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Don Berwick Wants You To Judge the Quality, Not Quantity, of His Service

Donald Berwick may not be long for public office, but he’s determined to leave a long-lasting mark on the U.S. health care system.

The nation’s top Medicare and Medicaid official had promised in February “the largest national effort on patient safety that we’ve ever seen.” And in April, Berwick and HHS Secretary Kathleen Sebelius finally unveiled the “Partnership for Patients,” a $1 billion initiative that will target hospital performance.  

Meanwhile, Berwick has overseen a slew of new federal rules intended to revamp payment and incent higher quality care.

“[T]here’s a right way to reform Medicare and a wrong way,” Berwick wrote in a Wall Street Journal editorial last week. And he’s convinced that his reforms — which are modeled on his successful patient safety campaigns at the Institute for Healthcare Improvement — are the right prescription for true health care change.

‘Partnering’ To Lower Costs

Compared to its health insurance changes, the Obama administration’s movement to improve patient safety is relatively bipartisan and non-controversial. Few dispute CMS’ stark data: the agency says it spent $4.4 billion in 2009 on care for patients harmed in hospitals and another $26 billion on patients who were readmitted within 30 days.

The Partnership for Patients, funded through the Patient Protection and Affordable Care Act, has two main goals: reduce preventable injuries by 40% and cut hospital readmissions by 20% by 2013. CMS says that achieving the Partnership’s goals would result in 1.8 million fewer patient injuries, allow more than 1.6 million patients to recover free of preventable complications and save up to $35 billion in health costs.

HHS said it would allocate up to $1 billion in federal health reform law funds to achieve the two goals. Half of the funds are already available, siphoned through the community-based Care Transitions Program, while CMS’ Innovation Center eventually will dedicate up to $500 million for demonstration programs that seek to reduce hospital-acquired conditions.

While the Partnership will eventually target all forms of patient harm, HHS has asked hospitals initially to focus on nine types of complications and medical errors, including adverse drug reactions, childbirth complications, pressure ulcers and surgical site infections. Partnership members will identify specific ways to reduce patient complications and injuries, according to the release.

The CMS Innovation Center will help facilities adopt effective, evidence-based improvements locally by sharing strategies among public and private partners nationwide. “With new tools provided by the Affordable Care Act, we can aggressively implement programs that will help hospitals reduce preventable errors,” according to Berwick. “We will provide hospitals with incentives to improve the quality of health care, and provide real assistance to medical professionals and hospitals to support their efforts to reduce harm.”

Other CMS Initiatives Designed To Reward Quality

New regulations unveiled by CMS also are designed to boost quality of care, in partnership with the Partnership.

For example, Medicare released its Value-Based Purchasing Rule on Friday. The program — which is required under the federal health reform law — will take effect in fiscal year 2013 and reward better-performing hospitals with commensurately higher incentive payments. The payments will be based on whether acute care hospitals meet certain care quality and patient satisfaction metrics, or how much hospitals’ performance improves across a set time frame.

Meanwhile, new payment regulations to govern Medicare reimbursement, such as the recently released rule for inpatient hospitals and for inpatient rehabilitation facilities, penalize providers that fail to share quality data. The inpatient rehab rule would require data on two quality measures: urinary tract infections associated with urinary catheters, as well as new or exacerbated pressure ulcers. Facilities that don’t provide data on the conditions would have payment rates lowered by two percentage points starting in FY 2014.

Some Criticism Amid Broader Enthusiasm

The Partnership was generally met with praise. More than 500 hospitals, physicians, employers, and nurse and consumer groups already have committed to participating in the initiative. But there’s caution around the plan’s specifics and some of the reimbursement changes.

According to Leah Binder, who heads the Leapfrog Group, CMS must make Medicare and Medicaid data publicly available so “the initiatives that take place in pursuit of patient safety are done in the sunlight.” David Classen, chief medical officer for the Computer Sciences Corp’s health care group, hailed the Partnership but warned that “the details aren’t there.”

CQ HealthBeat also reported that hospital officials are growing wary as CMS continues to pile on proposals to cut their reimbursement. One health care lobbyist said several industry leaders have “been having buyer’s remorse for six months now,” noting that “[t]he full impact of the law is finally becoming real.”

Berwick’s Future: As Shaky as the Overhaul?

According to Modern Healthcare, some health care stakeholders are worried that Berwick’s own uncertain future could hurt the Partnership’s implementation. Berwick has been a target of political criticism since emerging as a candidate to head CMS in 2010 and is not expected to win Senate confirmation to remain in seat past 2011.

Leigh Hamby, the top physician and chief quality officer at Atlanta’s Piedmont Healthcare, warned that if Berwick is pushed out at CMS, the agency’s safety initiatives might lose momentum and could return to “business as usual, operating as a payer instead of an agent of change.” Other quality leaders, however, say that the effort is sustainable without Berwick — even if it would be better steered by him.

“I may not agree with him substantively on everything, but he’s definitely doing a good job,” according to Tom Scully, who led CMS under President George W. Bush. Scully added that Berwick should “go out with his chin up happily on December 31 … [T]hat may or may not be right or fair — but that’s what’s going to happen.”

Berwick’s quality reforms — and his fate at CMS — bear watching in the months ahead. Meanwhile, here’s the key health reform news from the past week. 

