Thursday, April 01, 2010

A Better health reform ahead?

After the health care reform process finally played itself out -- only Nancy Pelosi really gets kudos from me on this -- I needed Dr. Atul Gawande's Better. Gawande is the engaging surgeon and New Yorker writer whose June article on medical costs was one of the few intellectually challenging contributions to the political fray.

Better is not deep or systematic. It's a collection of vignettes that consider how and when doctors do well and could do better. Gawande wants better outcomes for patients. He's a scientist; he examines evidence. He's a humane and imaginative individual; he tries to get inside of the minds of doctors and patients. He's sympathetic to human beings, whether they are doctors who become embroiled in assisting executions against the rules of medical ethics or patients who have experienced malpractice. And he's a terrific writer.

While I was reading Better, the Obama administration announced that it was appointing Dr. Don Berwick as its new Medicare/Medicaid chief. Like most people outside medicine, I never would have heard of the guy without this book.

Gawande describes Berwick's influence on health practice in this way:

Berwick is a former pediatrician who runs a nonprofit organization in Boston called the Institute for Healthcare Improvement. ...he is powerful not because of the position he holds... He is powerful because of how he thinks. ...

...To fix medicine, Berwick maintained, we need to do two things: measure ourselves and be more open about what we are doing. We should be routinely comparing the performance of doctors and hospitals, looking at everything from surgical complication rates to how often a drug ordered for a patient is delivered correctly and on time. And he insisted hospitals should give patients total access to information. ...He argued that openness would drive improvement, if simply through embarrassment. It would make clear that the well-being and convenience of patients, not of doctors, were paramount. It would serve a moral good, because people should be able to learn about anything that affects their lives.

Now Berwick is going to be powerful because he will have oversight of billions of government money going into the new system. Maybe this new health scheme will change more than who pays who for the bills.

Berwick will face a confirmation fight -- Republicans will fear the patient-concerned doctor can make reform popular. Health activists will need to afflict our more wavering Senators on this one.


Nance said...

I am thrilled with the work of Gawande and Berwick. And I am gratified each time Obama's administration makes a choice that I can applaud. As a provider of mental health care, I grieved with the families of medical patients who suffered from "non-mental" ailments and who died as the result of hospital neglect and medical malpractice; I problem-solved with the mental health patients who could not afford the medication prescribed them and with those whose health insurance refused coverage for perfectly standard medicines and psychotherapeutic modalities. Most of all, I despised the fact that, when I provided the medically-correct diagnosis in a new patient's record, both I and they knew there was a chance that a change of job would prohibit the treatment so badly needed when their new insurance denied coverage for a pre-existing condition. My greatest disdain was reserved for patients whose job stress triggered their symptoms and who were harassed into leaving their jobs when their employer-provided health premiums went up as a result of diagnosis and care; this was not at all unusual and was practiced by some of the largest corporate employees in our country.

Mental health care was a boot camp for what was wrong with the insurance status quo. I was in favor of starting with SOMETHING and I have real hope that there will be SOMETHING BETTER to come. Gawande could not be more right about the need for accountability in the medical profession.

libhom said...

I will never forgive Nancy Pelosi, Harry Reid, or Barack Obama for this wealthcare bill for the HMOs and the health insurers. The people on Medicare HMOs who will lose some of their medical care won't either. Neither will the people who will be fined for not being able to pay high premiums.

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