Dr. Don Berwick's 3 thoughts on the intersection of care quality and politics

Don Berwick, MD, says his "head is spinning" from the election, even a month after Republican Donald Trump beat Democratic candidate Hillary Clinton on Nov. 8.

"We have an elephant in the room and I thought it'd be a donkey," said Dr. Berwick, senior fellow and president emeritus of the Institute for Healthcare Improvement and the former head of CMS. Dr. Berwick addressed a press panel at the IHI National Forum on Quality Improvement in Health Care on Dec. 5 in Orlando.

"Healthcare costs…are soaring again, it's going to continue unless we change care," he said. "I read the political environment with that eye, which is — could we still change care? Is this trajectory of improvement going to be real or not?"

Below are three thoughts Dr. Berwick shared on the election results and their potential effect on the healthcare quality movement.

1. States, private sector and individuals taking on more responsibility. Even though the administration has not yet laid out details of what it will do once the ACA is repealed, Dr. Berwick sees broad themes in possible replacements emerging, one of which is moving responsibility to the states.

"One way or another, [they want to] get the federal government less active in trying to shape the financing and future of healthcare," said Dr. Berwick. "So I see states ending up with more on their plate. For patients, [it will be] in the form of more burden on them. I think for healthcare organizations it's suddenly, they're left holding the bag — the ball is in their court. I think that the euphemistic term 'personal responsibility' or 'skin in the game' is certainly part of the underlying if not explicit platforms we're seeing and I personally think that's a very dangerous way to go but it would result in shifting cost and burden to individuals and I believe…the burden will fall heavier on people who are lower income and more at-risk."

2. Reporting requirements may decrease under the new head of HHS. President-elect Trump said he would make Rep. Tom Price, MD, the secretary of HHS, which could have an effect on providers' reporting requirements, according to Dr. Berwick.

"Tom Price is an orthopedic surgeon, a fan of doctors and doctor practices, especially small ones," he said. "Doctors are extremely uncomfortable with transparency, for all sorts of reasons, and I don't know which way he'll call this. I don't know if he'll say you need to have the dynamics of openness apply or if he'll say we don't want to bother, hassle physicians and therefore we'll ease up on reporting requirements."

3. Quality improvement should roll along — with caveats. "I think value-based purchasing — the whole idea that if the government is going to buy care, it will be value-based — that's bipartisan. I think that kind of thinking will remain, and that helps the quality movement," Dr. Berwick said.

He also sees support for ACO and bundled payment programs, as well as MACRA.

"The concept that the country ought to be putting some resources into supporting experimentations, especially state-level experimentation, on new care models, I think is a good enough idea that no matter which side is approaching, it will stay. In terms of the quality movement itself, I think it's got plenty of gas. I don't think this will stop the quality movement."

However, he did add one caveat to that — "Safety-net providers are going to be under tremendous pressure here as Medicaid support goes down [and] different ways to cover noncitizen residents will be under attack," he said. "They're going to have to do some adjusting."

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