New CMS chief to focus on quality, organization and costs

In his first major remarks on the agency's direction, Dr. Berwick spells out his policy goals under a "Triple Aim" plan.

By Chris Silva — Posted Sept. 27, 2010

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The agency that oversees Medicare and Medicaid needs to focus on three main goals -- better quality of care, a more organized health system and lower per capita costs, said Centers for Medicare & Medicaid Administrator Donald M. Berwick, MD.

Dr. Berwick outlined his vision on Sept. 13 during a speech in Washington, D.C., his first major public address since President Obama appointed him in July.

Speaking at a conference hosted by America's Health Insurance Plans, Dr. Berwick lauded the Affordable Care Act as "the most significant health care legislation since Medicare and Medicaid were created." He noted how the new health reform law invests heavily in versions of integrated care that the agency is moving toward, such as accountable care organizations and medical homes. For example, CMS plans to start an ACO program Jan. 1, 2012, in which physicians and group practices can participate and potentially earn incentives for meeting certain quality standards.

Dr. Berwick spelled out his policy goals under three overarching points, which he dubbed his "Triple Aim" plan:

  • Better care for individuals by focusing on safety, effectiveness, patient-centeredness, timeliness, efficiency and equity. These also are the six areas of improvement that the Institute of Medicine has highlighted.
  • Better health for populations by focusing on "the upstream causes of so much of our ill health," such as poor nutrition, physical inactivity, substance abuse, unwise behavioral choices, violence and economic disparities.
  • Reducing per capita costs.

Several Republican senators have expressed concerns about Dr. Berwick, including past comments they interpreted as favoring government limits on health care and lauding Britain's single-payer health system.

At the AHIP conference, Dr. Berwick spoke of reducing costs while maintaining services for patients and "not harming a hair on any patient's head." He said costs could be lowered by eliminating "waste and needless hassles."

He said he is trying to focus his CMS colleagues on acute care, integrated care and community-based prevention as areas of strategic priority. Specifically, he said the quality of care in hospitals and outpatient clinical settings needs to be "much better, everywhere and for everyone."

This could be achieved, in part, by reducing fragmentation of care, Dr. Berwick said. "Too many of us know what fragmented, disorganized care looks like."

He commended the physician community for its work.

"The problems do not lie in any failure of good will, benign intentions or skills of our doctors, nurses, health care managers or staffs. With rare exceptions, they are doing their best. The problems lie in the design of the care systems in which they work, systems never built for the levels of reliability, safety, patient centeredness, efficiency or equity that we owe to ourselves and our neighbors."

Praise and criticism

Dr. Berwick's goals outlined at the AHIP conference were praised by Jack Lewin, MD, CEO of the American College of Cardiology.

"Don Berwick has been a longtime friend of the ACC, and I believe his presence at [the AHIP conference] highlights his commitment to listening to us and understanding our issues," Dr. Lewin said. "While he didn't go into great detail, he spoke at a high level about his vision for the health care system and ways the physician community can work with CMS to bring this vision to fruition. I believe it is important that we have both a physician and someone who understands quality at the helm of CMS."

But some GOP lawmakers were critical of Dr. Berwick's speech, particularly when he said, "My door is wide open to the associations, delivery systems, professions and other leaders who will join ... in pursuit of the Triple Aim for America."

Sen. John Barrasso (R, Wyo.) said he hopes Dr. Berwick will answer demands from Republicans in the House and Senate to testify before Congress on how he intends to run CMS.

"The doors of the U.S. Capitol are also wide open -- but Dr. Berwick refuses to cooperate with Congress," Barrasso said. "Republicans will continue to call on Dr. Berwick to come to the Hill and explain his plan to redesign the U.S. health care system. The American people deserve answers."

In July 14 letters to leading Democrats, Republican lawmakers asked for hearings with Dr. Berwick, citing the critical role he will play as provisions of the new health reform law take effect. Republican members of the House Ways & Means Committee followed with a Sept. 16 letter, again requesting Dr. Berwick to appear before them.

Dr. Berwick, a pediatrician, is the first permanent CMS administrator since Mark B. McClellan, MD, PhD, stepped down in October 2006. Obama appointed him as CMS administrator during a congressional recess, meaning the nomination did not require Senate approval.

As a recess appointee, Dr. Berwick -- a Harvard professor and a former president and CEO of the Institute for Healthcare Improvement -- will have the same authority as a permanent appointee. However, his appointment will expire at the end of the next session of Congress, meaning he can stay at CMS only through the end of 2011 unless the Senate confirms him later through the traditional nominating process.

The American Medical Association recently met with Dr. Berwick "on issues of critical importance to patients and physicians, including fixing the broken Medicare physician payment formula and achieving flexibility for solo and small physician practices in the development of new payment and delivery models, such as Accountable Care Organizations," AMA Board of Trustees Chair Ardis D. Hoven, MD, said in a statement.

"We were pleased to have the opportunity to have this discussion with Dr. Berwick, who committed to working with us to identify key priorities as we move forward," she said.

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