Why Obama Made the Right Call on Berwick

By  |  July 8, 2010 |  14 

The recess appointment of Don Berwick to lead CMS can be seen as a cynical act of political opportunism, sidestepping the Congressional approval process using a tactic worthy of Machiavelli, or Karl Rove. Or it can be viewed as a pragmatic decision by Obama to avoid a lengthy and exasperating re-litigation of the healthcare reform debate.

Death Panels. Been there, done that. So I’m going with Choice #2.

The right side of the blogosphere has erupted, painting Berwick as an effete academic who would have withered underBerwick the Klieg lights and piercing questions of the likes of John Ensign and Jim Bunning. Those of us who know Don have no doubt that he would have more than held his own in debating the lessons of England’s healthcare system and the necessity of clear-headed rationing choices. Don is serious, hyperarticulate and intellectually nimble; in a real debate with members of the Senate Finance Committee, all my money would have been on him.

But the Berwick “situation”, like they say on Jersey Shore, demonstrates a larger challenge. In the old days, when Medicare was a dumb payer of invoices, its chief could be a bureaucratic functionary, charged only with making the trains run on time. But today we need the Centers for Medicare & Medicaid Services (CMS) to be so much more: promoting new and innovative care (medical homes, accountable care organizations, healthcare IT) and payment (bundling, pay for performance, “no pay for errors”) models, extracting waste and fraud from the system, facilitating new levels of transparency (by healthcare organizations, hospitals, and individual doctors), catalyzing new ways of training future doctors (Medicare funds most of the nation’s residency training slots); the list goes on. In fact, the healthcare reform bill grants CMS extraordinary new powers to develop and implement these ideas.

In that context, CMS’s head honcho now needs to be someone with a point of view, passion, and a backbone. Although I guess there might be a healthcare version of Elena Kagan – a brilliant, charismatic leader who manages to come with a scanty written and oral footprint to be dissected and distorted – most healthcare folks with the Right Stuff will have a public record that illustrates that the person has periodically done battle with the status quo. I certainly hope so.

So we’re stuck: The very things that make Berwick right for the CMS role also make him a target in today’s political environment, where all serious debate is trivialized and caricatured via talking points and schoolyard name calling. (This week’s na na na na na was calling Berwick “Rationer-in-Chief.” One can hardly resist a comeback like, “And so’s your mother.”) In such an environment, the ends do justify the means. In making this recess appointment, Obama did not bypass a substantive airing of Berwick’s qualifications to run the most important healthcare organization in the country. Rather, he avoided a sandbox brawl. As Jonathan Cohn wrote in the New Republic,

For the record, a serious conversation about Berwick’s qualifications and plans would have been worthwhile. I’ve heard even people sympathetic to Berwick question whether his administrative experience is adequate. But, again, it’s hard to have a serious conversation when one of the two political parties refuses to be serious.

The Dems were well within their rights to use the recess appointment mechanism (as the Bushies did hundreds of times in their day), just as they were to use the reconciliation mechanism to pass the healthcare reform bill. Of course, the GOP is now completely free to paint the Berwick appointment as unacceptably anti-democratic. Who’s right? Who cares? The voters will ultimately decide.

But while we’re mulling it over, CMS will have its first permanent boss since 2006, and we’ll have healthcare’s most innovative and influential leader at the center of the action, when the need to improve the quality, safety, and efficiency of care has never been more pressing. I look forward to seeing how Don tackles these challenges – I think he’ll be terrific.

I’d be lying if I didn’t admit that – as a healthcare political junkie – I’ll miss watching the Senate hearings. But I’ll try to catch a few minutes of World Wide Wrestling tonight on the tube. That should give me my fix.


  1. philip wade July 8, 2010 at 8:55 pm - Reply

    I worked with Don in the early days of Harvard Community Health Plan. He is a total winner…then and now. I still ask the questions he was asking then. And we took off on quality in that organization. This is some very good news for our health care system

  2. Brad F July 8, 2010 at 9:15 pm - Reply

    Another fear, and you alluded to it above, is the political overtones of any tough decisions Berwick might face. Under ordinary circumstances, if there was bipartisan agreement to bring some fiscal sanity to the party, any drug, intervention, service, etc., that was excessive, inefficient, harmful–you pick the term–would be axed and no one would waver.

