As Republicans battle with Democrats and President Barack Obama over the future of the health care law, Donald Berwick, the administrator of the Centers for Medicare and Medicaid Services, is focused on something else.
"I go to work every morning with 100 million people in mind, Medicare and Medicaid beneficiaries," Berwick says, adding, "I can actually think about how to make things better for these people who depend on CMS to work in their interests."
Berwick, the former president and chief executive officer of the Institute for Healthcare Improvement, has been criticized by Republicans for his praise of the British National Health Service, as well as some of his past speeches and writings, which Republicans said showed that Berwick supported health care rationing – a charge he rejects. The controversy stalled his nomination and Obama moved Berwick into his post with a recess appointment last summer.
In a recent conversation with KHN's Mary Agnes Carey, Berwick discussed the agency's work with governors on Medicaid, how to make Medicare more efficient and what he's hearing from health care providers about a proposed Medicare regulation to create accountable care organizations, or ACOs, networks of doctors and hospitals that share responsibility for providing care to patients. This is an edited excerpt of that interview.
Q: Many state governors want federal officials to allow more flexibility on Medicaid. How is CMS responding to those concerns?
A: Each state is looking hard at Medicaid, which is a significant portion of state costs, and we need to be working with them to preserve the lifestyle and the well-being of the beneficiary and also to help the states with their problems. It's an area of a lot of work right now.
We have Medicaid action teams, which are available to any state. We'll be working together with states on the flexibilities they want and need, even while we are mindful of protecting the beneficiaries’ well-being and the proper stewardship of funding. We have many ways to help states and we are reaching out to them now.
Q: There's legislation pending on Capitol Hill that would waive the health law's
maintenance of effort requirement
for Medicaid. Are you concerned that proposal will become law?
A: I think it's important to maintain Medicaid coverage. The way out of the Medicaid dilemma is the same as it is for the rest of the American health care system, which is to improve care. Medicaid beneficiaries are very vulnerable. Their costs rise for the states as well as for them and the federal government when we don't properly coordinate their care, when we don't help them in their journeys through the care system. So we're focused on the improvement of care as the way to maintain the coverage and the well-being of the beneficiary.
Q: You're hearing a lot of complaints about the proposed regulation for accountable care organizations, or ACOs. Based on those comments, what changes might we see in the final regulation?
A: We're listening really closely. The comment period to me is exciting. Criticism is help. In this case, it's people coming at us with ideas about how to make the rule better. We'll be taking these comments very seriously so the final rule, I'm quite sure, will be improved over the current one from the viewpoint of the people we want to get engaged in the ACO world. We're on track to meet our deadline of having the program launch on Jan. 1, 2012. That's our goal and we're not giving up on that right now.
Q : You and others have been critical of Rep. Paul Ryan's "premium support" plan for Medicare. What's wrong with limiting the amount the federal government spends on beneficiaries?
A: I' not a fan of cutting care as the remedy to this problem. I think the focus should be on improving care and that's where the focus is. Most of the proposals I've seen on that side of the coin aren't about improving care at all. They are about shifting burdens to states and individuals who already are struggling to do the best they can. Medicare is a solid program. I go to work every morning with 100 million people in mind, Medicare and Medicaid beneficiaries. We're in a good partnership with states on Medicaid. I've got the back of the Medicare beneficiary. I can actually think about how to make things better for these people who depend on CMS to work in their interests.
Q: Short of major Medicare reform, what steps could the Medicare program take to reduce spending?
A: The main way we can work on costs while improving care is partnering with care providers. It's about pulling everybody together and deciding we are going to be cooperative with each other at getting what patients really want – better care at lower costs.
Q: You've given lectures to CMS employees. What do you talk about?
A: I want to help them understand more about how to improve their own work, and what it takes for a doctor or a nurse or a hospital to improve their work so we can be better partners with them. I've been teaching improvement. I've taught four, 90-minute classes, open to all employees. Those have been focused on quality and what's its nature and how does it improve? Customer focus, what does it mean to listen to a person you're trying to help? What Medicare does that can affect safety.
I'm a believer in that Gandhi quote, "You have to be the change you wish to see in the world." So we want health care to be continually improving, highly reliable, focused really on the needs of the people we're trying to help, joyful to work in. That's what we want from CMS, too, so we're working on internal change and external change.
Q: Your current recess appointment lasts until the end of this year. Have you had any conversations with anyone about your future?
A: This is a hard and exciting job. The way I'm dealing with the job is in the present. Every day, I'm going in and doing the very best I can do. The rest, what happens, happens. The [health care law] is a major, massive change in our policy opportunities. I really can work on behalf of improvement, which has been my life's work. And I'm doing that every day.