Obamacare

The Berwick Battle Begins

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The coming battle over President Obama's nomination of Donald Berwick to the top spot at the Centers for Medicare and Medicaid Services is, like the health care reform debate before it, a struggle between centralizers and decentralizers. Indeed, Berwick is an almost prototypical centralizer. In particular, he has repeatedly expressed fondness for Britain's NICE, which does cost-benefit analysis for the country's government-run health care system (ie: rationing). Philip Klein has done a thorough job of digging through Berwick's record:

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."

…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. The problem with any uniform medical guidance is that what's good for the "average" patient may not be right for any given patient.

Given President Obama's leanings on health care policy—as demonstrated in the recent health care legislation—it's not all that surprising that he would choose a strong centralizer for this role. But the choice continues a worrying trend toward health care policy that places far too much emphasis on centralized control and far too little on individual decision making.

NEXT: When You Say Bud, You Have Not Said it All, Thank You Very Much

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  1. It’s death laminate.

  2. Well, this should tear the scab off the health care reform wound nicely.

    1. What scab? The wound never healed due to the infections of uncertainty and doubt. The term you are looking for is ulcerated.

      1. The wound never healed because its still waiting for a doctors-appointment.

  3. So, what does Berwick say about the fact that Canada just came out and declared their national health system unsustainable?

    1. Canada just doesn’t have the Right People In Charge.

      1. They’re Canadian. Duh?

  4. Heh heh heh! Two more weeks, CMS. Two more weeks.

  5. I recall not too long ago that some foreign news outlet promoted an Onion piece they believed to be real news. It would be a comical misfortune if our bureaucrats, humorless stiffs that they are, were to do something similar but applied to domestic policy making…

    http://www.thedailymash.co.uk/…..hs-chiefs-?50-to-kill-cancer-patients-201004122630/

  6. 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.

    “If you think health care is expensive now, wait until it’s free.”

    1. It seems to me the hard part is not the valuation, but in knowing in advance which six months are the last.

  7. I’m just heading to the pool to resist socialism.

    1. I pee in the pool of socialism.

  8. 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.

    Not to be confused with Death Panels, which are of course just a fragment of Sarah Palin’s imagination!

    1. Dammit they’re LIFE Panels!
      [they decide who will live]

      1. I think “Schindler panels” has a nice ring to it.

  9. “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.”

    And insurance companies in the U.S. don’t? Whatever care you want, they will pay for, no questions asked? My dental insurance says my mouth is only worth $1,000. That’s all they will pay for. And haven’t insurance companies in the U.S. decided that Matt Welch’s life is worth, you know, $0.00?

    1. They did a bang-up job of fixing those “market failures”, then, didn’t they?

    2. And insurance companies in the U.S. don’t?

      No, they don’t. They certainly don’t put a dollar value on the final six months of life. They also don’t rule against the use of any drug.

      They may or may not agree to pay for a drug, but it is unusual for an insurance company to refuse to pay for an FDA-approved drug to be used for its approved purpose. Experimental or off-label uses? Sure, they’ll decline to pay for those. But so do the government programs.

      1. Experimental or off-label uses? Sure, they’ll decline to pay for those.

        Prescribing an appropriate RX off-label can be more effective than an indicated drug and cheaper than the co-pay in some cases.

    3. My dental insurance says my mouth is only worth $1,000. That’s all they will pay for.

      Well, that’s all you contracted with them to pay for. Why should they pay for more than you agreed to when you took the policy?

      1. Our employee voluntary dental insurance pays up to $1500 per participant per year. Several employees have said they could probably do just as well putting their bi-weekly premium in a coffee can.
        The only dental insurance that makes sense to most employees is if it is “free” i.e. paid for 100% by the employer.

    4. “One of the methods used by statists to destroy capitalism consists in establishing controls that tie a given industry hand and foot, making it unable to solve its problems, then declaring that freedom has failed and stronger controls are necessary.” Ayn Rand

      Interesting, isn’t it, that Progressives like Mr. Vanneman focus solely on whether X pays or not and totally ignores a number of salient differences between the two scenarios.

