By Mark Thill
I’m supporting Donald Berwick, M.D., for president.
Mark Thill
Writing in a recent issue of the Journal of the American Medical Association, Berwick, president emeritus and senior fellow, Institute for Healthcare Improvement, and former administrator of the Centers for Medicare & Medicaid Services, pointed out that we are about to enter “Era 3” of medicine and healthcare.
And I am ready to follow him there.
Era 1, he says, “was the ascendancy of the profession….Its norm include these: the profession of medicine is noble; it has special knowledge, inaccessible to laity; it is beneficent; and it will self-regulate. In return, society conceded to the medical profession a privilege most other work groups do not get – the authority to judge the quality of its own work.”
But all was not well. “The idealism of Era 1 was shaken when researchers…found problems, such as enormous unexplained variation in practice, rates of injury from errors in care high enough to make healthcare a public health menace, indignities, injustice related to race and social class, and profiteering.”
Enter Era 2 – the one we inhabit today.
“Exponents of Era 1 believe in professional trust and prerogative,” he writes. “Those of Era 2 believe in accountability, scrutiny, measurement, incentives, and markets….” But that’s not working either. “Physicians, other clinicians, and many healthcare managers feel angry, misunderstood, and overcontrolled. Payers, governments, and consumer groups feel suspicious, resisted, and often helpless.”
Era 3 will be “guided by updated beliefs that reject both the protectionism of Era 1 and the reductionism of Era 2,” says Berwick. But to become reality, nine changes must occur:
- Reduce mandatory measurement. “Intemperate measurement is as unwise and irresponsible as is intemperate healthcare,” he says. “The aim should be to measure only what matters, and mainly for learning.”
- Stop complex individual incentives. Incentivizing healthcare systems and large physician groups on the basis of improved health and lower costs is fine. But applying the same measures to individual physicians can be “confusing, unstable and invite gaming.”
- Shift the business strategy from revenue to quality. “This requires mastering the theory and methods of improvement as a core competence for healthcare leaders.”
- Give up professional prerogative when it hurts the whole. The most important question a modern professional can ask is not ‘What do I do?’ but ‘What am I part of?’”
- Use improvement science. “Modern quality sciences offer a sterling alternative to the hostility and misunderstanding that inspection, reward, and punishment create.”
- Ensure complete transparency. “The right rule is: ‘Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens.’”
- Hear the voices of the people served. “Clinicians, and those who train them, should learn how to ask less, ‘What is the matter with you?’ and more, ‘What matters to you?’”
- Reject greed. “Rapacious pharmaceutical pricing, hospitals’ exploiting market leverage to increase prices, profiteering physicians, and billing processes that deteriorate into games with consultants coaching on how to squeeze out more profit all hurt patients and impair trust. Era 3 needs much more restraint.”
See why I like this guy?
A vote for Berwick is a vote for better medicine.