Warning against “inauthentic” reformers, Berwick explains his priorities. Excerpted from “Modernizing Medicare and Medicaid: How to Upgrade America’s Health Care,” December 14, 2010.

DR. DONALD M. BERWICK, M.D., M.P.P., Administrator, Centers for Medicare and Medicaid Services (CMS)

CMS [the Centers for Medicare & Medicaid Services] feels to me day-to-day like three organizations at once. First, it’s a large insurance company. It’s the largest insurer in our country, and [it’s] responsible for making sure that the flows of reports occur for the 100 million people in the programs that we administer. The second component of CMS has to do with this new legislation, the Affordable Care Act, the most important piece of legislation since Medicare and Medicaid were founded. CMS has a big role in translating that law into rules, regulations and real activity.

What I’m bringing to CMS is the third role, and it has to do with the improvement of care in our nation. I proposed a rubric for my time there and the sort of image that I would like to have of CMS: That we will be, and are, a major force and a trustworthy partner for the continual improvement of the health and health care for all Americans.

That’s a carefully worded idea. A major force imagines an organization that is proactive, that is reaching out into the future and not just accepting things as they are, but also helping things get better. A trustworthy partner is key; it is more and more evident to me that no single organization in our entire country – government, private, public, CMS – can do the job we need to do to get America to reach the health-care system that we all want. It has to be done together. And we have to be the best possible partner across all the boundaries that we have, getting all the stakeholders in the health-care system together.

A major force and a trustworthy partner for the continual improvement, and that’s important also. It’s all too easy – especially in a stressed status quo – to check the good enough box. That’s not what American health care needs right now; we need a different attitude, an attitude of continued improvement, never done and never finished, no matter what you’ve done or what you’re doing. I’m very interested in helping that organization get oriented toward the continued improvement of care.

A major force and a trustworthy partner for the continual improvement of the health and health care – that’s important, also. Health care is the obvious job, because we fund and support the delivery of care, but if you work from the science we have, you know that the access to what we really want – vital lives, long lives, healthy lives – isn’t really achieved through the health-care system. Only 10 percent of the variation of health status can be achieved through health care. The other 90 percent depends on some things we can’t control, like genetics, but a lot of things we can, like behavioral choices. Effects in our environment, social and economic disparities, are the generators of bad health, the things we can do differently to be healthier. I’m interested in a CMS that’s interested in health as well as health care and is thinking very hard about how to build a healthy society that turns to health care only as a last resort, when the health-giving choices of our community and society have been exhausted.

Continual health and health care for all Americans, and that’s just a statement of fact. My job is of the well-being of a particular vulnerable subgroup of our country, the 100 million beneficiaries in Medicare, Medicaid and CHIP (Children’s Health Insurance Program). But I know that to navigate our country together toward the health-care system that we want and need, it would be foolish to pretend that we could shape health care on behalf of the 100 million of our neighbors and not do it for all of us. We’ve got to be partners with all the other stakeholders that are responsible for other members of society.

Now, the trampoline for all of that is the Affordable Care Act. It is an extraordinary piece of public policy. The Affordable Care Act is full of answers. It answers the needs of a lot of our neighbors and us.

Thirty-two million people who previously wouldn’t have health-care coverage will, one way or another, find health-care coverage through the Affordable Care Act. It’s an answer to them. It’s an answer to people with chronic illness in this country, people who have been told by their insurance company that they are uninsurable because they need care. The Affordable Care Act changes that; over time, all people can have access to coverage. It’s an answer to young people, under 26, who will now be covered by their parents’ policy. They would otherwise find themselves floating as they find their legs in the mature life ahead of them. It helps small business through subsidies. It helps people at the margins of low-income find their way toward insurance. It’s an answer to our country. Providing a sense of security to so many more of us so that we won’t have to wake up in the morning asking ourselves if we’ll have access to the health-care coverage we want. We won’t be bankrupted because of our health-care needs.

