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

The former head of CMS advocates for a single-payer system and for bringing "pride and joy" to the workplace among physicians, nurses, administrators, and executives who are all involved in doing the work of caring.

This article was originally published on January 14, 2016. This is the second of two parts. Read part one.

When Donald Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement, was a candidate for the head of Centers for Medicare & Medicaid Services, opponents seized on his admiration of Britain's National Health Service.

In the second part of Berwick's interview with HealthLeaders, (read part one), he spoke about his support not just for the Patient Protection Affordable Care Act, but for a single-payer health system. Both, he says, recognize health as a right and represent a needed "moral" approach to care. He also calls for a push to bring "pride and joy" to the workplace. The transcript of the interview has been lightly edited for clarity.

HLM: Do you think the provisions of the Patient Protection and Affordable Care Act will lead to quality improvements?

Berwick: I think it's a great step forward. [It's] not perfect, though. Part of the ACA is the insurance law. It's the attempt in our country to make healthcare a human right, to take a step in that direction. I thoroughly support it; I wish we could go further faster.

It's been productive and could be more productive. The decision to do this with private insurance systems was a political decision. We could have done it with an expansion of Medicare and Medicaid. But, we should be proud that the country is trying to make health a human right.

Donald Berwick on Better Care as a Route to Financial Success

I wish the Medicaid expansions were occurring in all states. I wish the exchanges had gone smoothly and had been more supported and had been more active in defending the rights of beneficiaries. But, all of those are improvements in a basically sound approach to improving healthcare coverage

On improvement, there is good news and news that could be better. There has been a lot of investment in transparency; remember, I'm not an enemy of transparency. There are parts of the law that are urging more access to Medicare data on the part of people who want to improve.

There is support for the Center for Medicare and Medicaid Innovation, which has been doing brilliant and immensely important work with HENs (hospital engagement networks), which are providing hospitals the chance to learn from and teach each other.

There is support for continuity. There are major investments in community-based care transitions medical homes, ACOs, bundled payments. All of these are attempts to change payments to be more supportive of the real needs of patients.

One the other side, I wish we had more national support for the work of improvement. Even better and stronger networks for change, maybe a little less reliance on measure, measure, measure and maybe a little more reliance on health, health, health.

HLM: You've taken a position in support of a single-payer approach to health coverage. Can you talk about why you think a single-payer system would improve care?

Berwick: Correctly managed it would. The first way would be by reducing the administrative burden. Right now, it's north of 15% of the money we spend on healthcare. It is going to manage paper. That's a function of a pluralistic insurance systems without coordination. Coding schemes, billing procedures, benefits structure, they vary. It's a zoo of challenges.

It leads to a lot of paperwork for everybody. For patients, families, government, hospitals, and doctors. A single payer system would be simpler to manage. People in other countries with consolidated payment systems can't believe the amount we've been spending on administration.

The second advantage of single payer is what I would call 'customer voice.' It allows the payer, if it is publically accountable, to sit at a table and on behalf of the public at large, and make requests and demands that would benefit the public.

As Medicare Administer, I could do that for 47 million beneficiaries and 50 million Medicaid beneficiates. I could see the data and say, 'we are doing a bad job on safety in nursing homes,' or 'we need to do more on care coordination between inpatient and outpatient care.'

Workarounds in Hospitals Raise Ethical Questions

I could go to the delivery systems and insist on the importance of protection for beneficiaries. In a multi-payer system, that gets much harder to do. There is no consolidated representation of the interests of the public.

In the single-payer system I got to run, Medicare, the focus was on the needs of beneficiaries and not the needs of shareholders. The organization runs very lean in terms of salary and staff. And it tries to make sure that the resources are used for beneficiaries.

Insurance companies argue for 15% of their revenue to be used for non-care purposes. In fact, their financial health is graded according to medical loss ratios.

The other thing that single-payer system allows is sensible transparency. All the data are in one place and you can begin to look at care in a more holistic, more thorough way and make that information readily available to the people who give care.

Right now we have a terrible problem of coming up with a unified view of the flow of money and the quality of care because there are so many different players who own so many different data sets. It gets really hard to manage quality in that environment.

HLM: You've also called for a more "moral" approach to the delivery of care. Could you explain what that would entail?

Berwick: If you think about the pursuit of health as the ultimate goal of the investment we are making, in our case about 18% of our gross domestic product, it would lead you to ask what creates health and what disturbs it.

The answers are pretty clear that among the great disrupters of health are injustice, inequity, racism, and a failure to regard healthcare as human right. These, to me, are moral issues. The commitment to a fair and just society, one in which equality is embraced, [is one] in which responsibility for each other is part of the fabric.

To me it sounds right. It matches my ethical frame. It also sounds smart because what you are interested in is people who can live lives at the highest level of function and be productive in society and enjoy their lives.

The relationships between poverty, injustice, racism and inequity on one hand, and health status, function, and longevity on the other hand, are very well described. I think health professionals need to be advocates for social justice. Hospitals need to inspect their processes of care to see that they are sensitive to issues of social determinants of health and social supports that people need in order to stay out of the hospital. That needs to be woven into the fabric of hospital care.

The wonderful work Rebecca Onie is doing at Health Leads is an example of equipping healthcare providers, in this case medical students, to reach out to patients and understand the full spectrum of their needs and not stop at the boundaries of job descriptions or the walls of the institution.

That's why integrated health systems, in the end, will have a better shot at success than hospitals. This does demand that hospitals reach outside their walls to give people the support they need.

HLM: The IHI Leadership Alliance is made up of 40 organizations working to pursue the triple aim: better care, better health and lower costs. You've said another area they will target is "joy in work." Can you describe that effort?

Berwick: You'll see in the work of the IHI an increasing focus on joy and pride in work as an essential goal. I would say any sensible hospitals leader has to realize that it is on the critical path to success.

There is growing evidence of problems of morale and burnout in the workforce, [among] doctors, nurses, administrators, and even executives. It is a signal of a problem that is very toxic to quality. In any service industry, let alone one that is dependent on compassion, the customer, the person you are helping isn't going to experience excellence in the hand of a demoralized staff.

Understanding what generates pride and joy is crucial. Understanding what generates pride and joy is not easy and the theory and approach are still very much under development, especially in an era of austerity. But it it's possible.

We will be making a big mistake if we continue on a trajectory of healthcare which continues to erode the energy and self-confidence and joy—that's the right word—of the people are doing the work of caring.

This is the second of two parts. Read part one.