The Donald Berwick Predicament:
Draws High Praise as Head of CMS but Wont Be Confirmed
Universally regarded
thoughtful guy who is not partisan; endorsed
by two former GOP heads of CMS but GOP senators say 'No'
By Harold Pollack
and Christopher Lillis, M.D., Kaiser Health News
Donald Berwick
Kaiser Health News
has a resource guide on Berwick with a biography, collection of
media profiles and a video interview
Click Here.
March 14, 2011 -
Dr. Donald Berwick runs the Centers for Medicare & Medicaid Services. He
now serves under a recess appointment that will expire at the end of
this year. And, although the president could take the politically risky
step of extending his tenure with another recess appointment, officially
naming him to run the agency for the long haul would require Senate
confirmation. News reports suggest that this won't happen. Berwick may
not even receive a hearing.
We can't
evaluate the backstage politics, but one thing is certain. Both
Democrats and Republicans should be dismayed at the sight of a partisan
campaign driving yet another distinguished figure out of American
government.
In a recent
letter, 42 Republican senators harshly urged that Berwick's permanent
nomination by withdrawn, citing his "lack of experience in the areas of
health plan operations and insurance regulation" as well as "his record
of controversial statements and general lack of experience managing an
organization as large and complex as CMS."
Because 42 votes is enough to
block his approval, Berwick has been described by some as a bureaucratic
dead man walking.
Dr. Donald M. Berwick has repeatedly challenged
doctors and hospitals to provide better care at a lower cost; may soon
run Medicare, Medicaid - March 29, 2010
As one supporter
told the New York Times: "Everybody here admires Don and the work
he's done, but he is not going to be confirmed. That's inevitable.
There's not a lot of optimism that the White House can do anything about
it."
You might think
there is some genuine issue regarding Berwick's professional stature,
his experience, his integrity or his job performance. There isn't - any
more than there is such an issue regarding whether Federal Reserve Board
nominee (and Nobel Prize-winning economist) Peter Diamond
has sufficient experience in monetary policy.
Berwick has
greater management experience than many previous CMS administrators. Few
have matched his knowledge of the American health care system or his
high standing within the medical profession.
He is one of the world's
leading experts in patient safety and quality improvement. A
pediatrician and health policy researcher, he has authored hundreds of
scholarly articles. He has spent decades in the trenches of the American
health care system seeking to improve it.
In 1999, he
co-founded the Institute for Healthcare Improvement, which has provided
guidance in the U.S. and abroad regarding strategies to improve health
outcomes. Most famous is the
100,000 lives campaign, which disseminates best practices to prevent
hospital-acquired infections and avoidable deaths.
He is intimately
familiar with many of the nation's best (and worst) health care
organizations. The new federal health law finances critical
demonstration projects to expand coverage, improve chronic disease
management and to improve care quality. He has virtually unique
credibility among physicians, hospital leaders and health services
researchers in leading these efforts.
He is exactly
the type of health policy wonk who, if circumstances were different,
might have been appointed to the same job under a Republican
administration. Thomas Scully, CMS administrator under President George
W. Bush,
got to the nub of things: "He's universally regarded and a
thoughtful guy who is not partisan. You could nominate Gandhi to be
head of CMS and that would be controversial right now." Berwick's
nomination was
supported by Gail Wilensky and Mark McClellan, two prominent
Republicans who ran CMS in two Bush administrations.
But, like every
seasoned and serious health policy researcher, he has provided a few
sound bites that political operatives can spin
in a systemic campaign to depict him as a left-wing figure. For
example, Berwick recommended that physicians "reduce the use of unwanted
and ineffective medical procedures at the end of life." One can present
such statements as supporting death panels. In fact, these comments
reflect a sensible and humane perspective shared by most physicians who
provide end-of-life care.
President Barack
Obama's adversaries are pursuing Berwick because he provides a valuable
political scalp in attacking the health law. Last year, opponents of the
measure waged
a deliberate campaign against him immediately following its passage.
In this climate, the most likely outcome of Berwick's nomination would
have been for it to linger for months and then to finally die under a
filibuster. Rather than see this happen and to waste months in the
implementation of one of the most complicated policy reforms in American
history, Obama gave Berwick a recess appointment.
Though not
ideal, this was the proper response to escalating, bluntly partisan
abuses of the Senate confirmation process. The proper purpose of the
confirmation process is to scrutinize nominees, to question them and
then to approve or reject them through an up-or-down vote. If senators
continue to exploit ossified procedures to simply obstruct opposing
administrations, presidents of both parties will pursue recess
appointments with greater frequency.
They will be
right to do so. Berwick serves a Democratic administration, but you can
bet that policy experts in the next Republican administration will
receive similar rough handling. Imagine what skilled Democratic
operatives could do to any Republican nominee who had genuine
private-sector "experience in the areas of health plan operations and
insurance regulation," say because they worked for an insurer or an HMO.
Imagine what
would happen if Democrats were to pursue the same sound-bite fishing
expedition that was pursued against Berwick. He stands accused of
praising Britain's National Institute for Health and Clinical Excellence
(NICE), which examines which therapies the National Health Service
should finance based on efficacy and cost-effectiveness.
McClellan praised NICE's approach in rather similar terms in
addressing America's escalating medical expenditures.
Does this mean
that McClellan supports death panels and rationing? No. Virtually any
policy expert who has had the courage to discuss delicate issues of
financing, palliative care or cost control has said something that can
be ripped out of context and used to politically embarrass or destroy
them.
Politics is a
rough business. Some rough and tumble personal criticisms come with the
territory. Still, the long-run consequences of blocking a
highly-qualified official such as Berwick are quite damaging
especially at this critical point in time.
As the new
health reform law is implemented, it will require many adjustments and
fixes along the way. Much public attention is focused on ideological
differences between Democrats and Republicans regarding expanded
coverage, the accompanying taxation, and more. Alongside the ideological
divide, it also poses technical challenges that are less ideological but
no less difficult to resolve.
The Obama
administration will need to work with the states and with both parties
in Congress to implement health insurance exchanges, to regulate
insurers, to expand Medicaid and more. This won't be easy. It will
require good faith collaboration in a very difficult and polarized
national moment. This task will also require public managers and policy
experts on both sides of the table who have the experiences, the
professional standing and the expertise to get the work done.
Our worst fear
is that the people best-equipped to do these jobs will view Berwick's
predicament and decide: It just isn't worth it. After all, people at
Berwick's or McClellan's level can pursue many other lucrative and
challenging opportunities that bring a lot less trouble and stress. For
government to succeed, we need such experts who can do their work at
least somewhat shielded from the immediate partisan fray.
Our cable-TV
political culture provides too little space for this. If we don't fix
this, we will all come to regret it.
Notes:
Pollack is a public health policy researcher at the University of
Chicago's School of Social Service Administration, and faculty chair of
the Center for Health Administration Studies.
Dr.
Lillis is a graduate of the Georgetown University School of Medicine and
practices medicine in Fredericksburg Va.
But, like every
seasoned and serious health policy researcher, he has provided a few
sound bites that political operatives can spin
