This is the transcript of my recent podcast interview with Don Berwick, Democratic candidate for Governor of Massachusetts. Visit the original post to listen to the podcast and read a summary. This is part of a series of interviews with all nine candidates for Governor. The full schedule is available here.
David E. Williams: This is David Williams from the Health Business Blog. I’m speaking today with Don Berwick, candidate for Governor.
Don, thanks for joining me.
Don Berwick: It’s my pleasure, Dave.
Williams: Don, does Chapter 224 represent the right approach to addressing rising healthcare costs? And if not, where would you say it misses the mark and what would you do differently?
Berwick: It’s directionally correct. The state should pursue what, in my former role, I used to call the Triple Aim: better care, better health, and lower cost through improvements. That means care that’s more reliable and safer for patients, a big emphasis on prevention and keeping people well and then reducing cost by improving care processes so they’re more coordinated and do less harm.
Chapter 224 works in that direction. It sets some goals for cost containment in the state. It encourages coordinated behavior among caregivers. It’s a step in the right direction. I am hopeful about it, but its major problems are that it’s primarily voluntary. It’s asking, with transparency and proper reporting, for the system to basically move in to a totally new configuration around coordinated care and cost containment on a voluntary basis.
It may need more teeth. It’s so urgent to get healthcare costs under control in the Commonwealth without harming a hair on a patient’s head. This is only done through improvement, but it’s so urgent given the amount of resources that healthcare is taking that we really can’t regard it as a leisurely task.
So my focus is on accelerating progress and making sure that the progress is real. I’m the only gubernatorial candidate who has put single-payer as a potential option for the state on the table. While Chapter 224 does its work, I would like to see us move very swiftly to understand whether and how we could move into a single-payer environment, which is a much more complex endeavor but potentially, with much more to gain.
Williams: Don, there are certain provider systems in Massachusetts that are reimbursed significantly more than others for the same services even though there are virtually no differences in quality. From your standpoint, does the state have a part to play in addressing those disparities in payment?
Berwick: Yes, it does. And as I say, we need to move toward better care and lower cost. To do that we need a lot more transparency about what these prices are, and more accountability for the systems that are charging significantly more. If we can establish that there’s a value relationship, then it has to be well known to the public, and payers and purchasers of care need to be alert to that and help patients stay alert to it. It doesn’t help anybody when they go to a more expensive service that isn’t doing any better, sometimes worse.
Williams: There are more than a dozen state agencies that have a role in healthcare. Do you think there is an opportunity to consolidate or rationalize some of them?
Berwick: Yes, there is. When I was leading the Centers for Medicare and Medicaid Services, one of my main goals there was to rationalize the many, many different silos or compartments within the agency. Sometimes that has to be done structurally. For example, I did merge quality functions under a single leader because it was just too disparate. We have to look for opportunities for that kind of thing at the state level.
But the other thing to do is to insist on and support high levels of cooperation. Sometimes, you don’t have to restructure, but you have to get around the table and say, “Look, there’s a patient here in the middle and we all have to work well to make sure the outcomes are best.” The same applies in the state to other areas like education and homelessness and substance abuse. I’m in favor of extremely high levels of cooperation with agencies and if they don’t cooperate, then we have to consider restructuring.
Williams: Government policy both at the federal level and the state level has encouraged adoption of electronic medical records. However, many providers complain about the systems and some of the benefits have been slow to materialize. Should state government play a role in helping to realize the promise of health information technology?
Berwick: The promise is great. When I practiced pediatrics, I always had an audited electronic record. That meant the record was never missing. If a consultant put a note in, I had it immediately, and if a lab test just came back, I had it instantly. So, electronic records can play a big role in helping physicians and nurses. They also can be available to the patients. So it’s a very important step.
We are making progress. Now more and more offices and hospitals are automated, have an electronic record with appropriate attention to confidentiality. But unfortunately, federal leadership here on information exchange and interfaces – so that the information could move around – has been very slow. The new wave of so-called Meaningful Use requirements at the federal level will help providers move more swiftly toward interface compatibility. The state should really support that. I’m encouraging relevant state agencies to get on board, and the providers of care to adopt these new standards as fast as they possibly can.
Williams: Hepatitis C is three or even four times more common that HIV. There are some new drugs that can cure the infection that are coming on the market this year, but they’re very expensive. What role should the state play in ensuring that residents are tested, linked to care and have access to these new medications?