Rolling Out the Reform Law

  • On Monday, Center for Medicare Deputy Administrator and Director Jon Blum said that federal officials are taking seriously the criticism and tough questions posed by the public regarding the proposed rules for accountable care organizations. During the comment period on the regulation, some comments have characterized ACOs as too similar to HMOs and questioned whether the rules will lead to provider consolidation. At a meeting sponsored by the College of American Pathologists, Blum said officials plan to carefully weigh comments on the rules as they come in and will consider whether to make changes (Adams, CQ HealthBeat, 5/2).
  • The number of young adults taking advantage of a provision in the federal health reform law that allows them to remain on their parents’ health insurance plans until age 26 appears to be outpacing previous estimates. HHS estimated that about 1.2 million young adults would sign up by the end of 2011, but early numbers from insurers show that the number might be much higher. WellPoint reported that the provision resulted in 280,000 new enrollees, while Aetna added about 100,000 plan members, Kaiser Permanente added about 90,000, Highmark added about 72,000 and Health Care Service added about 82,000 (Galewitz, Kaiser Health News, 5/1).
  • Last week, the Department of Defense issued an interim rule announcing that TRICARE — the military’s health care program — will cover dependents up to age 26. Before the change took effect, TRICARE only covered dependents up to age 21, or up to age 23 if dependents were full-time college students and their parents provided more than half of their financial support. The change means that TRICARE beneficiaries now are on equal footing with other young U.S. residents who became eligible for coverage under their parents’ policies through the federal health reform law (Pecquet, “Healthwatch,” The Hill, 4/28).
  • Although the federal health reform law requires private insurers and Medicare to provide preventive services with no out-of-pocket costs for patients, situations where the preventive test calls for a treatment procedure are causing confusion about cost-sharing. The confusion stems from situations in which physicians provide both preventive and therapeutic care in the same visit, according to Robert Zirkelbach, a spokesperson for America’s Health Insurance Plans (Meyer, Kaiser Health News/Los Angeles Times, 4/20).
  • Several health care industry and patient advocacy groups are preparing to launch a not-for-profit coalition that will advocate for simplified enrollment procedures in Medicaid and other government-supported health insurance programs. The new group, known as Enroll America, is slated to formally begin operations within four to six weeks, according to the group’s acting director, Rachel Klein, deputy director of health policy at Families USA. The temporary coalition will be sponsored by prominent industry groups and trade organizations, including the Pharmaceutical Research and Manufacturers of America, America’s Health Insurance Plans, the American Hospital Association and Kaiser Permanente (Adams, CQ HealthBeat, 4/26).

On the Hill

  • Last week, Republican leaders on the House Ways and Means Committee sent a letter to Internal Revenue Service Commissioner Douglas Shulman requesting detailed information on how the agency used money from the federal health reform law’s $1 billion implementation fund. Committee Chair Dave Camp (R-Mich.) and Oversight Subcommittee Chair Charles Boustany (R-La.) gave the IRS until May 12 to provide extensive documentation on spending from the implementation fund. The letter alleges that the agency already has received “tens of millions of dollars from this fund to implement parts of the health care overhaul” (Zigmond, Modern Healthcare, 4/28).
  • New legislation (HR 1213) that would repeal mandatory funding in the federal health reform law for states to establish health insurance exchanges would cut the federal deficit by about $14 billion over 10 years, according to a Congressional Budget Office analysis released last week. However, CBO noted that the legislation also would delay the operation of such exchanges (Lambert/Smith, Reuters, 4/28). Earlier this month, the House Energy and Commerce Committee approved HR 1213 — along with four other bills that would dismantle or defund the health reform law — and asked CBO to provide the analysis of the bill (Zigmond, Modern Healthcare, 4/28).
  • Last week, Senate Majority Leader Harry Reid (D-Nev.) said he could shelve a small-business research bill (S 493) over disagreements about a series of unrelated amendments, including one that would block implementation of the federal health reform law. The amendment would block the health reform law’s provisions from taking effect until various lawsuits challenging the law are resolved. According to CQ Today, the amendment was one of a series added to the bill by members of both parties under an open amendment process that Reid and Senate Minority Leader Mitch McConnell (R-Ky.) agreed to earlier this year (Friel, CQ Today, 4/27).
  • Meanwhile, the White House recently released records showing who White House Deputy Chief of Staff Nancy-Ann DeParle met with in her role as director of the White House Office of Health Reform during negotiations over the federal health reform law. In February, House Energy and Commerce Committee Chair Fred Upton (R-Mich.) and Subcommittee on Oversight and Investigations Chair Cliff Stearns (R-Fla.) sent a letter to DeParle, asking her to provide such information by March 4. The documents show that DeParle met with more than 100 representatives from hospital, physician, insurance and pharmaceutical companies, as well as other advocacy groups and lobbyists (DoBias, National Journal, 4/27).

In the States

  • On Monday, the Florida Senate voted 30-7 in favor of a state House-approved bill (HB 1193) that would prohibit state residents from being required to purchase health insurance as mandated under the federal health reform law, sending the measure to Gov. Rick Scott (R). Legal experts say that federal laws override state legislation. Scott, former CEO of hospital chain Columbia/HCA, has been an outspoken opponent of the overhaul (AP/Miami Herald, 5/2).
  • Last week, the Colorado House Health and Education Committee passed a bill (HB 1273) that would authorize the state to negotiate a compact with other states to create regulations that override the federal health reform law. The bill does not contain guidelines about the specific health care policies a compact might pursue, but advocates say the states might be able to design policies better than the federal government (Sealover, Denver Business Journal, 4/26). Also last week, the Colorado Senate gave preliminary approval to a bill (SB 200) that would create a state health insurance exchange as required under the federal health reform law. The bill would establish a nine-member board to develop the exchange (Sealover, Denver Business Journal, 4/25).



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