Berwick On Mass. Health Reform: More Pain, More Gain

Dr. Donald Berwick, former Medicare chief

I don’t know about you, but when my dentist says that I’m about to experience some “temporary discomfort,” I know what that really means is, “Hang in there, this is going to hurt like heck.”

In the Boston Globe, Dr. Donald Berwick, the widely admired former chief of Medicare and one of the nation’s leading health policy mavens, has just weighed in on the competing proposals for cost-cutting reform in Massachusetts. He argues in favor of aiming for more ambitious cost-cutting targets: The House’s tougher goal rather than the Senate’s less ambitious one, or even the still-tougher target put forth by business and religious groups.

I must say that what struck me most in his essay were the repeated references to pain for a good cause. Massachusetts needs “large-scale changes in delivery that will be temporarily uncomfortable for most providers.” Government must step in because “The changes are just too hard for most to face.” And “Undoubtedly, this transition will be wrenching.” I’m left wondering: Is there a political equivalent to Novocaine?

The whole piece is an important read but here’s an excerpt:

Bills now before the Massachusetts House and Senate can provide that will in the form of a cost target, and by creating consequences for missing it. The House would limit the growth of health care costs to the growth rate of the Massachusetts economy starting now, and then to 0.5 percentage points lower than the overall economic growth rate starting in 2016. The Senate is less ambitious; it would set a limit of 0.5 percent above economic growth until 2016, and then equal to it thereafter. Neither matches the bolder goal proposed last month by both the Associated Industries of Massachusetts and the Greater Boston Interfaith Organization: 2 percentage points lower than the overall growth rate.

Alarms are sounding. Massachusetts hospitals and other providers are warning that too stringent a target will harm care — and harm the state’s economy when unemployment is already high.

Undoubtedly, this transition will be wrenching. But no healthy industry can maintain jobs that depend on continuing services that add no value.

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  • Roger


    Under-resourced hospitals and physicians cannot bootstrap to compete for share against systems that are using their massive war chests to beat them out of every market in the state.  Wealthy systems build “clinical bridges” with hospitals and physician groups that assure them of referrals regardless of how inefficient they are.    By pouring resources into targeted hospitals and physician groups they effectively build a distribution channel that they own and can’t be disrupted.  There is no functioning marketplace in healthcare– that sort of wishful thinking will perpetuate and enshrine the monopsonies that are driving up costs.   

  • Dan Ross

    Why not facilitate hospital’s to compete with each other in the area of value? Value is: medical outcomes/cost + safety. The winners will be more efficient, produce quicker patient recovery, less inefficiency Thus perform at lower cost. Relying on government is tantamount to bringing the postal service into medicine.

  • Roger

    I would refine your question:  Will the pain be felt equally by all of us?  Dr. Berwick stubbornly ignores the fact that the spending on healthcare in MA already varies widely, with the wealthiest communities spending far more on their care than working class communities spend on theirs.  If the residents of Wellesley and Newton already have the luxury of spending 15%-20% more on their care, will a small reduction in spending matter as much to them as as a small reduction to those in East Boston or Lawrence?  

    Dr. Berwick’s endorsement of global payments and spending limits that will hit those with the least bargaining power the hardest, is an unfortunate endorsement of perpetuating the two-tiered system that insurers created by paying the largest systems far more than others for more than a decade.  Those providers that serve a more balanced mix of commercially insured and government pay patients were deprived of even inflationary increases while those with the largest and wealthiest commercial patient bases were bestowed with resources communities like Brockton or Holyoke could only dream of.   Dr. Berwick turns a blind eye to the resource imbalance that is crushing those who serve the poorest populations– and driving more and more commercial business to the most expensive providers.

    I had hoped for a more thoughtful and nuanced perspective from Dr. Berwick. Surely the former CMS director doesn’t believe that when powerful systems negotiate their global budgets they will not get more than their fair share?     

    Explain to me again how this global payment thing saves money?  And which populations it will hit hardest?  And who is regulation bad for?