    However, in the fight for the AARP consitutuency, any adversary of Medicare reform who can champion the cause of the senior set and portray CMS, Berwick et al as rationing Ayatollah’s, even if changes are postive and helpful to trust fund solvency, will make easy meat of the change agents. I am afraid the press will glom onto sound bytes awful quick and what would not have been a controversial decision, will erupt into another death panel extravaganza. The WSJ op ed and even mainstream press will embed irreversible impressions.

    How much leeway Obama and exectuive branch will give to CMS to potentially lose a whole voting block, or water down necessary changes, is not something discussed, but a fear I have. Berwick could have a helluva time, and while he might be tough–and most of us know what he is capable of, public opinion can move quick and cause problems that could paralyze reform efforts. The public may not know Don Berwick now, but I dont want him to become: “Oh, that guy…the one who spoke out against dialysis in 90 yo’s and killed that guy in Podunk.” Or so Mitch McConnell and Tea Party says.


  3. bev M.D. July 8, 2010 at 9:47 pm - Reply

    Addressing Brad’s comment, I have recently learned, if I didn’t know already, that the naysayers are going to find a way to naysay no matter what you do. Therefore, the same things are going to be said about Dr. Berwick no matter how he was appointed. A recess appointment merely puts him in the position and working while the natterers natter on, rather than sitting in a hard chair in a hearing room, wasting his time.

    I would like to thank Dr. Wachter for a well articulated and supportive post about a true star. It’s refreshing to see someone have the guts to say positive things about good people rather than remain silent while the haters tear them down.

  4. Angela July 8, 2010 at 11:31 pm - Reply

    As an R.N. who is on disability I worry about the current path that our medical system is taking. I have seen,and see presently. In addition to my own health problems I am also a co-caregiver for my Grandmother who is 84 with multiple medical problems and dementia as well as helping care for my Mother who has Sjorgen’s Syndrome. While I agree with cutting Medicare waste,I am concerned about services being cut that are offered through Medicare. While Donald Berwick sounds good,his positive,even rosy, comments about the NHS in England are disturbing. Hopefully he will all of us concerned about him wrong.

  5. Alfred July 9, 2010 at 5:51 am - Reply

    Redistribution of wealth is:

    A – Socialist

    B – Fascist

    C – Communist

    All are failed systems.  Dr. Berwick is not an innovative thinker.  He is mired in the past.  Socialism had it’s heyday in the early to middle part of the 20th Century.

    Americans (and I’m not concerned with any other part of the world, I live in the present, the here and now, in the USA) will rise to confront a problem and find a solution which respects each person.

    Dr. Berwick has no respect for the people of this country.  He will mandate wealth transfer because he cannot envision himself as a charitable person, and extends this opinion to all Americans.  Or, he does perceive himself as charitable, and feels a compelling need to force his opinion on Americans.  Neither shows respect for the people of this country.  He disdainfully looks down his smug nose convinced his opinion is the only one of value.

    Now he can smugly run one-sixth of the USA economy from his ivory tower.  The term which comes to mind is dictator.  Very Fascist, such as Hitler and Mussolini. Very communist, such Stalin.  i am a free person.  Dr. Berwick and his ilk want to enslave me.

    Leftists do not engage in meaningful discussion.  They take the low road of character assassination rather than confront issues.  They fully understand this is what they do, and they release vitriolic attacks on people who speak the truth.  The truth, facts, and history are their enemies.  They seek to be totalitarians in the present.  Facts don’t get in the way of a good story.  The Leftist way defined in ten words.

  6. JustAPatient July 9, 2010 at 4:45 pm - Reply

    Alfred – your comments are clearly the most ironic posted on Bob’s site since its origin. Leftists do not engage in meaningful discussion??? They take the low road of character assassination rather than confront issues??? … they release vitriolic attacks on people who speak the truth??? Facts don’t get in the way of a good story??? You just accused a man of being both a fascist and a communist! While you may disagree with the prescriptions Berwick will advocate, he undoubtedly is in command of the facts surrounding this debate. Care to share some of your own? And without vitriol and character assassination?

  7. Jazlyn July 10, 2010 at 5:15 am - Reply

    For the first time since 2006 The Centers for Medicare and Medicade finally have a stable chief. The Health Care Reform Bill has produced many questions to many individuals, and I think that it is President Obama’s call to appoint Donald Berwick to the position of operating the Centers. More and more individuals are using Medicare or Medicade to cover medical costs, and those who aren’t, are frequently getting payday loans to cover their medical bills. I am hoping that Berwick will make our health care system better rather than making it more complex and confusing.