      1. Insurance companies are semi-private companies. (Regulations have turned them into half-government, half-private utilities).

      2. Such regulations make it impossible for competition to work effectively in the half-private sector.

      3. Until recently, one had a choice whether or not to engage their services. Once the entire medical system in the U.S. is nationalized one will have only one provider choice, by law, as is nearly the case now.

      4. Government health care is inherently opposed to competition. Just as the Feds had to disallow most areas that FedEx, et al could compete with the Post Office, so they are gradually doing so in the case of health insurance.

      In short, Mr. Vanneman, like all Progressives, makes no distinction between goods and services delivered voluntarily in the free market and those delivered by stolen money and delivered under coercive mandates.

      The value of freedom, both morally and practically, never gets a fair consideration. Respect for individual rights are simply not on the menu.

  10. I understand the concerns re: Berwick’s statement on NHS. However, he’s best known and had the greatest impact on quality improvement in health care;
    something that is sorely needed.

    1. Yeah, and Mussolini made the trains run on time.

  11. As a typical American, I want Obama to have dictatorial power over me. I trust every single decision he makes.

  12. In Obamacare, death is a COST SAVINGS. Great. My wife, on Medicare, has already had an MRI refused by Medicare. Refused bcuz NOT approp for that problem – detection of brain lesions. Previously NEVER HAD A PROBLEM w/ private insurers for MRI.

  13. Am I missing something, aside from even the least compassion for the aging boomers his policies will kill?
    In the short run his denial of care will save money, and in the long run it will destroy the middle class approval of this little slice of the welfare state. What’s not to like?
    Libertarians have really lost the battle for ideas when we can’t get behind demanding death panels when we’re coerced to pay for the effects of other people’s habits.

  14. Remember, when all else fails….. BLAME B U S H

  15. There should be a fight to keep this creep out of any government position. These are the people Obama is placing to take away your personal freedoms.

  16. sorry all, but calculating the value of treatment in quality of life years makes total sense. especially when defining a public service designed to maximize the common good. if you want more,get supplemental insurance.

    We already ration now, but solely on the basis of wealth, rather than need. Sorry, that is not a moral way to provide healthcare to a society

    1. sorry all, but calculating the value of treatment in quality of life years makes total sense. especially when defining a public service designed to maximize the common good.

      With the right presumptions, any conclusion makes logical sense. See, for example “public service” and “designed to maximize the common good.”

      We already ration now, but solely on the basis of wealth, rather than need.

      Defining “rationing” to mean “you must pay for it” strips the term of all meaning.

  17. Berwick is another radical socialist, the kind Obama loves. Vote for a conservative this November to stop this march towards socialism!

  18. Look at the handling of the Gulf oil spill by Obama and the Federal Government, and realize that they are moving forward with the Federal Government takeover and micro-management of our nations entire healthcare system! Imagine its blood and not oil? If you think we have a national emergency now wait until your life and health, and the lives and health of your children rest in the hands of the same people that handled Katrina, the Underwear bomber, and now the Gulf oil spill? Obama and the Democrats are forcing us into a disaster beyond imagination!!!!!

    1. No huge fan of Obama, but I’m not sure exactly what he could have done differently about the oil spill. Even if they required a contingency plan for capping the well, they wouldn’t have any way to know whether it would work without experiencing an actual emergency.

  19. Truly frightening. Those who refuse to learn from the past are destined to repeat it.

    Obama and the other wingnuts always display the ultimate arrogance, they think they know better.

    Which is why they will fail, and take us with them, unless the HCR bill is repealed.

  20. Government of the people, by the bureaucrats, for the people.

    Canada is Not going to be happy about it when we take away their other option.

  21. My Wife is a physician. How do you reconcile pay for performance if the patients do not comply with the Doctor’s orders? Noncompliance is one of the elephants in the room in this debate.

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