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My Right Knee

Donald M. Berwick, MD, MPP
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From the Institute for Healthcare Improvement, Cambridge, Massachusetts.

Note: This paper is based on a plenary address, “My Right Knee,” delivered at the Institute for Healthcare Improvement's 15th Annual National Forum on Quality Improvement in Health Care, New Orleans, Louisiana, on 4 December 2003.

Acknowledgments: The author thanks Jane Roessner, Valerie Weber, and Frank Davidoff for their extraordinary help in preparing this manuscript.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Donald M. Berwick, MD, MPP, Institute for Healthcare Improvement, 20 University Road, 7th Floor, Cambridge, MA 02138; e-mail, dberwick@ihi.org.

Ann Intern Med. 2005;142(2):121-125. doi:10.7326/0003-4819-142-2-200501180-00011
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Times have been good recently for quality improvement in health care, but in 2004 the stakes on improvement went up for me personally. The problem we need to solve is this: Despite the good news, improvement is still happening in pieces. It must take some different level of energy, insight, and courage than we have mustered so far to get to total quality of care. Where will we find the courage we are going to need?

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Grahic Jump Location
Figure 1.
Radiograph of the author's knees, showing “bone-on-bone” osteoarthritis of the right knee.
Grahic Jump Location




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Is this the future of American Medicine?
Posted on January 23, 2005
Benjamin L Sapers
Rhode Island Hospital
Conflict of Interest: None Declared

Dr. Berwick writes with insight on some of the important inefficiencies and flaws in our system but I fear his attitude speaks louder than his words. Gandhi appears several times in the article as if to provide an approving stamp of compassion, and Berwick calls for better care not only for his knee but for a "Thai with dengue or an African with AIDs." But his is not a universal prescription for care: it is a prescription for grease to the squeaky wheel. He needs an appointment "any day [he] wants it" because he is "really busy" and cannot wait; yet at the same time he wants all his questions answered to his full satisfaction. He is like the patient who stomps his foot angrily when the doctor is running late but then stays in the examining room for 1 hour dissecting his concerns while other patients"”perhaps including the Thai and the African--languish in the waiting room. This is part of human nature, but does not lend itself to a just and universal health care system. To add injury to injury, he asks for no "needless deaths"¦or pain" and yet in his own non-medical life courts both climbing Mount Ranier five times: woe to the poor knees.

Berwick seems to be one of the many medical consultants who believes that apeing business models is the only way to save American medicine. He quotes glowingly Paul O'Neill and his idea of a "habit of excellence," the same O'Neill who has presided over the decline of the American economy over the last several years. Medicine can never be truly run like a business: one does not refuse to serve the customer in the ER because he cannot pay. Berwick's hybrid model which to me looks something like a Wal -Mart staffed by Gandhis may appear to be an answer to him, but I remain unconvinced.

Conflict of Interest:

None declared

Why Dr. Berwick can't get what he wants
Posted on February 9, 2005
Kevin C. Fleming
Mayo Clinic
Conflict of Interest: None Declared

While the application of the "total quality" method might seem appropriate to medicine, one fundamental problem exists. The "quality movement" is, of course, a concept borrowed from business models, which can be traced back to Deming's seminal work. However, there is a critical difference between US medicine and other businesses that makes Dr. Berwick's search a fool's errand. Specifically, "total quality" was primarily intended as a method to increase sales and profits in a business operating in the free market, and US Healthcare is simply not a free market.

According to OECD data from 2001, health care accounts for 13.9% of GDP, and 44.6% of health care expenditures in the US were paid by public systems such as Medicare, Medicaid, the VA and other military care, public health clinics, and other programs.[1] However, when one includes tax subsidies and public employee benefits, the current tax-financed share of health spending is nearly 60%.[2] Government mandates and regulations add another layer of public expense to health care in the US. From 1970 to 1996, state and federal mandates increased 25-fold, an annual growth rate of 15%.[3] Thus public spending, not private outlays, already pays the majority of US health costs.

