Berwick on Everything Health Care

Posted on | January 28, 2008 | Comments Off on Berwick on Everything Health Care

Can we manage the health of populations while improving the experience for individuals?

One of the pleasures of the Families USA Health Action conference was that the speakers represented a nice blend of top politicians and genuine health care experts. Tony Fauci MD, the wonderful head of NIH’s National Institutes for Allergies and Infectious Diseases, who talked about Global Health, was followed by the equally impressive Don Berwick MD, the Founder and leader of the Institute for Healthcare Improvement. I’ve heard Dr. Berwick speak several times and am always delighted by his cogent, comfortable, sensible presentations.

I can think of several people who, if they gave one, deserve a health care Nobel Prize for the positive impact they’ve had on millions of people through their work to change the industry. Dr. Berwick is one. (Others include Jack Wennberg MD, the founder of the Dartmouth Atlas, and David Eddy MD, who leads the Archimedes Project and who coined the term "Evidence-Based Medicine.")

As fate had it, I was delayed coming into Dr. Don Berwick’s talk, and arrived just when he had covered the quality improvement goals of health care – that it should be safe, effective, patient-center, timely, efficient and equitable – that were defined by the 2001 Institute of Medicine report, Crossing The Quality Chasm.

Dr. Berwick’s talk was peppered with interesting, mildly provocative observations.

More than any other physical test, skin color (that is, race) is the best predictor of health status. Sad but true.
Our health system’s performance is limited by human frailty. To improve, we need to build identify those frailties and build dykes around them. That is, fortify processes that are vulnerable to human error.
American health care STEALS from other important societal functions that desperately need the money it consumes. Other industrialized nations – he pointed to Sweden as possibly having the best health system currently – provide care to all their citizens for 60% or less than what it costs us. Maybe we should be spending 9% of Gross Domestic Product, but 16+ percent is outrageous, based on the fact that most developed countries do a better job for far less. Whatever we spend on the greedy health care industry, we’re unable to spend on other things that also matter tremendously: education, infrastructure, the environment.
We drive low value in American health care. As the Dartmouth folks have demonstrated repeatedly, demand is driven by supply. As a rule, we don’t make clinical choices based on data-backed determinations of value. (I believe that will change as Health 2.0 ramps up.)

But the most important message of Dr Berwick’s presentation was his explanation of what he calls the Triple Aim. This ideal here is to transition our health system to a state of "simultaneous, integrated work to improve the patient’s experience with care over time and the health of a defined population while containing cost per capita of health care."

In other words, manage the health of populations while improving the experience of individual patients. At the same time, reducing the cost of care for each patient.

I wholeheartedly agree that these are the goals of a truly effective and efficient system. They’re also wholly elusive given the current structure and political realities of American health care. Dr. Berwick is aware of this. In an earlier presentation on the same topic – see here for a copy – he lays out a list of system characteristics that are necessary to achieve these goals. All are tall orders that America’s health care industrial complex would fight. They include

• Population budgets
• Discipline of a cap on total budget
• Population view of health status and care needs
• Measurement capacity
• Capacity to integrate care experience through time and space
• Capacity for proactivity
• “Memory”of the person
• Capacity for system redesign and execution
• Leverage to mold the environment.

Still, its very worthwhile to have this kind of vision, this level of specificity, and the drive to continually frame our current progress against them. Through patience, an ability to articulate need and solutions, and diplomacy, Dr. Berwick has facilitated tremendous quality advances in hospitals across the country. And that lends him enormous authority to urge the process on.