Health reform: A facelift for Medicare?

Last week a reliable source confirmed that the rumors were true: Don Berwick will be named the next director of the Center for Medicare and Medicaid Services (CMS). My elation was tempered by curiosity: Why would the dynamic and innovative director of IHI (Institute for Healthcare Improvement) want the top job at perhaps the largest health care bureaucracy in the nation?

Alumni of The Dartmouth Institute, where I received my public health degree (and my current employer), are often familiar with Dr. Berwick from his annual lectures in the class of Dr Paul Batalden (whose lessons I've previously invoked). Dr. Batalden was an early mentor to Berwick, and one of the founders of IHI.

Anyone interested in how a Berwick-led CMS might change, or curious about his career change, should read his 2008 paper in Health Affairs, "The Triple Aim: Care, Health, and Cost." I'm no mind reader and have only spoken with Don Berwick once, but after reading that paper, I think I understand exactly why he accepted this position, and at least a few ways that CMS might change under his tenure.

Berwick's "Triple Aim" targets what he sees as the necessary goals of health care improvement: "Improving the individual experience of care; improving the health of populations; and reducing the per capita costs of care for populations." For most players, Berwick notes, self-interest prevents working towards all three aims at once. But Medicare is a notable exception. In fact it's an example of what Berwick calls an "integrator," or entity responsible for all three of those aims within a defined population

"An effective integrator would work persistently to change the "more-is-better" culture through transparency, systematic education, communication, and shared decision making with patients and communities, rather than by restricting access, shifting costs, or erecting administrative hurdles." Writes Berwick and his coauthors. This includes "deploying resources to the population, or… specifying to others how resources should be deployed."

I imagine CMS in the coming years will change in a couple of important ways, including the following:

A renewed focus on evidence-based effective care; standardization of measures and definitions; expanded use of data, for example sharing regional Medicare data so private health systems or payers can benchmark their expenditures

Traditional Medicare measures focus on quality of care (primarily through process measures, with limited outcomes and safety measures.) Look for new Medicare measures that focus on costs and health status, two necessary components to calculate the value being provided by care systems.

Coordinated, patient-centered care delivery, and adopting functional technology. Berwick asserts the need for "building the capability and infrastructure to enable primary care practices to function in [an] expanded role" that includes, among other things, "a patient-controlled personalized health record." As he assumes the position of Uber-integrator, prepare for incentives to deploy functional health IT tied to measures of health improvement and cost reduction on a scale never before witnessed in US health care.

Now I'm getting excited about this health reform thing!