Berwick nomination nonsense

By ROBERT PEAR

WASHINGTON — President Obama’s nominee to run Medicare and Medicaid, Dr. Donald M. Berwick, is a man with a mission, a preacher and a teacher who has been showing hospitals how they can save lives and money by zealously adhering to clinical protocols for the treatment of patients.

Hospital executives who have worked with Dr. Berwick describe him as a visionary, inspiring leader.

But a battle has erupted over his nomination, suggesting that Dr. Berwick faces a long uphill struggle to win Senate confirmation.

Republicans are using the nomination to revive their arguments against the new health care law, which they see as a potent issue in this fall’s elections, and Dr. Berwick has given them plenty of ammunition.

In two decades as a professor of health policy and as a prolific writer, he has spoken of the need to ration health care and cap spending and has confessed to a love affair with the British health care system. He has made numerous public appearances to talk about health care and has published a book of his speeches on the topic.

Mr. Obama nominated Dr. Berwick on April 19 to be administrator of the Centers for Medicare and Medicaid Services, the largest purchaser of health care in the United States. The post has been vacant since October 2006, and the need to fill it has become more pressing with passage of the new law. The agency must write and enforce dozens of regulations to expand Medicaid, trim Medicare and test new ways to deliver care.

The Senate Republican leader, Mitch McConnell of Kentucky, describes Dr. Berwick as an “expert on rationing.” Senator Pat Roberts, Republican of Kansas, calls him “the perfect nominee for a president whose aim has always been to save money by rationing health care.”

Dr. Berwick, a pediatrician, is president and co-founder of the Institute for Healthcare Improvement, a not-for-profit organization in Cambridge, Mass.

In an introduction to Dr. Berwick’s book, Dr. Frank Davidoff, a former editor of the Annals of Internal Medicine who works for the institute part time, said, “Don Berwick preaches revolution.”

He is trying to overthrow “a stupid system” that serves the needs of doctors, administrators and insurers rather than patients, Dr. Davidoff said.

Administration officials say they are confident that Dr. Berwick will be confirmed, and they say Republicans have taken his comments out of context. In fact, many of the comments have been repeated, with slight variations, in Dr. Berwick’s articles and lectures over the years.

In an interview last year in the journal Biotechnology Healthcare, Dr. Berwick said, “The decision is not whether or not we will ration care — the decision is whether we will ration with our eyes open.”

Asked about such statements, Reid H. Cherlin, a White House spokesman, said: “Rationing is rampant in the system today, as insurers make arbitrary decisions about who can get the care they need. Don Berwick wants to see a system in which those decisions are transparent, and the people who make them are held accountable.”

In his book, “Escape Fire: Designs for the Future of Health Care,” Dr. Berwick sharply criticized “the dangerous, toxic and expensive assumption that more is better.” He insists that the nation can cut health costs without harming patients because vast sums are misspent.

“I have said before, and I’ll stand behind it, that the waste level in American medicine approaches 50 percent,” he said in an interview in the journal Health Affairs in 2005.

Dr. Berwick has championed efforts to “reduce the total supply of high-technology medical and surgical care” and to consolidate services in regional centers.

Long before the uproar over “death panels” last year, Dr. Berwick was urging health care providers to “reduce the use of unwanted and ineffective medical procedures at the end of life.”

“Using unwanted procedures in terminal illness is a form of assault,” he said in 1993 at the annual conference of his institute. “In economic terms, it is waste.”

On more than one occasion, Dr. Berwick has suggested a need for a cap on total health spending, with limits on annual increases.

In speeches and articles celebrating the 60th anniversary of Britain’s National Health Service in 2008, Dr. Berwick said he was “in love with the N.H.S.” and explained why it was “such a seductress.”

“The N.H.S. is not just a national treasure,” he wrote; “it is a global treasure.” Among its virtues, he told a British audience, is that “you cap your health care budget.” Instead of trying to protect the wealthy, Dr. Berwick wrote, the British recognized that “sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just must redistribute wealth.”

Dr. Berwick offered a suggestion to the British: “Please don’t put your faith in market forces.”

“In the United States,” he wrote, “competition is a major reason for our duplicative, supply-driven, fragmented care system.”

Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, said he had no doubts about Dr. Berwick’s academic and professional qualifications, but wanted him to explain his comments on rationing.

“It doesn’t help him to say good things about the British health care system,” Mr. Grassley said after meeting with Dr. Berwick on Wednesday. Whatever doubts might exist in Washington, Dr. Berwick has fans in hospitals around the country.

Theodore E. Townsend, president of St. Luke’s Hospital in Cedar Rapids, Iowa, said: “Dr. Berwick has inspired me and this community. He has used his charisma and his leadership ability to improve the quality of care at hundreds and hundreds of hospitals. I can’t think of anyone else who has had that kind of impact.”

Donna C. Isgett, senior vice president of McLeod Health in Florence, S.C., said Dr. Berwick had been “instrumental in catapulting us to a much higher level of care.”

“He rolled up his sleeves and worked with our employees to reduce medication errors, infections, accidental falls and mortality rates,” Ms. Isgett said. “We are not a prestigious institution in Boston. We serve rural counties in one of the poorest regions of the country, but Don has been here and knows us.”