Elizabeth Warren gets a lot of attention, but I think this Obama appointee is just as interesting.
President Barack Obama appointed Dr. Donald Berwick head of the Centers for Medicare and Medicaid Services Wednesday. Berwick, known as a passionate advocate for improving the health care system, was nominated earlier this year but his nomination turned out to be controversial. Some Republicans accuse him of favoring health care rationing — a charge Democrats dismiss as nonsense.
Here is Doctor Berwick, in 2005, on the idea that the way to cut costs on health care is to charge people more out of pocket in the hope that they’ll ration their own care:
The one part of the plan that I am absolutely against at the moment is the shifting of burden to individual patients. I do not believe that making the individual American patient more “cost-sensitive” has any rationale in science, ethics, or evidence. It will fail, and it will fail miserably. It will result in a shifting of care away from the people who need it the most. It is a displacement of responsibility for changing the system. You know, if CalPERS or Xerox or GE can’t change care through using its purchasing power, then I absolutely promise you that Mrs. Jones can’t. The idea that she will now be more sensitive because she pays an extra ten bucks out of pocket is, to me, nearly stupid. So I really disagree with that element of the agenda. Internationally, when one looks at high-performing systems around the world—and ours is nowhere near the highest-performing one—it is almost a routine characteristic of the best systems that they have first-dollar coverage, and there is no attempt to make patients pay more when they’re sick, which is a stupid thing to do.
I don’t know how someone who uses blunt words like “fail” and “stupid” is going to survive in that job, but it’s certainly refreshing.
He might be fun to watch.
IM
Isn’t that old news? That’s the NHS fan, right?
PurpleGirl
The one thing I’ve never understood is how Mrs. Smith or Mr. Jones is supposed to self-ration care when they don’t know how to evaluate treatment options or even how to tell to begin with what their problem is. A higher co-pay just means people won’t seek treatment at the beginning of a problem and therefore end up sicker when they do. (I guess this is really a feature if you think poorer and sicker people should just die.)
kay
@PurpleGirl:
There are not many people who are cheaper, sorry, more frugal than me, and I have no idea how to evaluate if I really, really need a CAT scan:
cat48
I agree that he’s interesting. I wish we could have had confirmation hearings, but it seems that the more ACA is talked about, the more controversial it becomes. This is by design for the repubs. It would have a show trial.
Bill Mahr made a good point about rethugs last nite. Since when does the other party get to come in and repeal every program the other party passed? He seemed quite irritated. I wish more people felt that protective of HC & Finreg that at least have a start now. I would hate to see that happen.
Larry Signor
I hope this is a sign Barack is back and ready to kick some GOPher ass.
kay
@cat48:
I don’t think confirmation hearings would have enlightened anyone. He’s got this huge body of work, and his positions are complex and data-driven. His whole career would be reduced to whatever maximum conflict-chosen, scary phrases sold ad space. We can’t keep promoting people who lie all the time and this person intends to tell the truth as he understands it.
A lot of people are making a lot of money because Americans don’t understand their own health care system. I don’t see any incentive to change that re: commercial media so it’s going to have to happen step by agonizing step.
I hope he sticks with plain language. Even if he lasts a year he’ll move the debate forward.
kommrade reproductive vigor
He is going to make my job awesome. Nice to see Cedar Rapids get a shout out, also2.
Bob L
@cat48: More to the point since when has that been an entire party’s agenda. Undo what the other side did and then refuse to deal with the problem.
cat48
@Kay I think we need all the info we can get, too. Honesty in medical care is important to me too. I don’t mind blunt, honest
info provided to me; but it just doesn’t hit every person the same way sometimes. Since he’s a pediatrician & I just became a grandmother, I think I’ll read some of his work.
cat48
@Bob L:
Also, those pre-existing condition ins. pools start this month and I can’t be kicked off my ins anymore beginning 9/24, I think. College kids and some children are already eligible. What about us?
Cliff
Huckabee Opposes Insurance For People With Pre-Existing Conditions
http://tpmdc.talkingpointsmemo.com/2010/09/huckabee-opposes-insurance-for-people-with-pre-existing-conditions.php?ref=fpb
WTH is wrong with these Rethuglicans? In what world does this argument make sense?!
kay
@cat48:
There’s a lot at the link.
I think we have this desperation approach to medical care, because we’re all conditioned to think that it’s a commodity that is in short supply (some people don’t get any!) so we have to race to secure our “portion”, and a bigger portion means better.
That’s difficult for me to believe, because I just watched our sole local (private) hospital build an elaborate new addition, complete with amazing wall ‘o water indoor fountain and atrium.
I deal with people in my work who walk around with huge swellings on the side of their face because they can’t afford treatment for an infected tooth, or the day off to seek public treatment far away, or they lose a “perfect attendance” bonus.