This is an important disinction because the US government sets prices (from doctor's fees to hospital stays) for its Medicare and Medicaid programs. Fixing prices for an industry, while intended to reduce outlays, removes the essential information provided by prices, which best reflect supply and demand. This imposes "the impossible burden" of replacing the intricate information available through prices with a centralized bureaucracy that must somehow learn what people want and provide it by orders and protocols. [4] In contrast to price rationing present in the free market, health care outlays under Medicare and Medicaid are rationed by means other than price, such as wait lists, drug formularies, limited treatment options and discrimination by age or disease. Additional effects of non-price rationing (i.e. fixed prices) include underfunding, shortages, delayed diagnosis and treatment, reduced quality, and health worker strikes. [5] As a result, investment and rewards are not determined by meeting patient needs, but instead by surviving the below- cost payments offered by the government, achieved by shifting those costs onto younger insured patients (a method becoming less and less available).

For the healthcare competition that does exist in the US, the incentives are skewed to favor innovations that raise costs or increase quality regardless of expense. These incentives discourage cost sensitivity for patients while providers are incented to increase services, maximize reimbursement, make expensive referrals and practice defensive medicine.

In short, incentives matter. And the incentives of the current US healthcare system are unable to create the "total quality" system desired by the author. The problem is one of basic economics, not a lack of "energy, insight, and courage". Attempts to change human behavior by rousing admonitions rather than improved incentives is doomed to failure.

1. OECD, Table 10: Total expenditure on health, %GDP, Table 12: Public expenditure, % GDP; Organization for Economic Co-operation and Development: OECD Health Data 2003; (http://www.oecd.org/document/16/0,2340,en_2649_37407_2085200_1_1_1_37407,00.html)

2. Woolhandler S, Himmelstein D; Paying For National Health insurance "“ And Not Getting It; Health Affairs (21) July/Aug 2002, pp.89-95.

3. PriceWaterhouseCoopers, "The Factors Fueling Rising Healthcare Costs," April 2002; pp.1-13

4. Hayek FA, The Road to Serfdom; The University of Chicago Press, Chicago, 1944 and 1994; pp. 97-111

5. Sowell T. Applied Economics: Thinking Beyond Stage One; New York, NY: Basic Books; 2003:72-6.

Conflict of Interest:

None declared

Author Replies
Posted on April 1, 2005
Donald M Berwick
Institute for Healthcare Improvement
Conflict of Interest: None Declared

I understand Dr. Sapers' skepticism, given how poorly designed health care is today. My vision, however, is hardly that of a "Wal-Mart." It is of a health care system that seeks to address each individual patient on his or her own terms, so far as possible. I believe that dedicated clinicians indeed try to do that as a matter of personal mission, and I also believe that modern understandings of health care as a system (not "apeing business models") with open-minded, scientific redesigns, can go a long way toward that vision. For example, waiting times can be reduced dramatically with relatively simple changes in time-honored, but illogical, scheduling systems. (Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA 2003; 289:1035-40.) Much safer care is with our reach, if only we will commit to new levels of reliability in our processes.

Dr. Fleming accurately notes the toxicity of current financing systems with respect to the changes we need for truly patient-centered, reliable care. (Leatherman S, Berwick D, Iles D, Lewin LS, Davidoff F, Nolan T, Bisognano M. The business case for quality: case studies and an analysis. Health Affairs 2003; 22:17-30.) I disagree, however, about the promise of making patients more "cost sensitive," which usually means shifting costs to individuals. I find little evidence that that helps, and, besides, illness and poverty are too closely correlated to make that ethical social policy. (Galvin R. A deficiency of will and ambition: a conversation with Donald Berwick. Health Affairs - Web Exclusive 2005; January 12, 2005; W5-1 to W5-9.) Indeed, nations with globally-funded, often government sponsored, health care with universal access, seem in important dimensions to outperform our system at far lower cost. (Davis K, Schoen C, Schoenbaum SC, Audet, A-M J, Doty MM, Tenney K. Mirrow, mirror on the wall: looking at the quality of american health care through the patients' lens. The Commonwealth Fund: New York; 2004.) "Total quality," in my view, will be found sooner in a health care system with clear mandates, policy guidance, universality, flexible funding, and public accountability than in one relying on the invisible hand of a market to care for the sick.

Conflict of Interest:

None declared

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