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April 12, 2016

Berwick: The 9 changes needed to make health care more ‘moral’

Daily Briefing

A clash between health care's two eras of "professional dominance" and "accountability and market theory" is harming clinicians, communities, and patients—but there's a better way forward, former CMS administrator Donald Berwick writes in a JAMA viewpoint.

Era 1: 'the ascendancy'

Medicine's first era—dating "back to Hippocrates" in ancient Greece—"was the ascendency of the profession," Berwick writes.

It was grounded in a belief that the profession "has special knowledge," is "inaccessible to laity," results in good, and "will self-regulate." As a result, society provided those who practiced medicine with a rare privilege, Berwick says: "the authority to judge the quality of its own work."

But those foundations were shaken when researches began to examine the field and found "enormous unexplained variation in practice, rates of injury from errors in care high enough to make health care a public health menace, indignities, injustice related to race and social class, ... profiteering," and wasteful spending, Berwick notes.

Era 2: 'the present'

That helped spawn medicine's second era, whose backers "believe in accountability, scrutiny, measurement, incentives, and markets" through "the manipulation of contingencies: rewards, punishments, and pay for performance," Berwick says.

But the conflict between the first era's "romance of professional autonomy" and the second era's accountability tools have put the morale of clinicians in jeopardy, Berwick argues.

"Physicians, other clinicians, and many health care managers feel angry, misunderstood, and overcontrolled. Payers, governments, and consumer groups feel suspicious, resisted, and often helpless." Both sides, Berwick says, dig in further, resulting in "immense resources [being] diverted from the crucial and difficult enterprise of re-creating care."

Era 3: 'the moral era'

Berwick says it is time for medicine's third era—which he calls "the moral era"—"guided by updated beliefs that reject both the protectionism of era 1 and the reductionism of era 2."

The new era will require at least nine changes to medicine, he says:

1. Reducing mandatory measurement. Much of the current era's mandatory measurement is "useless," Berwick argues, wasting valuable time and money for providers. Berwick says that payers should work with the National Quality Forum to reduce the volume and total cost of mandatory measurement by 50 percent within three years and by 75 percent within six years. "The aim should be to measure only what matters, and mainly for learning," Berwick says.

2. Stopping complex individual incentives. For most, "if not all," clinicians, Berwick argues that the best form of compensation to promote value-based care is "salaried practice in patient-focused organizations." He says payers and health care organizations should halt complicated incentive programs for individual clinicians and that CMS "should confine value-based payment models for clinicians to large groups."

3. Shifting the business strategy from revenue to quality. Improving quality is "a better, more sustainable route to financial success" than focusing on maximizing revenue, Berwick says. To that end, Berwick argues that health care leaders need to view "mastering the theory and methods of improvement as a core competence," while payers need to delink reimbursement rates from input metrics that "are not associated with quality and drive volume constantly upward."

4. Giving up 'professional prerogative' when it harms the team. "The most important question a modern professional can ask," Berwick says, "is not 'What do I do?' but 'What am I part of?'" He adds that young doctors should be trained to value citizenship over professional prerogative, and "physician guilds should reconsider their self-protective rhetoric and policies."

5. Using improvement science. "Four decades into the quality movement," Berwick observes, "few in health care have studied the work of Deming, can recognize a process control chart, or have mastered the power of tests ('plan-do-study-act' cycles) as tools for substantial improvement." Improvement science, he says, must become a core part of preparing clinicians and managers.

6. Ensuring complete transparency. The rule for transparency, Berwick argues, should be, "Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens." He says Congress, insurers, and regulators should take steps to ease data sharing, and that states should adapt all-payer claims databases.

7. Protecting civility. "The rhetoric of era 1 can slide into self-importance; that of era 2, into the tone of a sports arena," Berwick says. "Neither supports authentic dialogue. Medicine should not ... substitute accusation for conversation."

8. Hearing the voices of patients and families. Further empowering patients and families to shape their care will improve care and lower costs, Berwick says. "Clinicians, and those who train them, should learn how to ask less, 'What is the matter with you?' and more, 'What matters to you?'

9. Rejecting greed. Berwick lists several ways he says the industry has "slipped into tolerance of greed," from high drug costs to "profiteering physicians." Berwick says that stakeholders need to "define and promulgate a new set of forceful principles for 'fair profit and fair pricing,' with severe consequences for violators." He also calls on professional organizations and academic medical centers to "articulate, model, and fiercely protect moral values intolerant of individual or institutional greed in health care" (Berwick, JAMA, 4/5).

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