Berwick points to Bernard Lown, MD, a cardiologist who invented the defibrillator and whose Lown Institute won the Nobel Prize in 1995. [Note: Berwick is a volunteer member of the Lown Institute Advisory Council.]
"Dr. Lown has concluded…that about half, maybe more, of the revascularizations that we do in this country—stents and coronary artery bypass graft surgeries for stable coronary disease—are unneeded. They don't relieve symptoms any better than medical management does; they don't lengthen life; and they don't prevent future heart attacks. They don't do anything."
This is controversial, Berwick allows. "But I'm just saying what if he's right. This is the monster under the bed. We're doing 600,000 stent procedures a year and 500,000 CABG operations.
"All those angiography suites and all those gleaming operating rooms, and proud technically brilliant cardiologists—what happens to them? What happens to the business model for the heart hospital? The stent vendor... when the evidence accumulates, if it accumulates, that what we do a lot of doesn't help anywhere near as much as we thought. It's very scary."
Berwick added that "it will take courage to name and address what I believe is a large proportion of American healthcare that just doesn't help people, but subjects them to risk."
5. Distinguish profit versus greed. The American healthcare marketplace generates "energizing entrepreneurship and what I'll call proper competition," Berwick said. "But on the other hand, it has cynical, calculating greed in it. And we do not have method sin public policy or in private to tell the difference between entrepreneurship and greed and act on it."
He gave three examples, one of which resulted in a pharmaceutical company raising a $300 cost for a course of a generic hydroxyprogesterone that interrupts premature labor—to prevent low-birth weight babies—to $25,000, largely borne by the Medicaid program and the taxpayer because 50% of labor and delivery costs are borne by Medicaid. "And the threat and cost of low-birth weight babies are concentrated in families with economic and social disadvantage."