Donald Berwick on Better Care as a Route to Financial Success

The former head of CMS says "we will never solve the problem of cost and finance by focusing on cost and finance." Instead, it will be resolved "by focusing on the design and redesign of healthcare and the improvement of its quality."

This is the first of two parts. Read part two.

Donald Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement, believes health leaders need to focus on system redesign and quality, rather than on the bottom line to contain costs he describes as "out of control."

Some hospital chiefs have a hard time seeing that, he says. And while he believes in transparency, Berwick maintains that hospitals need a break from "measure mania," which he sees as more burdensome than helpful.

Q&A: Donald Berwick Calls for 'Moral' Approach to Healthcare

The former head of the Centers for Medicare & Medicaid Services, and the newest member of the Massachusetts Health Policy Commission talked with HealthLeaders Media this week. This is the first of a two-part interview. The transcript below has been lightly edited.

HLM: What are the most pressing quality issues facing hospitals today?

Berwick: The cost of healthcare in America remains out of control and continues to erode other important agendas in public and private policy and action. I see, by far, the biggest opportunity for proper cost reduction to be through the continued improvement of care.

I deeply believe that better care is lower-cost care. I see that hospital leaders continue to have difficulty in making that link and centering improvement in the strategic agenda of the hospitals. They are still driven by revenue maximization, market share, and more traditional approaches to management of the top line instead of the actual quality of care.

Berwick: The quality of hospital care is important in its own right. But there is also this immense opportunity to use the improvement of care to get costs to a reasonable level.

It's important to recognize that we have not yet sufficiently changed the payment system to align with what needs to be done. So, hospitals remain in a difficult position with a payment system that encourages revenue maximization as a strategy.

If you look at what is happens in hospitals, we have tremendous areas of overuse of procedures, technology, and tests that cannot help people. They are being done for historic reasons.

We have a tremendous amount of paperwork and non-value added activity that staff are forced to engage in and that the patient pays the price for. We have continuing problems with coordination and continuing problems with safety.

If we were able to address each of those, focusing on overuse of ineffective care, focusing on administrative burdens, focusing on safety and reliability of care and really getting authentically focused on the needs of patients, costs would fall and not rise.

HLM: Can you talk about your call for a reduction in the number of quality measures now required of hospitals and health systems?

Berwick: Over the past 20 years, as evidence grew about defects in care, there was sense of alarm. The reaction was to try to turn the lights on, to increase knowledge about the performance of healthcare in many, many dimensions for many people.

As a result, we began a festival of measurement, an almost measurement mania, where we began to believe that the solution to performance was transparency and measurement. I'm a complete fan of transparency, but we've overshot.

Now, the number of metrics exceeds the ability of any reasonable human being to consume usefully. And, there has been insufficient diligence about the alignment and harmonization of measures.

HLM: In the age of big data, why aren't there measurements offering insights needed to improve care and contain costs?

Berwick: A lot of the measurement is managed by organizations and people who are not deeply enough involved in the delivery of care. So there is a gap between the measurement enterprise and the care enterprise.

That's costly because the measurements then lack meaning in the care process. I think the time has come for a whole new era of disciplined skepticism about measurement… preserving and increasing the measurements that tell us how things are going and allowing the workforce and the system to do their work. These are costs that take resources from actual patient care and even from improvement.

HLM: How can hospitals respond to your call for a 50% reduction in quality measures?

Berwick: The methods for doing that need to be worked out. You don't want to throw the baby out with the bathwater, but harmonization is key.

When we are trying to measure something thing four or five different ways—stop and measure it one way. With each of the metrics we're using, subject them to a test. Are the results of the measurement used by anyone? If we are doing measurement and recording data that no one uses, stop it, because there's no action being taken. It can't be useful.

HLM: What kind of measurements do you think work?

Berwick: I personally think the measures that end up having most value are not at the atomic or system levels. They are about achievements for patients—length of life, quality of life, satisfaction. Patient-centered measures are the ones that will survive the scrutiny best. I'm a fan of PROMs and PREMs (patient-reported outcome measures and patient-reported experiences measures).

These are becoming better and better and could provide a more consolidated basis for what we are doing and [how we improve].

HLM: How do you see hospitals responding to the push for patient-centered care?

Berwick: I think there is a new, more modern level of authenticity about that focus on [patient] needs that hospitals have found difficult to adopt, in which you really do regard the patient and family not as your guests, but as your hosts.

I've often said we need to act not like we are hosts in our organizations, but like we are guests in people's lives. That's a shift of power. We are asking the people we serve more and more about how we are really doing, what they really need, what they want and what they don't want and tuning in more to their real needs and desires instead of our habits.

HLM: You talked about costs being the biggest problem facing hospitals, but you have suggested that those looking to improve quality take some time to consider changes without considering the price. How can hospitals address costs while making changes that don't account for costs?

Berwick: My plea is to take the spotlight off finance and profit as the primary responsibility or activity of senior leaders because I believe we will never solve the problem of cost and finance by focusing cost and finance. We're going to have to solve that problem by focusing on the design and redesign of healthcare and the improvement of its quality.

As long as executives are leaning in on revenues and profits, they will not have the energy; they are not evincing the confidence to work on care as the route to success.

I promise healthcare leaders that if they will focus on quality as their central agenda, on the needs and desires of the people they serve, if they focus on waste and its continual reduction, if they focus on the experience of the workforce, they will be financially successful.

Maybe that sounds paradoxical. But the route to financial success in healthcare in the future is not in the study and management of finance. That's the wrong agenda. It won't succeed.

This is the first of two parts. Read part two.