save a ton of resources, public and private, and that money could be reinvested in some of the other urgent things we need to do.
But it’s turning the Titanic...
Yeah, but the Titanic can get turned. It’s leadership, it’s calling the public’s attention to how crucial this enterprise is, restoring hope to the public; people have been so persuaded that the only way we’re going to save health-care costs is to take things away from people. Absolutely not. Rationing is nonsense, we don’t need it. And we can have all the health care we want and need. We just need to change the care, so it’s responsive to people.
We need leaders that can explain that to the public. And I think, argue the moral case here, which is, it isn’t right to be a state in which children go hungry, or in which kids fail to be prepared to enter school, or, our communities don’t have bike paths and recreational opportunities; that’s not right. And so, fixing health care isn’t just a kind of smart economic idea. It’s a moral idea, and I think it’s crucial.
I’m going to ask a Self magazine-type question. Do you exercise everyday? We often come across doctors who are telling people what to do for health but the doctors don't do it themselves.
I really do try. I’m not doing as much as I would advise my patients to do, I freely admit that, but I love exercise. I bike ride when I can, cross-country ski, I can’t wait for the snow...Flying across the snow on snow skis, there’s nothing better. And I’m trying to use stairs instead of elevators. You know the simple fact here, which is, 20 minutes of walking a day, four days a week, is as good as any miracle drug we’ve come up with. It prevents heart disease, it prevents strokes, it prevents breast cancer, for Pete’s sake! And you don't have to go to the gym and...
Sweat, sweat for hours. Just a simple pattern of activity helps.
Would you implement any sort of policy à la Michael Bloomberg to nudge people toward that sort of better behavior?
I’m a great believer in the wisdom of the public given the right information, and my bias is less towards restriction, and more toward knowledge. And I think if we really had an enterprise embraced by professionals as well as media, lay public, that makes people aware of how much they can control their own health, their own well-being, their own education, I think we would see responses, not perfect, but, I think we have to be very careful in this country when we tie people’s hands. It’s a matter of giving people information on the basis of which they make the choices, and in the end, you know, I’m no smarter than the person I’m trying to help, and I know that. And I think it’s wise to trust people. When it’s a public safety issue, you know, second-hand smoke, or, driving without a seatbelt, then of course...
What do you think of the Vermont model, moving toward a single-payer system?
I hope a state in this country tries a single-payer system. We’ve talked about it long enough, there’s great debate about it, anger, assumptions; we’ll be so much better off when it’s actually been tried. At the national level, we stepped away from it, people prefer, in this country, a pluralistic system, and one that has a, you know, a base of insurance in the private sector; but if one state tries, we’ll learn from it, success or failure, so I cheer them on, and would think that they may be doing something that has a lot of sense behind it.
How about the SNAFUs around the Obamacare rollout?
With respect to the exchange rollout, of course I was part of the preparation of the regulations for Obamacare during the 17 months I served President Obama, heading CMS... We tried to do something very difficult in this country. We’re trying to set up a whole new system for getting healthcare insurance to people that really need it, but can’t get it. That involves a lot of changes, in data systems, it involves interfaces that we never had to build before, between Medicare and the Internal Revenue Service and the Treasury Department, between Medicaid and the federal government, between states and the federal government, between data repositories that are very distant from each other...
So it’s a very big task, any company that looked at this would have said, “Wow, we’ve got a big job ahead,” and we all knew it. We have a big job. So, yes, it did not go right, not at first. We’re only, what, two or three weeks into it? And, you know, everyone wants a higher functioning system than we have now... Some of the state exchanges have gone up much more easily now. California, which is a massive enterprise, has done very, very well. That should give us hope this should work.
But you know, with something this complicated, it just usually doesn’t work right the first time, and here’s what I think: I think if we were in a less polarized political climate, where people weren’t looking for bad news and ways to throw brick bats at each other, we might, as a nation, look back and say, “Oh, well, boy, we did have a hard problem here, and it didn’t go right the first time, and oh let’s fix it now, we’re smart enough to do that,” and we are smart enough to do that, and we will fix it. And I have trouble panicking here. I think it’ll come out all right, and I can’t give you a timeframe, but, the other thing I always remind myself is, this is not a sprint, it’s a marathon. We are a nation on the move, a nation headed toward equity and justice in health care, and better health care! And, you know, that’s a several-years’ journey, and we’re on a wave now, of difficulty, and we’ll get through this. Let’s keep our eye on the ball here, which is health care as a human right...for everybody.
Do you not panic over the states that have decided not to go along with this?
I lament that. I mean, the states that are not going along with the expansion of Medicaid, or are dragging their feet on getting their exchanges set up, they’re leaving people to suffer. That means that human beings at the margin of income, the margin of health, are not going be able to find the care that we ought to promise them, that those states ought to promise them, and I get offended — I get ethically offended, the idea that we would be a country where sick people can go with their needs unmet, because they don’t happen to be wealthy, or they don’t happen to fit a profile. That’s not the way I think- it’s not worthy of us.
Massachusetts is better than that. We’re a state that isn’t letting that happen. I do think that the states that are standing aside now from Medicaid expansion, from the set-up of the exchanges, they will regret it, they will change, and there will be some period a few years from now, we’ll look back and say, “Boy, it took them a while to get on board, but eventually they did.” No smart state, in the long run, is going to stay out of this.
Just one more question, which is, why do you think people are so horrified by this law? I mean, the vitriol and the hatred and the, I mean — it’s health care. It’s insurance companies. It is intimate, and it’s personal, but why the level of antagonism?
Well, I don’t have the secret either. The facts are, we have a magnificent law. It’s a majestic law. Perfect, no. But worthy of our country, yes. It’s a law that’s trying to make health care a right and help health care become what it must be for us.
But why is that so offensive to --
Because I think the law is a symbol, and I don’t think it’s about the law. I think we have a partisan divide here that’s reached a level of rancor in which the law is a convenien whipping-post. It’s a lightning rod for deeper levels of anger about this President, who I think is a fantastic president, he’s leading our country into some very important new territory...
It symbolizes the President, he put his name on this law, and I think it’s a way to get at him. And I think that the very idea of a social contract, the moral fabric that underlies the law: commitment to each other, justice in American society, compassion as a basis for public action, duties to each other...
I think there are other ways to look at the world, which I don’t share, which have to do with, “Well, wherever you ended up, you deserve it.” I don’t think that. I think if you ended up in trouble, we help you. And that basic divide has come to a boiling point in this country. I am sure, I am sure we will get beyond this. I don’t think the public will stand for it, I don’t think the public’s going to stand for a country that, a) can’t get decisions made and actions done, and b) that’s willing to throw anyone under the bus. I’m not. And I think that this law represents something important in America. It’s the idea that we are, at some very deep level, in it together and responsible for each other.
(Thanks to Rachel Bloom for transcribing and Abby ELizabeth Conway for help with the audio.)
This program aired on October 18, 2013. The audio for this program is not available.
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