Controlling health care costs needs to happen from within

Austin American-Statesman, July 2, 2010

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[Don Berwick] may well be this country's only real hope of improving health care while reining in costs. Despite Republican rhetoric, Berwick, more than anyone, recognizes that local communities and clinicians, not a national system, will be the ones to rein in costs.

The White House nomination of Dr. Donald Berwick to head the Centers for Medicare and Medicaid Services seems to be imploding. If it does, it would be a missed opportunity for our country.

Conspicuously absent from the health care overhaul were meaningful measures to control costs. There’s a reason for that: Government cannot legislate that issue, as health care is inherently too complex. An example of a clumsy congressional attempt was the enactment into law in the late 1990s to cut Medicare physician payments. The draconian law has resulted in politically messy fights, with Congress blocking the cuts 10 times in the last eight years, including four times since January.

If there’s one man in the country who knows how to proceed with controlling health care costs, it’s Berwick, a Harvard clinical professor of pediatrics and health care policy.

Republicans should be the ones most interested in his nomination succeeding. Stunningly, they are the ones opposing it. Why? They cite remarks he has made — all taken out of context — about rationed care, the British National Health Service and primary care “medical home” models of care.

Professors by nature think outside of the box, and they are rewarded for it. Any beginning student of U.S. health care policy learns that in a country with a fifth to a quarter of its population uninsured, it’s a matter of public policy by omission that health care is rationed. I suspect most health care policy professors will rightly instruct that if rationing is a given, then as a society, it’s in the public interest to do so with eyes open rather than closed, something Berwick referred to in an interview last year in the journal Biotechnology Healthcare.

In this interview, Berwick referred to an initiative funded in the American Recovery and Reinvestment Act of 2009 to evaluate the comparative effectiveness of targeted therapies and recommend reducing those that are ineffective and costly. The program is named Comparative Effectiveness Research; he calls it what it is, evidence-based medicine. He cautioned against mandating compliance with CER directives, preferring instead making information and research available to clinicians in the form of advisories.

Berwick knows what he’s talking about. He founded the Institute for Healthcare Improvement in the early 1990s, which has worked with thousands of hospitals worldwide to develop evidence-based best practices. As part of Ascension Health, the hospital where I’ve worked as a neonatal intensive care nurse for 30 years is one of those hospitals working with IHI. Berwick certainly has made a transformational change in my area and in most areas of my hospital.

During this past decade, Berwick’s organization successfully has tackled some of the most deadly, costly, tragic — and avoidable — events in health care: hospital-acquired pneumonia from ventilator usage, central venous line infections, adverse drug reactions and many more. Real cost controls in health care will take place from within the industry, and using evidence-based practice is the best hope.

In my own area, we have effectively eliminated birth trauma injury to term infants. Our hospital also worked with Berwick’s organization to develop another IHI life-saving innovation — rapid-response teams. These teams, which have spread all over the United States, consist of a critical care nurse and respiratory therapist available 24/7 to seek out patients and answer calls from nurses on the floor, usually outside of the intensive care unit, who see patients going downhill. The teams provide oxygen, IVs, drugs or other therapies to stabilize patients.

Hospitals have seen a 50 percent reduction in “code blue” calls — patients who need to be resuscitated because they’ve stopped breathing and their hearts have stopped beating. Every time I hear the hospital operator call overhead, “Rapid response team, report to room X,” I smile and think of Berwick. I think of how grateful that patient and his or her family will be that the patient was caught in time before it was too late.

The smile vanishes quickly, though, when I think of the impending disaster of taking professorial remarks out of context and destroying what may well be this country’s only real hope of improving health care while reining in costs. Despite Republican rhetoric, Berwick, more than anyone, recognizes that local communities and clinicians, not a national system, will be the ones to rein in costs.

Inglis is an editor and neonatal intensive care staff nurse with the Seton Family of Hospitals in Austin and a former student of health care policy.

Toni Inglis, MSN, RN CNS (retired), FAAN, a lifelong Austin resident and retired neonatal intensive care nurse and editor of NursingNews, writes a monthly opinion column for the Austin American-Statesman editorial page.