Kaiser Health News (KHN) reports that “the nomination of Dr. Donald Berwick to run the agency overseeing Medicare appears to be languishing.” Friday, KHN’s “Health Policy Week in Review” quoted a story that appeared in the New York Times a few days earlier:
"Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader. But a battle has erupted over his nomination, suggesting that Dr. Berwick faces a long uphill struggle to win Senate confirmation. Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall's elections, and Dr. Berwick has given them plenty of ammunition. In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system."
KHN also points out that according to The Hill, although Senate leaders are nearing an agreement to allow more than 60 Obama nominees to be approved to begin work, Berwick is not on the list . "'He will not get unanimous consent,' a spokesman for Senate Minority Leader Mitch McConnell (R-Ky.) told The Hill.
I am not at all persuaded that Berwick’s confirmation is in trouble.
As the highly-respected president and CEO of the Institute for Health Care Improvement, Dr. Berwick enjoys support that ranges from the AARP to three former directors of the Centers for Medicare and Medicaid (CMS) who served under Republican presidents. “This is not really about Don Berwick,” John Rother, executive vice president for policy and strategy at the AARP told McClatchy Newspapers. "In ordinary times, the nomination of somebody with Don's record and standing in the field would not be controversial.” Thomas Scully, who led the CMS under President George W. Bush agrees: "He's universally regarded and a thoughtful guy who is not partisan. I think it's more about … the health care bill. You could nominate Gandhi to be head of CMS and that would be controversial right now."
Berwick also enjoys warm endorsements from the American Association of Family Physicians, the American Medical Association, and the American Hospital Association. He is known for his ability to listen to other medical professionals, hear their concerns, and collaborate with them.
That said, I do think that conservatives will do their best to postpone the confirmation hearing. And the longer they defer the hearing, the more time they will have to try to demonize Berwick.
Plucking Quotes Out of Context
The Times suggests that “Berwick has given them plenty of ammunition,” implying that it might be Berwick’s own fault if his opponents turn his words against him. But, in fact, Berwick chooses his words with great care. He hones his speeches; he is not a loose cannon.
Nevertheless, conservatives are adept at “cherry-picking” quotations, plucking one or two sentences out of context to suggest, for example, that Berwick would like to “ration” Medicare. And in a world of “cut and paste” journalism, truncated quotes are repeated over and over, until they become facts.
The Columbia Journalism Review’s Trudy Lieberman recently described how the myth-making machines works: “Republican senators are out for Berwick’s scalp and have begun using the specter of medical rationing as the way to turn him into a headhunting trophy. They like to bring up certain statements that Berwick has made like this one: “The decision is not whether or not we will ration care. The decision is whether we ration care with our eyes open.”
As Lieberman points out “opponents usually omit the last sentence of the quote, “And right now, we are doing it blindly.” Ripping two lines out of context, critics also tend to ignore the first sentence of Berwick’s statement. Here is what he actually said, in a 2009 interview with Biotechnology Healthcare: “We make these decisions all of the time. The decision is not whether or not we will ration care. The decision is whether we ration care with our eyes open. And right now, we are doing it blindly.”
Rationing “With Our Eyes Wide Open”
In context, it’s clear that Berwick is saying that we already do ration care, but we do it wantonly, according to ability to pay, without regard to whether the patient needs the treatment. Berwick suggests that we should decide which treatments to pay for “with our eyes wide open” –looking at medical evidence about risks and benefits. If even a small pool of patients who fit a particular medical profile would be helped by a service or product, they should get it: “’Evidence-based medicine’ is not just a catch phrase;” he writes, “it is a promise we want to make to our patients – to use all the care – and only the care – that can help them.” Somehow this last sentence never seems to show up in the hundreds of blog posts and news stories that have been written about Berwick in the last two months.
Usually we think of “rationing” as restricting consumption of a commodity that is in short supply. But in fact, the root of the word “ration” is “reason” and this is much closer Berwick’s meaning. His aim is to make the system more rational by using medical evidence to distribute products and services. The goal: “to get the right care to the right patient at the right time.”
