A missed opportunity to improve the quality of Medicare
Guest columnist Wayne Larrabee writes about the missed opportunity for improvement in Medicare quality with Medicare chief Don Berwick's departure. Though Berwick's opponents suggested quality improvements would interfere with care, Larrabee argues they are compatible.
Special to The Times
DON Berwick stepped down as Medicare chief in December because his Senate confirmation was blocked. It is worthwhile to revisit the controversy surrounding his prior recess appointment.
In essence, he was criticized for his role in bringing quality processes into our disjointed health-care system. His opponents are convinced that his recommendations to improve safety and quality are incompatible with a compassionate personalized medicine. Many physicians and others who work in our health-care system would strongly disagree.
Dr. Berwick and other health-policy experts changed the landscape forever when they published two widely read reports from the Institute of Medicine: "To Err Is Human: Building a safer healthcare system" in 1999 and "Crossing the Quality Chasm: A New Healthcare System for the 21st Century" in 2001. The latter's conclusion is that "... between the healthcare we now have and the healthcare that we could have lies not just a gap, but a chasm" has been widely accepted. These and other contributions spawned the rich and productive quality movement in health care. The basic conclusions are that health care should be safe, effective, patient centered, timely, efficient and equitable.
Many of us believe the quality movement and the personalized medicine we desire for ourselves and our families are in truth complementary. Most physicians favor well-designed systems that in addition to preventing errors provide invaluable information and analytical tools for quality improvement.
Leaders in medicine have long understood that while physicians' knowledge and technical skills are essential, other competencies are necessary for patients to receive optimal care. Our medical schools now evaluate broader system skills, while medical certifying boards require lifelong learning and understanding of these skills.
Is there a danger that such systems will interfere with physicians providing optimal care for their patients? Perhaps, but it is more likely they will benefit both physicians and patients.
The challenge as always is to design effective, flexible systems that can be modified based on experience. For example, electronic medical records are being implemented in all of our major hospitals and many smaller facilities. Mandates for excessive documentation with these records often force physicians and nurses to spend less time interacting with patients and far more interacting with keyboards. Nevertheless, electronic records dramatically increase the information available to the physician and provide analytical tools to improve clinical decision making. With most innovations there are problems after implementation, but with time and energy they can be addressed.
Therefore we need good systems that respect the human wisdom of health-care providers — that help them without interfering unnecessarily with their practice. Such systems are best developed by those who understand the art of healing as well as its science.
Berwick is as qualified as anyone I know for this role. He once shared with me an essay he wrote about his father, who was a role model for him and embodied the qualities we would all like in our personal physician. Berwick knows the science of the quality movement because he as much as anyone developed it, but he also knows the need to preserve our ability to treat each patient with dignity, respect and compassion.
It will not be easy to design systems to improve patient care and also preserve a personalized care but we must try. There will be problems, as we see now with electronic medical records, but we can change policy and solve them. All of us will be patients eventually and we will all benefit from the increased quality such systematic change will bring.
We can only hope Berwick's successor will continue to develop the quality and patient-centered systems for Medicare he has pioneered and advocated.Wayne F. Larrabee Jr., MD, practices at Swedish Hospital and is a University of Washington clinical professor. He has served as president of both the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology.
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