  8. Maggie Mahar July 11, 2010 at 2:42 am - Reply

    Bob Wachter–

    Thank you. This is the most persuasive and cogent argument I have seen as to why the recess appointment made sense. I plan to link to it on HealthBeat.

    As you say: “The very things that make Berwick right for the CMS role also make him a target in today’s political environment, where all serious debate is trivialized and caricatured via talking points and schoolyard name calling.”  You (and Jon Cohn) are right: there wasn’t going to be a substantive debate of the issue at the hearing…

    I agree that Berwick could have handled the hearing. But I don’t think the American public needed to watch their elected representatives turn into trolls on C-Span  We’ve already watched a year of ugly debate on healthcare reform.

    Will this make Berwick more of a target? I don’t think so. As Bev M.D. points out, “the same things are going to be said about Dr. Berwick no matter how he was appointed.”

    I also don’t  think that this means the administration will give Berwick less leeway because the administration itself decided to expedite his appointment.

    The reform legislation purposefully gives both CMS — and the Secretary of HHS — great new freedom. The White House wants Berwick to use that freedom to improve care and reduce costs.

    As for the public, most people don’t know or care what a “recess appointment” is.

    Finally, I don’t see Don Berwick becoming “easy meat.” He’s not a politician, but he understands politics.

  9. Jack Percelay July 11, 2010 at 2:43 am - Reply

    Despite, or perhaps because of Alfred’s hyperbole, I am optimistic that Berwick’s ability to focus on changing the outcomes and refusal to accept the status quo (think of IHI’s bundles of success) will lead to meaningful changes. Not every idea will be successful, but I think those that are will be acknowledged, accepted, and exported, and look forward to more reasonable dialogue when Berwick’s nomination is resubmitted to the Senate.

  10. Rational MD July 14, 2010 at 2:46 am - Reply

    You know, there is a tough pill American need to swallow, which is you can’t have everything, all the time, including living forever. I don’t have a problem with 95 year old mom being started on hemodialysis, I just have a problem paying for it. So listen up America, if you want treatment beyond what is reasonable, you better step up and pay for it — and while you’re thinking about that babyboomers, please conceive a plan on how you’re going to care for you elderly parents — physicians can help, but it’s not our responsibility to be the cruise directory for you parents and decide what to do with them when they can no longer live on their own.

  11. Wachter Groupie July 15, 2010 at 11:25 pm - Reply

    Berwick is part of the equation to eliminate thoughtfulness and creativity in the care of patients.

    He will apply evidence based quidelines, even though many are flawed for specific patients, as a bastion of meaningful use by the computerized robots aka physicians, forced to click on meaningfully unusable EMRs and CPOEs, preprogrammed with Berwick’s “experts”‘ decision support to treat all patients the same.

    Yup, the Big O made the right choice for the government’s invasion of medicine.

  12. TrueJack July 20, 2010 at 9:38 pm - Reply

    CMS expansion and certainly Government expansion is in every way horrible for the future of this country. More clearly, government run healthcare will be a disaster!!!

    Physicians are very rapidly giving away their profession to government decision-makers and unless we stand up and say, “ENOUGH”, we will soon be collecting a paycheck from Mr. Obama. Every bureaucrat that gets “appointed” to a new office, including Berwick, is merely a symbol of our failure to stop the government from trampling us. I’m disgusted by CMS and JCAHO’s involvement in healthcare. Non-physicians will never understand the art of medicine. I’m sick of order sets and guidelines. I’m sick of the idea that a physician could be lableled “disruptive” for speaking his mind in the hospital. Most importantly, I’m sick of spineless physicians thinking that “the other guy” will stand up and try to do something about government takeover of our profession.

    Bigger government will lead to tyranny which will ultimately lead to revolution. That’s it! Keep it simple. Berwick, if you (CMS) target physicians for pay cuts, you will be responsible for the death of thousands of our greatest citizens because, quite frankly, we are already underpaid for the amount of work required to care for a Medicare patient. If you think a nurse, a PA, or a NP can adequately replace a physician, good luck with your political career. I’ve polled over 2000 Medicare patients and 95% of them have already decided to crucify the government if their physician drops them because of your “cost-saving” measures.

