Donald Berwick -- Nominee Loves Health Care Rationing

Donald Berwick is Obama's pick to head the Centers for Medicare and Medicaid Services who defends government rationing of health care.  He is has praised Britain's awful health care system called NICE that puts a price tag on a person's life.  I hope the Republicans are somehow able to block his nomination. 


While much of Washington is focused on President Obama's Supreme Court pick, Republicans are gearing up for a confirmation battle over another Obama nominee who promises to put health care back in the spotlight.

At issue is Obama's choice to head the Centers for Medicare and Medicaid Services, Donald Berwick, a Harvard professor with a self-professed love affair with Britain's socialized health care system. In his writings and speeches, Berwick has defended government rationing and advocated centralized budget caps on health care spending.

"Cynics beware, I am romantic about the (British) National Health Service; I love it," Berwick said in a July 2008 speech at England's Wembley stadium. "All I need to do to rediscover the romance is to look at health care in my own country."

While Berwick would not have the authority to impose a British health care system on the United States in one fell swoop, as head of CMS, he would be running both Medicare and Medicaid. Given that the two programs alone account for more than one out of every three dollars spent on health care in America (all government programs combined account for 47 percent), private players tend to follow CMS's lead. Berwick himself has made this point.

"(G)overnment is an extraordinarily important player in the American health care scene, and it has inescapable duties with respect to improvement of care, or we're not going to get improved care," he said in a January 2005 interview with Health Affairs. "Government remains a major purchaser.… So as CMS goes and as Medicaid goes, so goes the system."

There are two basic visions for how to contain the growth of health care spending. The free market approach would give individuals control over their health care dollars, with the idea that it would encourage more shopping that will drive down costs and increase quality as has happened in every other aspect of the consumer-based economy. But the other approach, employed by nations such as Britain, is to have the government ration care to meet a global budget.

President Obama rejected the market-based approach, and sought to drastically expand insurance coverage while reducing health care costs. But according to a report by CMS's chief actuary, the new law will actually increase health care costs. That leaves rationing of care based on a bureaucratic notion of the common good as the remaining option for containing skyrocketing spending, and it's an outcome that Berwick himself once predicted would be necessary to achieve universal coverage.

"(T)he Holy Grail of universal coverage in the United States may remain out of reach unless, through rational collective action overriding some individual self-interest, we can reduce per capita costs," Berwick wrote in an article for Health Affairs he co-authored in 2008.

He went on to write that, "The hallmarks of proper financial management in a system… are government policies, purchasing contracts, or market mechanisms that lead to a cap on total spending, with strictly limited year-on-year growth targets."

On a number of occasions, Berwick has praised Britain's National Institute for Clinical Excellence (NICE), a body of experts that advises the government-run health care system on how to allocate medical spending based on cost-benefit analysis. Among other decisions, they have ruled against the use of cancer-treating drugs and put a dollar value on the final six months of human life.

"NICE is extremely effective and a conscientious, valuable, and -- importantly -- knowledge-building system," Berwick said in an interview last June in Biotechnology Healthcare. "The fact that it's a bogeyman in this country is a political fact, not a technical one."

The national health care law that President Obama signed in March will greatly expand the role of CMS by adding an estimated 15 million beneficiaries to Medicaid. In addition, the law contains a number of initiatives, to be spearheaded by the Secretary of Health and Human Services in conjunction with the head of CMS, to provide incentive-based pay to doctors and hospitals based on performance. This builds on the comparative effectiveness research provision of last year's economic stimulus package. While none of these measures will have the same sway as NICE does in Britain, taken together, they will move America in a NICE-like direction, especially with Berwick at the helm.

In 2003, Berwick signed on to an open letter in Health Affairs, called "Paying for Performance: Medicare Should Lead." (Among his co-signers was Nancy-Ann DeParle, the current White House health care czar.) "Our recommendation-to the executive branch; to Congress; to employers and health plans; and to hospitals, physicians, nurses, and other health professionals -- is that payment for performance should become a top national priority and that Medicare payments should lead in this effort, with an immediate priority for hospital care," the letter read. It went on to say that the CMS administrator's successors must continue to show "aggressiveness and commitment" to the cause, noting that, "A major initiative by Medicare to pay for performance can be expected to stimulate similar efforts by private payers…"

The idea of paying doctors and hospitals for delivering better quality health care and of offering guidance on best practices seems benign enough. As the letter put it, "Quality is not an issue for partisanship." The problem arises when government bureaucrats or expert panels are in the position of judging quality, performance, and best practices which get applied across a broad and diverse population.

As cardiologist Sandeep Jauhar argued in a September 2008 New York Times op-ed, pay for performance initiatives can cause unintended consequences such as doctors overprescribing certain medications that are deemed effective and carry bonuses. He also recounted how an initiative in the early 1990s to give report cards to doctors performing coronary bypass surgery prompted doctors to cherry pick patients to avoid the most severely ill cases that could jeopardize their grades.
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H/T The American Spectator