His aim is not cut to Medicare, but to improve it by eliminating some of the waste that clogs our bloated system—the unnecessary, often redundant tests, the ineffective, unproven treatments that expose patients to risk without benefit . . . and the hospital errors that, too often, lead to longer stays, more medication, another surgery.
In December, Berwick made his agenda clear when he challenged an audience of doctors and hospital administrators to reduce the number of tests and treatments that their patients undergo “by 10 percent”: “Do that without a single instance of harm, without rationing effective care, without excluding needed services for any population you serve." (Hat tip to McClatchy Newspapers’ reporter David Goldstein for calling attention to Berwick’s words)
But do we have the medical evidence needed to cut waste without lowering the quality of care? Yes, says Berwick: “Through modern clinical epidemiology, technology assessment, and clinical research, we have developed powerful new tools to assemble, digest, and judge the evidence-base for clinical practice. Rational care plans can emerge, based firmly in scientific evidence, and drawing on research published in hundreds of journals that serve as the basis for the expert opinions and guidance of professional medical societies."
At the same time, he would not impose comparative-effectiveness research (CER) on doctors and patients. In the Biotechnology interview, he agrees that “mandatory compliance with CER directives could be dangerous, if you overdo the tightness of the connection between the knowledge of effectiveness and the rules of compliance. Then you get into the ‘proletarianization’ of medicine — physicians, payers, and patients being told what to do instead of being able to use their own judgment. There’s a balance here between advisory declarations with enough knowledge that they really have some force, and requirements.”
Trudy Lieberman Calls for Context and Clarity
At the end of her column in the June 14 issue of the Columbia Journalism Review, Lieberman notes that conservatives have a way of making a sound-bite their own: “As we reported in the March/April 2010 issue of the Columbia Journalism Review, when the discussion of ‘death panels’ made its way into the media, the press let right wing ideologues set the agenda and spread misinformation, allowing weeks to pass before refuting their false claims. By then it was too little too late.
“This time, we’d like to see the media act as leaders instead of followers.” Lieberman writes. “For starters, they can begin to quote Berwick accurately . . . None of this business about selective quotes that opponents will inevitably use.”
Unfortunately it may once again be too late.
If you Google “Berwick” and “the decision is not whether or not we will ration care,” you will find those two lines culled from a 1200-word interview have been repeated more than 10,000 times. One wonders how many reporters actually read the piece in Biotechnology Healthcare– and how many were simply repeating what they read in another paper, or on another blog.
How Cherry-Picked Quotes Wind Up in the Mainstream Media
No surprise, the truncated quote often shows up on avowedly conservative blogs such as netrightdaily , Redstate.com, Americans for Prosperity, and Frontpagemag.com. As well as in local newspapers such as The Trentonian
The Times story is instructive; it shows how much confusion a few familiar quotes repeated out of context can create. The article does not set out to bludgeon Berwick. It begins by describing him as “a man with a mission, a preacher and a teacher who has been showing hospitals how they can save lives and money by zealously adhering to clinical protocols for the treatment of patients.” (Though, at the very end, the lead wobbles. Is “zealously” adhering to protocols good or bad? Hard to say.)
New York Times’ reporter Robert Pear goes on to suggest that Berwick faces a “long uphill battle to win confirmation.” And in describing the “ammunition” that Berwick has given his opponents, the reporter notes that Berwick “has spoken of the need to ration health care . . . and has confessed to a love affair with the British health care system.”
Throughout the piece, rationing becomes a leitmotif: “The Senate Republican leader, Mitch McConnell of Kentucky, describes Dr. Berwick as an ‘expert on rationing.’ Senator Pat Roberts, Republican of Kansas, calls him “the perfect nominee for a president whose aim has always been to save money by rationing health care.’ . . . Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, said he had no doubts about Dr. Berwick’s academic and professional qualifications, but wanted him to explain his comments on rationing.”
