One Man's Trash is Another Man's Treasure

Don Berwick is out as the Director of CMS, and one of his deputies is in-line to be his replacement.

Here is a nice article about his efforts to transform healthcare in the US from the New York Times:

http://www.nytimes.com/2011/12/06/opinion/nocera-dr-berwicks-pink-slip.html

Here is a nice item from the Washington Post:

http://www.washingtonpost.com/blogs/ezra-klein/post/cms-administrator-don-berwick-steps-down/2011/11/23/gIQAdXs2oN_blog.html

Here is a nice article from Boston about his priorities:

http://www.boston.com/Boston/whitecoatnotes/2011/12/don-berwick-five-principles-for-change/qWyl3sMa8yXCFd97qKLF0H/index.html

It is clear that it was his ambition to do a lot of good at CMS. There is no disputing that a year is too short a time to understand an organization so vast, let alone transform it. The consensus is that he hoped to replicate the NHS in the US. If all of this were easy, he would have done it all in a year, and we would be talking about all of the great things he accomplished.

Here is a recent item about the status of the NHS:

http://apnews.myway.com/article/20111211/D9RID8800.html

Ignore the inflammatory anecdotes in the article.  They’re data, but they’re not especially useful data.  I could generate equally emotional anecdotes to support the other side, but these would still not constitute useful data.  Pay attention to the real systematic numbers, which are the real crux of the debate.

They are in a pickle. There is no easy way out of the difficult situation in which they find themselves. It is ironic that the British have as much trouble predicting the consequences of changes as we in the US do, in spite of the widespread belief that they actively control every aspect of care. Well meaning people come to opposite conclusions about the consequences of change, with the Docs and nurses at odds with government, just as in the US.  I see it this way: if you spend less, you are likely to get less.  Worse, in a command economy, the free market does not seize every opportunity to reduce costs.  Medical inflation has many costs, but regulation is likely a major unrecognized driver. If you read this article, it is hard to avoid concluding that the British spend too little on health care.  It is also hard to reconcile the details of this article with the representations of many who advocated for the Affordable Care Act.

John Goodman wrote this recent item about health care:

http://townhall.com/columnists/johncgoodman/2011/12/17/is_liberalism_a_religion

In it, he makes a convincing case that efforts to improve access to care have had the opposite effect in Massachusetts, and draws the expected analogy to Canada and Great Britain, where there are now explicitly two standards of care: that for those who can afford to get out of the national system, and that for those who are stuck with it.  In Great Britain, something like 10% of people seek their care outside the system.  This fact is critical in its importance. First, the money these people spend out of pocket is not included in the estimates of overall or per-capita expenditure, which is likely far more substantial than widely reported.  This would suggest that the Brits spend more on health care than widely believed, and with less, not more efficiency, as widely alleged. These same people also shorten the wait times for a variety of critical services, and reduce the demand for resources in every dimension, including hospital and ICU beds.  The gap between what the NHS provides and want the population demands is thus larger than widely represented.

Finally, this recent report from NCEPOD

http://www.ncepod.org.uk/

represents their usual outstanding work in understanding the failures of the NHS.  In a sentence: patients who would go to the ICU in the US often go to the wards in the NHS, and a large percentage of those patients die.  It is worth noting that a large percentage of patients admitted to the ICU in either system die, and that the devil is in the details of the differences.