    Lastly, is it just me or is it completely obvious that the government is simply trying take over every industry so that they can keep the profits themselves. I believe very strongly that the government, using CMS, plans to replace the health insurance industry in order hoard profit.

  13. MikePQMD July 23, 2010 at 6:46 pm - Reply

    There are oodles of issues within this discussion. The frenzy over this appointment and the health reform debate, in general, revolves around the irrefutable fact that we can no longer afford to give everyone what they want from the healthcare system.

    To our current system, if you have coverage, you have access. If you have access, you have rights. Conversely, if you don’t have coverage, you have no rights. In other words, in America, access to healthcare has truly been a privilege, not a right. Will making it a right steer us into global oblivion?

    It has come to this–as it already has to virtually every other country–because we kind of, sort of recognize that we have limited resources to pay for healthcare, and that it might be a good idea that those resources be spent to their best effect. But what is their best effect? THAT is healthcare’s Helen of Troy.

    The knee-jerk interpretation of the above paragraph is that this means rationing of care to sick people, death panels, and the like. But if the Dartmouth-Atlas Project has revealed anything it’s that about one-third of our healthcare spend produces no appreciable value for patients. That means that buried within the healthcare industrial complex, there are hundreds of millions of dollars of waste and loss. Identifying and redistributing that money would go a very long way to pay for improved coverage and access. That’s about rationing existing resources, not codifying euthanasia.

    I spent five years working with the NHS in England (at the same time Don Berwick was working with them) on various projects. The project on corporate governance was designed specifically to hold NHS trust (hospital) boards accountable for spending limited resources to their best effect. At the point of care, that meant scrutinizing and comparing budget requests in hospitals, in an apples-to-apples manner, based on the budget request’s ability to affect quality, safety, patient satisfaction, staff retention, etc.

    For those business-minded capitalists, if you knew your management was spending your company’s precious resources on things that did nothing to sustain or grow your business, wouldn’t you demand a better way to ensure that every dollar spent returned value? Isn’t this the most capitalist of capitalist thinking?

    I don’t believe on any level that Don Berwick or anyone in the Obama Administration is conspiring to build death panels to euthanize people, or to steal from the rich and give to the poor. We need a more sensible and realistic understanding of what the word “rationing” now means in healthcare.

    The National Institute for Clinical Excellence (NICE) in England is often cited as being in the forefront of this modern concept of rationing. But there are others right here in the good ole US of A doing great work. The Harvard-based Institute for Clinical and Economic Review, led by Steve Pearson, is a leader in the practice of this thinking. Another great group furthering this agenda is the International Society for Priorities in Healthcare.

    Thank you, Dr. Wachter, for addressing this provocative topic.

  14. doctor donut August 15, 2010 at 3:56 am - Reply

    Berwick is a visionary and a genius. Also an idealist and an idealouge who will now be consumed by the machine. He will not be able to continue his work at IHI, which, unlike CMMS, is an innovative, effective and widely respected vehicle for healthcare progress. The loss is huge. Not faulting Emperor Obama for the selection, but I cannot name many successful thinkers/doers who have moved from the academy to the bureaucracy with meaningful success or satisfaction. I wish him the best.

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About the Author:

Robert M. Wachter, MD is Professor and Interim Chairman of the Department of Medicine at the University of California, San Francisco, where he holds the Lynne and Marc Benioff Endowed Chair in Hospital Medicine. He is also Chief of the Division of Hospital Medicine. He has published 250 articles and 6 books in the fields of quality, safety, and health policy. He coined the term hospitalist” in a 1996 New England Journal of Medicine article and is past-president of the Society of Hospital Medicine. He is generally considered the academic leader of the hospitalist movement, the fastest growing specialty in the history of modern medicine. He is also a national leader in the fields of patient safety and healthcare quality. He is editor of AHRQ WebM&M, a case-based patient safety journal on the Web, and AHRQ Patient Safety Network, the leading federal patient safety portal. Together, the sites receive nearly one million unique visits each year. He received one of the 2004 John M. Eisenberg Awards, the nation’s top honor in patient safety and quality. He has been selected as one of the 50 most influential physician-executives in the U.S. by Modern Healthcare magazine for the past eight years, the only academic physician to achieve this distinction; in 2015 he was #1 on the list. He is a former chair of the American Board of Internal Medicine, and has served on the healthcare advisory boards of several companies, including Google. His 2015 book, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age, was a New York Times science bestseller.


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