Pear acknowledges that, according to administration officials “Republicans have taken his comments out of context.” But the reporter doesn’t seem to buy that argument, noting that, “In fact, many of the comments have been repeated, with slight variations, in Dr. Berwick’s articles and lectures over the years.” Then, Pear offers an example:
“In an interview, last year in the journal Biotechnology Healthcare, Dr. Berwick said, “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”
Oh no, not again. The same two sentences—cast in the future tense—with no hint that we already ration care and do it in an irrational way. Ironically, Pear is using a snippet that has been ripped out of context to counter the argument that Republicans have taken Berwick’s comments out of context.
Pear does give Reid H. Cherlin, a White House spokesman, a chance to explain: “Rationing is rampant in the system today, as insurers make arbitrary decisions about who can get the care they need. Don Berwick wants to see a system in which those decisions are transparent, and the people who make them are held accountable.”
But because the quote omits the two sentences that frame the statement, a reader may well be left with the impression that Berwick favors “transparent rationing.” In other words, as one of his critics puts it, “we’ll know who is on the death panel.”
An alert reader will notice that, in the middle of the article, Pear offers two good examples of what Berwick actually means by “rationing”: “In his book, Escape Fire: Designs for the Future of Health Care, Dr. Berwick sharply criticized ‘the dangerous, toxic and expensive assumption that more is better.’ He insists that the nation can cut health costs without harming patients because vast sums are misspent. . . .” He explains how Berwick would “ration” end-of-life care: “Long before the uproar over ‘death panels’ last year, Dr. Berwick was urging health care providers to ‘reduce the use of unwanted and ineffective medical procedures at the end of life. Using unwanted procedures in terminal illness is a form of assault’” he said in 1993 at the annual conference of his institute. ‘In economic terms, it is waste.’”
But as the Times’ article moves forward, it continues to see-saw.“’I have said it before, and I’ll stand behind it, that the waste level in American medicine approaches 50 percent,’” Berwick declared in an interview in the journal Health Affairs in 2005. “Dr. Berwick has championed efforts to ‘reduce the total supply of high-technology medical and surgical care’ and to consolidate services in regional centers,” Pear adds. Does this mean that Berwick views “high tech surgery” as “waste”?
If only reporters would quote one or two other lines from the same 2005 Health Affairs interview: “Innovation is absolutely crucial, and I don’t think we should slow down our investment in better technologies,” Berwick said. But, he explained, “we have a learning disability in this country with respect to the difference between technologies that really do help and technologies that are only adding money to the margins of the companies that make them, without essentially paying their way in value. . . One of the drivers of low value in health care today is the continuous entrance of new technologies, devices, and drugs that add no value to care. If we had strong national policy, it would allow us to know the difference,” he adds, referring to the fact that, under current law, the FDA does not ask drug-makers or device-makers to show that a new product is in any way better than –or even as good as—products that are already on the market.
As the Times' story rolls toward a conclusion, the emphasis seems to falls on restricting healthcare in order to save money: “On more than one occasion, Dr. Berwick has suggested a need for a cap on total health spending, with limits on annual increases.
“In speeches and articles celebrating the 60th anniversary of Britain’s National Health Service in 2008, Dr. Berwick said he was ‘in love with the N.H.S.’ and explained why it was ‘such a seductress.’
“The N.H.S. is not just a national treasure,’ he wrote; ‘it is a global treasure.’”
“Among its virtues, he told a British audience, is that ‘you cap your health care budget.’”
Some might well call this type of reporting “balanced.” But as a reader trying to thread my way through a controversy, I find it dizzying. I want to know: is Berwick’s idea of “rationing” a threat to Medicare, or not? If I were a Medicare patient, I would be nervous.
If Berwick said one thing in one speech, and something else in another speech, one would have to say that that the fault is his. He changes the message, depending on the audience. But the truth is, if you look at any of the conservatives’ favorite “pull-out quotes” in context, you’ll find that the message is the same: “rationing” is never about cutting care that would help a patient. Don Berwick wants to save money by improving Medicare.