Along with that set of answers comes a set of questions. The key question with respect to the future is: It’s great that we have better coverage and can get the coverage we want and need, but what care? Coverage of what system? It feels like there are almost two parts to this tectonic change in our stewardship of our health-care system. Phase one is making sure people can get the coverage and care they need; it’s well underway now. But the second phase, one that requires even more dedication, has to do with shaping a care system that is sustainable. We know that the health-care system, as it currently functions, isn’t sustainable and it wouldn’t have been sustainable even if we didn’t supply the expanded coverage from the Affordable Care Act.  It’s not sustainable because of its fragmentation, the fact that we build a health-care system in pieces instead of as an entirety; it exists in events instead of journeys. What we know from science, and certainly our own experiences, is that it’s not what we need. It’s certainly not for those of us with chronic illness or ongoing needs who are making the journey through our health-care system at different times. A sustainable health-care system has to make sense for those who need it today, and unfortunately, our health-care system does not. 

I’ve talked for years about the three-part aim that I’ve now proposed [should] become the rubric for the achievements of [CMS].  A major force for the continual improvement of the health and health care for all Americans. What do I mean by improvement? I mean three things. One is better care for the sick. Better care for individuals: safe, effective, efficient, timely, equitable care. That’s not an unfair request, and it’s not out of reach. In The New England Journal of Medicine [in the November 25, 2010, issue] is a report from North Carolina by Chris Landrigan and his team tracking 10 hospitals in North Carolina from 2002 to 2007 to study the cause [of] injuries to patients. This is the harm part, the safety part: People get hurt in hospitals, they get infections they shouldn’t get. They get pressure ulcers that could have been avoided; I visited a senior center that had zero pressure ulcers, so that can be achieved. But we’re not there, and better health care for all individuals would mean a vast investment to make hospitals as safe as they can possibly be, which would be much safer than what it is today. The kind of safety we’ve come to expect from our automobile or in our hotel room should be expected when it comes to our health care too. Patient-centeredness, the dignity to be honored as an individual with respect to what they know and what they can contribute. Timeliness, efficiency, equity – we can do far better, but we’re not there yet.

But that’s just one aim; the second aim has to be about the things that bring us into the hospital in the first place. Our heart attacks, strokes, consequences of substance abuse, and the unwise choices we make lead to care in the first place and we can do a ton about that. An enormous percent of things that lead us to illness are things that we can control. Now, we have been giving lip service to prevention in this country since the words lip service have been invented, but we have not invested in it at the level we could. The Affordable Care Act improves that; we now have, under Medicare, well-adult visits at no cost to the medical beneficiary every single year. That’s the second aim: better care and better health for populations.

The third aim is to do it all for less. Lower cost through improvement; that’s the secret. I’m not talking about hurting a single hair on a person’s head, I’m not talking about withholding a particle of data, but through an agenda of improvement we can lower costs of health care. We know it can be done.

That’s the three-part goal that I feel properly represents the social need that the Affordable Care Act encapsulates, whether we’re talking about Medicare or another source of support or care for people. Better care, better health, better cost. But all of this will involve change, and I think CMS, in partnership with those many other stewards of health care within our nation who are willing to shoulder the burden of finding a [health-] care system, can do better.

That leads me to my final thought, a key word, really: authenticity. Let me explain what I mean. Change is hard, but it’s the only way to improvement. In this enormous industry where so much is invested in the status quo, there will be two different voices for better health. One will be authentic; they’ll be the real partners and want to work together, not just with CMS but also with everybody, to try to birth better care, better health, and lower costs for all Americans. But another voice, hopefully a minority, is inauthentic. Those that are so invested in the status quo that they’re smart enough to grab the new words. But they will only use those words to cloak the current reality. They become cloaks for the status quo, and that’s inauthentic. The partners that I will seek with CMS are the authentic ones, the ones for whom change is not just acknowledged as necessary but also embraced because in the end it’s what we want for our families and ourselves. In that authentic search, you will have no better a partner than CMS and no more willing a colleague than me.