Don Berwick, MD, was a pediatrician and the guy Barack Obama wanted to lead CMS. Berwick was also trained in public health and since the 1980s wanted to instill the type of quality metrics we use with building cars, etc. You can see an interview with him here and what I said about it here. You can pretty much say that Berwick was the father of the quality movement. What he missed back in 2011, explaining the benefits of making sure hands are washed in the hospital or that certain checklists that need to be completed, was that the administrators and insurers were going to expand this crap into areas where things CANNOT and SHOULD NOT be measured.
Recently, in this article called Doctors are so much more than quality metrics, here are Dr. Berwick’s most recent quotes:
- “I’m all for transparency, but in my opinion we’ve overshot,” he says. “Any payer can ask for measurement and write their own rules as to what should be measured. It’s phenomenal, and it erodes productivity.”
- A further potential hazard posed by metrics is what Berwick calls “managing the measurement”—that is, focusing on the metric itself rather than on patient care. He cites his experience being in charge of quality of care management at a Boston HMO. “I had an unlimited budget for breast cancer screening and follow-up and we got good results for those. The problem was, as an oncologist pointed out to me, we really decreased the amount of work on breast cancer care. So measurement, by casting a light, led us to look under the light rather than thinking more broadly about the pattern of care.”
- “I have tremendous doubts about the accuracy and utility and overall wisdom of quality metrics at the individual level,” Berwick says. “When it’s a ‘falling off a log’ standard that you know everyone would want the same way then it’s good to know we’re adhering to the standard. The problem comes when we don’t get a chance to modify them to fit individual needs. Can we really be smart enough to write rules that get down to the level of what’s right for each individual patient? So we have to be really careful about these rule-based standards.”
- Another problem Berwick cites is that often doctors don’t provide care in isolation. “Physicians are enmeshed in a highly interdependent system of relationships,” he notes. “So maybe Dr. Jones’s patient had a particular outcome, but Dr. Jones is working with Dr. Smith and Dr. White. It’s hard to separate who’s doing what.”
- A subtler, but still important effect of metrics as a reimbursement tool, Berwick points out, is to discourage doctors from caring for “difficult” patients—those with behavioral health disorders, or who are just plain ornery. “If you put in a system that dings doctors for low scores on patient satisfaction or efficiency measures, but the problem lies in the variation of the patient population, you’ve done exactly the wrong thing,” Berwick says. “Instead of helping doctors take on the tough cases, you make it riskier for them.”
Everything I warned about for years Berwick is saying now. He helped to start this!
The funny thing is that if Obama wanted him in charge of CMS today the Democrats, after reading these quotes, would block him.Tweet