Berwick’s “Love” For the U.K.’s National Health Service
If you think conservatives are fond of the phrase “rationing with our eyes wide open” imagine what they do with Berwick’s declaration of love for the NHS. “I am romantic about the NHS,” Berwick said in July 2008. “I love it. All I need to do to rediscover the romance is to look at health care in my own country.”
In May, Kansas Sen. Pat Roberts read the lines on the Senate floor and then asked, rhetorically: “Why is this important? Because the NHS rations health care.”
At the beginning of this month David Catron reprised the quote in the American Spectator, followed by several paragraphs denouncing the NHS as “a third-world operation that employs Soviet-style central planning to produce terrible care and worse outcomes. . . . if confirmed, this man will do real damage.".
Two weeks ago, right-wing pundit Betsy McCaughey used the same familiar lines in a New York Post.Op-ed, explaining that Berwick likes the NHS for its “central planning, frugality, wealth redistribution and rationing.”
Fox & Friends, The Boston Globe Op-ed, the New York Times article, and virtually all of the blogs cited above bring up Berwick’s admiration for the UK’s healthcare system. Google “Berwick” and “love” and “NHS” and you’ll get 18,400 results..
What most fail to mention is the context. Berwick made the speech on the occasion of the NHS’ 60th birthday. Quite naturally, he had some nice things to say. You don’t go to a birthday party and begin your toast by roasting your host.
But Berwick’s detractors ignore the second half of the 3,000-word speech which begins: “Is the NHS perfect? Far, far from it. I know that as well as anyone in this room. From front line to Whitehall, I have had the privilege to observe its performance and even to help to measure it. The large scale facts are most recently summarized in the magisterial report by Sheila Leatherman and Kim Sutherland sponsored by The Nuffield Trust called The Quest for Quality: Refining the NHS Reforms. They find some good news. For example, after ten years of reinvestment and redesign, the NHS has more evidence-based care, lower mortality rates for major disease groups (especially cardiovascular diseases), lower waiting times for hospital, outpatient, and cancer care, more staff and technologies available, in some places better community-based mental health care, and falling rates of hospital infection. . . . There is less progress in some areas, especially by comparison with other European systems, such as in specialty access, cancer outcomes, patient-centeredness, life expectancy and infant mortality for socially deprived populations. In other words, in improving its quality, two facts are true: the NHS is en route, and the NHS has a lot more work ahead.”
Berwick then devotes 1250 words to “ten suggestions” as to how the National Health Service could do better.
He begins by urging the NHS to “put the patient at the center – at the absolute center of your system of care. . . . It means asking, “How would you like this done?” It means asking, “How can I help you?” and then you fall silent and you listen.”
He goes on to tell the NHS that it should “strengthen the local health care systems – community care systems – as a whole.” In addition, he argues that NHS must “reinvest in general practice and primary care. These, not hospital care, are the soul of a proper, community-oriented, health-preserving care system. General practice, not the hospital, is the jewel in the crown . . . “
Berwick explains that the many “governmental and quasi-governmental organizations concerned with assessing, assuring, and improving the performance of the NHS need to collaborate. . . . they do not work well with each other. The nation lacks a consistent, agreed map of roles and responsibilities that amount, in aggregate, to a coherent system of aim-setting, oversight, and assistance.”
Finally, Berwick exhorts the NHS to “train your health care workforce for the future, not the past. That workforce needs to master a whole new set of skills relevant to the leadership of and citizenship in the improvement of health care as a system – patient safety, continual improvement, teamwork, measurement, and patient-centered care, to name a few.”
The speech ends with a question: “Would it not be thrilling in the next decade for the NHS – the National Health Service – to live fully up to its middle name?” If someone other than Berwick had said this, it definitely would have sounded snarky. Coming from Berwick, it was meant as inspiration, and my guess is that the audience took it that way.
Nevertheless by the time Berwick finished with his “10 suggestions, I can only imagine that his audience was exhausted at the thought of how much work lies ahead. If this is “love” it is what they call “tough love.”
Does Berwick want to model Medicare on the NHS? I don't think so.