Donald Berwick, Obama's Controversial Medicare Chief

  • Share
  • Read Later
Goodman Media International / AP

Donald Berwick was named by President Obama as the head of the Centers for Medicare and Medicaid Services via a recess appointment

(3 of 3)

Berwick has some Republican fans. The notion that a rogue Berwick plans to enact a rationing agenda is "ridiculous," says Gail Wilensky, who served as a CMS administrator under George H.W. Bush and who has advised Berwick on how to approach his new job. Elsewhere, Berwick has been endorsed nearly across the board, with the list of medical associations, hospitals and patient-advocacy groups that want him to lead CMS running to seven single-spaced pages. Three former CMS administrators who served under Republican administrations back him, including Mark McClellan, who held the job from 2004 to 2006. McClellan has also counseled Berwick. Among his advice: Don't take anything personally. "A lot of people talk about health care reform as being just about expanding coverage and that's important," says McClellan. "But if we really want to do something about cost and quality, we've got to find better ways to deliver care. That's where Don can have the most extensive and direct role."

Notably, Berwick has never said health care decisions should be based on cost — i.e., explicitly rationed — but he contends that there are billions of dollars of waste in the U.S. health care system that could be eliminated without any effect — except possibly fewer unnecessary knee surgeries. "There are a lot of tests done, a lot of procedures, a lot of hospital admissions which we really know scientifically cannot help the patient," he told a PBS interviewer in 2009. "I think working hard on the overuse of ineffective practices is a very good way for us to save money and not harm a hair on a patient's head."

Critics might say that while this might be true, government shouldn't be the one choosing which procedures and practices are worth doing. Yet Medicare, the world's largest health care payer, already does this, deciding which medical care it will reimburse. Private insurers, taking their cues from Medicare, do it too.

Medicare is such a driver of the overall U.S. health care system that the Affordable Care Act in fact targets most of its real reform within the program itself. The law calls for a series of Medicare payment-demonstration projects — familiar territory for Berwick — that will allow hospitals and health systems to experiment with changing systems and payment structures to reward quality and save money in the process.

The success of these demonstration projects could determine if the Affordable Care Act changes the practice of medicine and saves money or whether it simply cuts one entitlement program (Medicare) while expanding another (Medicaid) and creating a whole new one (federal subsidies to help Americans buy private insurance).

Berwick will have the final say on which Medicare pilot projects get funding and he will choose the head of the Center for Medicare and Medicaid Innovation, a newly created division where "all our hopes and fears lie," according to Len Nichols, director of the Center for Health Policy Research and Ethics at George Mason University. Wilensky, the former CMS administrator, agrees. "Ninety percent of what might be regarded as health care reform is tied up in that innovation center," she says.

Lofty efficiency goals notwithstanding, the first job of any CMS administrator is "just managing the fire hose," says McClellan. And whether Berwick has the management chops to run a massive federal agency is less clear. "I don't feel like a leader — inattention to detail is my biggest defect," Berwick told U.S. News & World Report in 2006. "I want everyone to like me, and yet I'm aware that when you're pushing for change, that isn't always going to happen. To be more effective as a leader, I would probably want to thicken my skin."

And though under the terms of a recess appointment he only has his job until January 2012, Berwick will be called to testify on Capitol Hill in the coming months. "Right now, he's in there as damaged goods and he can only hide so long," says Republican Senator John Barrasso, a leading Berwick critic. "We're going to smoke him out."

  1. 1
  2. 2
  3. 3
  4. Next