Berwick: This is very important progress. Hepatitis C is a very difficult and dangerous infection. We can cure it in two out of three cases, and I think we could eradicate the virus. It does require use of medicines that are advanced. Once we have in our hands the technology that is proven to work, we have to make sure that it’s accessible to everybody. This makes it even more important to achieve healthcare reform, because as these effective technologies come around, we need to guarantee that patients have access to it. At the same time, we have to recover money from ineffective care, wasteful care, and harmful care.
The healthcare reform piece we started to talk about at the beginning of this interview is very relevant to making sure that everybody can get all the care they want and need. I abhor the concept of rationing. I think there’s no way we should be withholding any effective treatments from patients. We need to work very hard to make sure that we have the resources liberated from healthcare waste, so we can rededicate them to things like proper Hepatitis C care.
Williams: There are multiple healthcare-related ballot questions for the voters in 2014. What are your thoughts about those questions?
Berwick: The nurse staffing ratio issue is one that I’ve looked at for many years. I don’t think it’s a good idea to legislate ratios. I think what we should legislate is adequate care. I favor standards in the Commonwealth in which we absolutely guarantee that all patients have adequate nurse coverage at all times, and for those who need hospitals, the clinic and managerial staff are monitoring and assessing that.
To put a specific ratio into legislation could be a mistake. It’s trying to do management with law and I fear that a ratio in law that’s intended to be an adequate number will soon become a ceiling. Then places will say, “well, I’ve met the law, so I don’t really want to talk about whether the care really was adequate.” I don’t think that’s a good idea.
For non-profit organizations executive compensation needs to be looked at carefully. It has to be highly responsible. I have not looked at the particular ballot issue that you were talking about enough to have an opinion yet on that initiative. But we would expect from our non-profit organizations fairness in the compensation system so they could be held above reproach.
Williams: What did you learn from running CMS that will be useful as Governor?
Berwick: I loved running CMS. It’s the largest agency by budget in the federal government at $800 billion. It’s 5,500 employees. They had not had a leader for six years, so they were just ready for leadership. For 30 years, I’ve worked in executive positions. I started and grew a non-profit organization that works on healthcare improvement all over the world. I know a lot about executive leadership for improvement in quality and excellence.
I brought those skills to CMS and it was amazing to watch the uptake in the workforce. They absolutely embraced it. I set very high goals. I invited everybody to join as a single team. We talked about tearing down boundaries among departments. I encouraged them to innovate in their jobs. So the workforce had the support from me to try new things. Even if they failed, we still learned. I emphasized customer focus. I brought in the mother of a patient and had her lecture to all 5,000 people, for example.
What I learned there was the public sector workforce was just as eager to be proud of their work, and just as amenable to learning about modern approaches to improvement as any workforce I’ve ever dealt with. If I get to the corner office as Governor, I will bring that to the corner office. We will work very hard on excellence and quality in operations of the state government, from top to bottom, end-to-end, and I will personally invest in that as I did in leading CMS. What I learned there is that it works in government just as it does in the private sector, if you’ve got a leader that understands that.
Williams: A lot of the emphasis in healthcare reform and even implementation of the Triple Aim has focused on adults. And I wonder whether there are any special policies or approaches that are needed for the pediatric population.
Berwick: Yes, I think there are. Basically, a lot of the heat and light goes where the money is spent. Of course, pediatrics and kids in the healthcare sector don’t explain a lot of the spending. That explains why you see that attention on adults. The well-being of children poses a very exciting challenge, and one that the state ought to be embracing, which is to understand child well-being as a totality. A healthy child isn’t just getting good healthcare. They also need a healthy environment. They need parents who have a secure role in the economy. They’re not being challenged by unsafe streets, or threats in the air, in the environment, or from pollution.
If you want to have a healthy child, you have to think systemically. Bringing together agencies both in the private sector and government around the well-being of the child is key. I’d love to foster a community-by-community endeavor in the entire Commonwealth on a voluntary basis. That means involving every community to improve the well-being of every young child, in cooperation with families, to assure a child’s readiness for school, good nutrition, and high self-esteem. We can do that in the Commonwealth.
It’s kind of health, but it’s the big idea of health, not the simple one. The same actually does apply to a frail elder or a person with a chronic illness. But for kids, especially, we have to get together and cooperatively help.
Williams: Thank you for answering all my questions. I want to give you the opportunity if you’d like to add anything.
Berwick: Your questions have been great. I want to emphasize how excited I am about the possibility of bringing my skills in executive leadership and improvement into the leadership role of Governor. I’ve worked in large systems and I understand how to recruit the energies of the workforce on behalf of the people who are served. That’s what is most exciting to me about the prospect of being Governor of Massachusetts.
Williams: Don Berwick, candidate for Governor of Massachusetts. Thank you very much.
Berwick: Thank you.
—March 5, 2014