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Berwick, new Medicare chief, an admirer of an imperfect NHS

By MICHAEL KIRKLAND   |   July 11, 2010 at 6:30 AM   |   Comments

WASHINGTON, July 11 (UPI) -- U.S. President Barack Obama's recess appointment of Dr. Donald Berwick to head Medicare and Medicaid avoided a savage fight in Congress with Republicans still tasting bile after the passage of healthcare reform earlier this year.

But conservative blogs are in an uproar over past Berwick comments that any just healthcare system must "redistribute wealth" -- at least healthcare wealth -- from the rich to the poor.

"You could have protected the wealthy and the well, instead of recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any healthcare funding plan that is just, equitable, civilized and humane must -- must -- redistribute wealth from the richer among us to the poorer and less fortunate," Berwick said in a 2008 speech in London on the virtues of the British healthcare system. "Excellent healthcare is by definition redistribution. Britain, you chose well."

As a recess appointment, Berwick doesn't require congressional approval and has all the authority of a confirmed appointee. His tenure will expire at the end of the next congressional session in late 2011.

And though there won't be any blood officially spilled in Congress, his selection and the method of putting him in office have conjured a firestorm of criticism from the GOP and conservatives, who point to his admiration of the British government-run healthcare system as evidence of his unfitness to serve, despite a torrent of praise from the medical community.

Britain's National Health Services makes some decisions based on cost-effectiveness, which critics say amounts to healthcare rationing.

In that 2008 speech in London marking the NHS's 60th anniversary, Berwick praised the British system as "one of the truly astounding human endeavors of modern times. Just look at what you are trying to be: comprehensive, equitable, available to all, free at the point of care, and -- more and more -- aiming for excellence by world-class standards."

Britain had not chosen an easy path, he said. "No one should wonder that, as the NHS celebrates its 60th birthday this week -- an age at which humans recognize maturity -- it seems still immature, adolescent, still searching."

Berwick said the United States chose an easier path "because we do not promise healthcare as a human right. Most of my countrymen think that's unrealistic. ... Here, you make it harder for yourselves ... . You cap your healthcare budget, and you make the political and economic choices you need to make to keep affordability within reach. And, you leave no one out."

That aspect, the political and economic choices to make healthcare affordable, is what worries U.S. conservatives, critics say.

"In the U.S., we favor specialty services and hospitals over primary care and community-based services," Berwick said in his speech. "Americans are not guaranteed a medical home, as you are, and we face a serious shortage of primary care physicians. Hospitals (in the United States), on the other hand, are abundant, with many communities vastly over-bedded -- an invitation to supply-driven care. Coordinated care -- care that keeps people from having to use hospitals -- is rare; so are adequate home healthcare, hospice services, school-based clinics. Community social services and our mental health services are undefended, isolated and insufficient. Public health and prevention are but stepchildren. Here, in the NHS, you have historically put primary care -- general practice -- where it belongs: at the forefront."

Berwick asked, "Is the NHS perfect? Far, far from it." He offered 10 suggestions for improving NHS, including putting the patient "at the absolute center of your system of care."

In announcing the recess appointment, Obama acknowledged that had he gone through the usual nomination route -- the doctor actually had been nominated in April before the recess appointment sidetracked the whole confirmation process -- Berwick may have been subjected to some rough treatment.

"It's unfortunate that at a time when our nation is facing enormous challenges, many in Congress have decided to delay critical nominations for political purposes," the president said in a written statement.

Berwick, a pediatrician, is a professor at Harvard and the founder and chief executive officer of the non-profit Institute for Healthcare Improvement.

The doctor, of course, has many defenders, among them a long list of senior citizens advocates, including the hugely influential AARP.

AARP Executive Vice President John Rother, in a glowing statement of support, said: "The nomination of Dr. Berwick comes at an important time as the administration begins implementing health reforms that add new benefits to Medicare while protecting the access of older Americans to their doctors and hospitals. Dr. Berwick's expertise on healthcare innovation and his dedication to quality improvement and patient safety would benefit the millions of low-income and older Americans served by Medicare and Medicaid."

Under healthcare reform, Medicare is a testing platform for many provisions to reward providers of quality healthcare and penalize providers of poor healthcare, The New York Times reports. The law also seeks to expand Medicaid to cover 16 million more low-income people.

In another expression of support, Dr. James F. Burdick, professor of surgery at Johns Hopkins University School of Medicine, in an op-ed in The Baltimore Sun called Berwick a "champion of healthcare improvement."

Burdick called the healthcare law, the Patient Protection and Affordable Care Act, incomplete, though it "sets the stage for important healthcare reform. And it does so with a flexible structure that is perhaps unprecedented in U.S. law. It is 'unprescriptive,' leaving details open to be decided by doctors. In this, Congress has said just the right thing to American Medicine: Figure it out and get going with it."

Hospital and physicians groups joined in the approbation.

Republicans were not so kind.

U.S. Sen. Chuck Grassley of Iowa, the Senate Finance Committee's ranking minority member, said the administration "has taken advantage of the fact that there's no check on its power, with one party control of Congress and the White House."

U.S. Sen. Orrin Hatch of Utah said: "The American people deserve better than this type of arrogance of power. ... No senator -- Democrat or Republican -- was given the chance to ask Dr. Berwick about his strong support of Britain's single payer National Health Service or his belief that government delivers higher quality care than the private sector."

An editorial in The Wall Street Journal was even more critical.

"Circumventing Senate confirmation to appoint the new Medicare chief is part of the same political willfulness that inflicted ObamaCare on the country despite the objections of most voters," the Journal said.

The "progressive" non-profit Commonwealth Fund, a Berwick supporter, points to his writings over the years to help fill in the blanks that might have been erased by confirmation hearings.

Last year, Berwick joined other physician "health policy thought leaders" to write in the New England Journal of Medicine that doctors should lead the effort "to establish affordable, high-quality healthcare in this country." The group said physicians should help create consensus for among other things, a public option insurance -- rejected by Congress in the healthcare reform law enacted this year.

Berwick and his co-authors argued for more pro-active efforts by physicians on healthcare reform.

"Two threats in particular put reform at risk: conflicting doctrines (regarding the creation of a new public insurance option and government support for comparative-effectiveness studies) and opposition to change among some current stakeholders. In the face of this uncertainty, physicians have a choice: to wait and see what happens or to lead the change our country needs. We'd prefer the latter," they wrote.

In a 2006 preface to an issue of the Journal of Ambulatory Care Management, Berwick wrote that U.S. healthcare is "neither patient-centered nor collaborative," and that the "quality chasm" will never be closed without a complete restructuring of the U.S. healthcare system.

In 2005, Berwick shared the authorship of the Institute of Medicine's landmark report on medical errors, "To Err is Human: Building a Safer Health System," which found that up to 98,000 die each year because of medical errors.

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