Con­trol­ling health care costs needs to hap­pen from within

Austin American-Statesman - - OPINION - Inglis is an edi­tor and neona­tal in­ten­sive care staff nurse with the Se­ton Fam­ily of Hos­pi­tals in Austin.

The White House nom­i­na­tion of Dr. Don­ald Ber­wick to head the Cen­ters for Medi­care and Med­i­caid Ser­vices seems to be im­plod­ing. If it does, it would be a missed op­por­tu­nity for our coun­try.

Con­spic­u­ously ab­sent from the health care over­haul were mean­ing­ful mea­sures to con­trol costs. There’s a rea­son for that: Govern­ment can­not leg­is­late that is­sue, be­cause health care is too com­plex. An ex­am­ple of a clumsy con­gres­sional at­tempt was the cut Medi­care physi­cian pay­ments in the 1990s. The dra­co­nian law has re­sulted in po­lit­i­cally messy fights, with Congress block­ing the cuts 10 times in the last eight years, in­clud­ing four times since Jan­uary.

If there’s one man in the coun­try who knows how to pro­ceed with con­trol­ling health care costs, it’s Ber­wick, a Har­vard clin­i­cal pro­fes­sor of pe­di­atrics and health care pol­icy.

Repub­li­cans should be the ones most in­ter­ested in his con­fir­ma­tion. Stun­ningly, they are the ones op­pos­ing it. Why? They cite re­marks he has made — all taken out of con­text — about ra­tioned care, the Bri­tish Na­tional Health Ser­vice and pri­mary care “med­i­cal home” mod­els of care.

Pro­fes­sors by na­ture think out­side of the box, and they are re­warded for it. Any be­gin­ning stu­dent of U.S. health care pol­icy learns that in a coun­try with a fifth to a quar­ter of its pop­u­la­tion unin­sured, it’s a mat­ter of pub­lic pol­icy by omis­sion that health care is ra­tioned. I sus­pect most health care pol­icy pro­fes­sors will rightly in­struct that if ra­tioning is a given, then it is in the pub­lic in­ter­est to do so with eyes open rather than closed, some­thing Ber­wick re­ferred to in an in­ter­view last year in the jour­nal Biotech­nol­ogy Health­care.

In this in­ter­view, Ber­wick re­ferred to an ini­tia­tive funded in the Amer­i­can Re­cov­ery and Rein­vest­ment Act of 2009 to eval­u­ate the ef­fec­tive­ness of tar­geted ther­a­pies and rec­om­mend re­duc­ing in­ef­fec­tive and costly ones. The pro­gram is named Com­par­a­tive Ef­fec­tive­ness Re­search. He calls it what it is — ev­i­dence-based medicine. Repub­li­cans are ac­cus­ing him of ad­vo­cat­ing “ra­tioning of health care,” a fright­en­ing con­cept to the pub­lic. In fact, given a ra­tioned care en­vi­ron­ment, he is look­ing at the data to sug­gest ef­fec­tive ther­a­pies.

Repub­li­cans should also ap­pre­ci­ate is his dis­taste for manda­tory com­pli­ance with CER di­rec­tives. He prefers mak­ing in­for­ma­tion and re­search avail­able to clin­i­cians in the form of ad­vi­sories.

He founded the In­sti­tute for Health­care Im­prove­ment in the early 1990s, which has worked with thou­sands of hos­pi­tals world­wide to de­velop ev­i­dence-based best prac­tices. Ber­wick cer­tainly has made a trans­for­ma­tional change As­cen­stion Health, where I worked for 30 years as a neona­tal in­ten­sive care nurse.

Dur­ing this past decade, Ber­wick’s or­ga­ni­za­tion suc­cess­fully has tack­led some of the most deadly, costly, tragic — and avoid­able — events in health care: hos­pi­tal-acquired pneu­mo­nia from ven­ti­la­tor us­age, cen­tral ve­nous line in­fec­tions, ad­verse drug re­ac­tions and many more. Real cost con­trols in health care will take place from within the in­dus­try, and us­ing ev­i­dence-based prac­tice is the best hope.

In my own area, we have ef­fec­tively elim­i­nated birth trauma in­jury to term in­fants. Our hos­pi­tal also worked with Ber­wick’s or­ga­ni­za­tion to de­velop an­other IHI life-sav­ing in­no­va­tion — rapid-re­sponse teams. These teams, which have spread all over the United States, con­sist of a crit­i­cal care nurse and res­pi­ra­tory ther­a­pist avail­able 24/7 to seek out pa­tients and an­swer calls from nurses on the floor, usu­ally out­side of the in­ten­sive care unit, who see pa­tients go­ing down­hill. The teams pro­vide oxy­gen, IVs, drugs or other ther­a­pies to sta­bi­lize pa­tients.

Hos­pi­tals have seen a 50 per­cent re­duc­tion in “code blue” calls — pa­tients who need to be re­sus­ci­tated be­cause they’ve stopped breath­ing and their hearts have stopped beat­ing. Ev­ery time I hear the hos­pi­tal op­er­a­tor call over­head, “Rapid re­sponse team, re­port to room X,” I smile and think of Ber­wick. I think of how grate­ful that pa­tient and his or her fam­ily will be that the pa­tient was caught in time be­fore it was too late.

The smile van­ishes quickly, though, when I think of the im­pend­ing dis­as­ter of tak­ing pro­fes­so­rial re­marks out of con­text and de­stroy­ing what may well be this coun­try’s only real hope of im­prov­ing health care while rein­ing in costs. DBer­wick, more than any­one, rec­og­nizes that lo­cal com­mu­ni­ties and clin­i­cians, not a na­tional sys­tem, will be the ones to rein in costs.

Dr. Don­ald Ber­wick

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