How the hell did this happen? There’s a lot of money around. Why isn’t more of it going to medical care?
Larry Signor
With universal health care, a “pre-existing condition” would be an oxymoron, like Huckabee. WTF is with that name? Sounds like a nym.
Unabogie
@Cliff:
Don’t forget, Huckabee is the “populist” tea bagger. I’d like every GOPer to have to answer whether or not they agree with old Huck, here.
REN
I’ll take blunt and honest all day everyday. Life’s short , do what needs doing while you have the chance. The reason Republicans try to prevent these appointments is they have no wish to debate with a person like this.In an intellectual firefight , where pesky facts keep cropping up,they are a bit short of ammunition.
slag
I liked that Op-Ed! It was a little repetitive of Gawande’s longer article (in the New Yorker?), but it gave a good summary of some healthcare challenges and ways of finding solutions. I agree completely that this guy sounds interesting. Keep us updated on him, please!
Allison W.
@Cliff:
Huckabee is a preacher/man of God, right? or was? That is such an evil thing to say and he knows it that’s why he used a house as an example.
Mnemosyne
@Cliff:
A world where birth defects and genetic diseases only happen because God is mad at you. If God has cursed someone with Type I diabetes, they should accept that and let themselves die slowly rather than thwart God’s will by keeping themselves alive with insulin.
/Christianist
Jager
Here is our system in a nutshell:
I paid (for years) a $20 co-pay for my generic blood pressure medicine, paid it month in and month out. One day the lady pharmacist asked me why am I paying the co-pay when I could buy it for $11 without going through my insurance company? So I pay the 11 dollars a month and go through the hassle of going to CVS every month to pick it up. My Dr. nieghbor asked me why I go through that shit and writes me 3-3 month prescriptions, I take it to CVS, they give me 90 pills for 11 bucks, same price as 30 pills! I asked the nice lady pharmacists why 90 sell for the same price as 30…she replied, beats me.
Crusty Dem
Berwick is awesome. My sister (dr, geriatrician, medicare specialist, hospitalist, etc) is interested in improving metrics and swears by his writings on the subject.
Frankly, I’m dismayed that “rationing care” is such a trigger. We need to ration care (as the Cedar Rapids CT study demonstrates) because right now all sorts of “care” is a variant form of fraud or abuse. I worked in a Neurology department and saw first hand that care (particularly diagnostics, oddly enough) that billed well was abused well. And this was a nationally respected top 10 department associated with a top 10 medical school, but everyone needs to make their bank…
Having a group of doctors own equipment/treatment facilities that they then refer patients to is fucking absurd, but it happens everywhere. It’s not even close to the worst of the worst, but fuckall don’t we know better? Ok, probably not..
Cliff
@Allison W.:
He is a man of evil. just read the whole disgusting thing:
http://www.thecloakroomblog.com/wp-content/uploads/2010/09/0917frc-huckabee.pdf
Martin
Well, I think he’s missing some real problems. Saying that we can’t influence costs by influencing individual behavior isn’t accurate. There is a real problem with people with colds insisting on seeing doctors and getting antibiotics, people that should go to urgent care going to the ER because its financially advantageous, medical groups charging patients $50 for a $6 splint you can pick up at CVS, and so on. We won’t significantly bend the cost curve this way, but you bend the cost curve by a thousand cuts, and these problems do need to be solved. The ER problem needs to be solved with legislation on insurers and hospitals, but I don’t have a problem with not charging patients to see a PA and if they insist on seeing a physician against the PAs advise, charging them for that, and charging them for the unnecessary prescription. I do believe that patients have the right to disagree with their physician, but that right needs to be in tension with reasonable costs to society.
Certainly there’s room for consumers to play a more direct role in these costs without screwing them on service.
Martin
@Jager: Exactly this. You’re limited in your options because of the prescription, but that’s a reasonable limitation. Beyond that, there should be room for consumers to take that prescription and make cost-conscious decisions. And to be honest, that part is getting somewhat better. We use Target and Costco for generics all the time now. It’s a partial measure because the generics don’t work well enough in some cases, but for the cases where it does, it’s a nice option.
Mnemosyne
@Martin:
Usually I agree with you, but of those three things you listed, only one of them is actually the choice of the consumer. If your doctor says you need a splint and offers to splint it at the office, how many patients are going to say, “Nah, I’ll go home and do it myself”? You’re going to do what the doctor advises because he’s the doctor and you assume he knows what he’s talking about.
