The New Health Dialogue

Since 8 Tuesday morning (I’m writing this in a hotel lobby at 4 in the afternoon) I have been trying to figure out how to capture in a few blog paragraphs how Don Berwick managed to turn a snow-dusted red squirrel into a metaphor for both high quality health care -- and for the world his baby grandson will inherit.

Having concluded that I can’t quite convey what Berwick  achieved in his annual IHI conference keynote – watch speech   excerpts on IHI’s website -- I offer a pale substitute. Watching a squirrel on a still and snowy New Hampshire trail is important to Berwick. Really, really important to Berwick. If he had had  knee replacement surgery a few years ago – unnecessary knee replacement surgery, as it turns out -- he wouldn’t be “ski skating” on that trail (don’t ask --ski skating is harder to describe than the squirrel). He’d certainly never be able to share it with his grandson.

Berwick’s job as IHI president and CEO isn’t just to promote research and training and initiatives about health care quality. It’s also to energize his audience, at this annual conference and beyond, to make them believe they can create the quality care  that they and their communities need and deserve. By quality he means economically sustainable, morally just, efficient and effective patient-centered health care. And part of what he does here, when he isn’t talking about squirrels (or sheep, for that matter) is to showcase places around the country, and around the world, that are achieving it.

• Sentara Williamsburg hospital has not had a single ventilator-associated pneumonia case in five years.
• The Seton Family of Hospitals has had only one birth trauma out of its last  10,000 births.
• Palmetto Hospital in South Carolina cut standardized mortality rates in half.
• Henry Ford Health System has not had a suicide of a high risk patient for a year.
• The Zorko Clinic in the Upper East Region of Northern Ghana hasn’t had a neonatal or child death for 15 months.

The list goes on. This is a big conference. Physically and conceptually.

In his speech, Berwick spoke favorably about Congress’s efforts to expand coverage. Covering everybody is right and it is just, he said.  But as we’ve written here before, Berwick doesn’t just want health care reform. He advocates health care Re-Form.  And he doesn’t think legislation in Washington, as it now stands, achieves that, at least not transformative re-form. But it’s not at all clear that’s a bad thing, in the squirrel’s eye view of the world.

“Congress hasn’t led us to a new care system and I don’t think it will. Congress won’t give America even a vague prescription much less a detailed set of rules for that. How could they? How could Congress possibly know enough to specify, for every community, the exact design for that: care that is safe, effective, patient-centered, timely efficient and equitable?” he asked.

It was less a rhetorical question than a challenge to his audience. If Congress doesn’t transform U.S. health care, they must do it themselves.

Later, in a smaller group conversation, where his role wasn’t so much to motivate as to reflect, Berwick offered a slightly different perspective. What he sees in Congress right now -- and the legislation is still evolving -- does not rise to Berwick’s definition of transformative. But he did see change, constructive change, short of transformation. He saw value in payment and systems changes in the bill -- a bit of “re-forming” along with the reform. Bundled payments will help hospital innovators already cutting the waste. Measures aimed at reducing hospital readmissions and hospital acquired infections and a host of reporting and accountability and reporting measures will contribute “quite a bit toward aggressive quality improvement” though not enough to change the basic structure of the system, he told us.

His worries:  that incentives could be designed in ways that hurt the innovators, the early adopters, the doctors and nurses and hospitals and health systems that have already squeezed out waste and begun providing less expensive, higher quality care. He believes cooperation and collaboration within a community -- including among competitors -- is essential, and he worries that anti-trust measures too strictly construed could be counterproductive if they conflate cooperation with collusion.

His hopes -- because Don is a self-described optimist, he does optimism for a living -- is that the changes in the U.S. health care system will take off with unanticipated force, speed and success. That changes both within and far beyond Washington will accelerate, and become transformative. “We’ll pass the legislation. And the system is going to surprise everybody.” He mused about what it would be like if government economists could measure optimism, award it a value. “There is a missed beat there,” he said of the CBO’s “scores” of the bills. “But how do you score possibility and optimism and reinvention?”

Neither CBO nor OMB has an answer to that. Maybe they should ask the squirrel.