I’m also wondering how the heck going to the ER is “financially advantageous” for anyone. I guess that if it means you don’t have to lose out on a day’s wages to see the doctor and can do it on a weekend, that would be a financial advantage, but that seems more like a symptom of a problem with how our benefits are structured, not that evil selfish people are exploiting the ER so they don’t lose out on their wages.
futzinfarb
Kay, Kay, Kay. Why must you insist on taking the good doctor’s words out of context? When he said “stupid” it was in the context of “nearly stupid.” Such a typical libtard misrepresentation, turning the meaning on its head.
quaint irene
Sorry, ‘Dr.’ Huckabee. Even disregarding the stupidity and outright callousness of that statement-Insurance companies have a creative way of deciding what is a pre-existing condition. Like, you might be healthy but there’s a family history of diabetes. Bingo, no insurance for you, you’re a risk!
Martin
@Mnemosyne:
I’ve actually had my doctor do this. We talk about health care costs a lot, so I don’t know that he’d have done it with many patients, but he’s said ‘I’m going to suggest you use this device. It costs $40 here, or $5 at CVS, your choice. In truth out of pocket it was $0 there and $5 at CVS, because my employer-paid insurance was covering the $40, but I went with CVS anyway.
The incentive system in place is oftentimes backwards, as in that case. If I’m the idealized free-market consumer with perfect knowledge and perfectly selfish reasoning, I’d be better off going with the $40 item which covers doctor or nurse time I don’t need because it was $0 out of pocket, but that’s far and away the worse decision from a health care/GDP perspective.
Things get really complicated when trying to work out a system that would solve the anecdotal problem I just described without screwing patients (there are plenty that probably should have the doctor take care of it, so removing that option is unlikely to be a good idea) but I’m convinced that in the vast, overwhelming number of cases that primary care physicians and nurses are the best deciders of what’s best for patients and the cost of care. That is, if we turned the decisions over to them (as opposed to the claims adjuster handbook) without interference that we’d wind up with both cheaper and better care.
aimai
@kay:
I think what strikes me specifically about Huckabee’s version of health care is that he doesn’t get that giving people coverage for pre-existing conditions is precisely *selling them fire insurance before the house burns down*–building larger, bigger, more comprehensive insurance groupings spreads the risk and shifts the costs so that new insureds are paying and pooling even as other people with heavy medical needs are needing to be served. Almost all illness, in a sense, is a “pre-existing condition” because most illnesses,especially those that are age related, evolve over time. You want to get people paying into the system, and using the system, for years before even suspected pre-existing conditions kick in in order to mitigate the damage.
Which goes, in a sense, to your point which is that good healthcare *will be expensive*–but its worth it. When you compare what is spent on sports franchises and their stadia to what is spent on getting people free and easy access to dental care its astonishing. I know which one is more important to society, and its not sports stadia.
aimai
Older
@Martin: People do not go to the emergency room because it’s “financially advantageous”, they go because they don’t have a regular doctor because they can’t afford to go to a doctor. They have no insurance. Do you know what an ordinary office visit costs if you have no insurance? A recent visit to my primary care physician cost $285, according to the statement rom my insurer.
$285!! And that was just to talk to him about an ongoing condition (no lab tests for instance). Of course, my insurer bargained it down to $20 from me and $20 from them, but if I were not insured, I would not be able, on my own, to bargain it down.
It may be that you think that because emergency rooms have to treat anyone who comes to them, that they will do it for free if the patient is poor. THIS IS NOT TRUE. They will collect.
They will call you into court, and they will win their case, and they will garnish your wages, your probably pitiful wages (because the kinds of jobs that don’t offer benefits don’t offer much money either). And the amount they collect will not be the amount that I would pay, or even the amount that I and my insurer together would pay, but that first amount, the one from which the bargaining starts, or would start if these people could bargain.
And at the emergency room it is more likely to be $2850 than $285. It is not “financially advantageous” for poor people to go to the emergency room. It is their only choice.
Sue McClure
The idea that health care is like any other consumer good that we can bargain for as we would a car does not fit the real world. My own experience after I was hit by a truck while riding my bike was very instructive. Concussion, multiple fractures–certainly not a situation where I could tell EMS to go online and find the cheapest Life Flight service, nor could I even make the decision about life flight or not. As it turned out, my insurance pays 85% of the “usual and customary” cost; what they don’t tell you is that they don’t have contracts with any emergency service or life flight– “because there are too many of them” I was told when I complained. As a result, my insurance paid $5000 of a $12,000 bill, just for the helicopter trip (which I don’t even remember). This was one of the three largest insurers in the state of Texas and my company has what is considered a good plan.
As I recovered and went for out-patient visits, I discovered the $45 copay for each visit to the orthopedist. I could pay it, but many cannot. What is the point of discouraging people from going to appointments which will help them recover and get back to work? (The copay was particularly irritating when I got the itemized bills, which showed that the insurance company paid the doctor $25 for each visit.) The costs associated with my accident plus 3 months off from work would have sent many people into bankruptcy, and not from any frivolous use of the healthcare system.
John Bird
Cool, thanks for the heads-up. Had heard good things about Berwick but this quote really rocks me back and makes me take notice.