Refocusing on the Patient: Dr. Donald M. Berwick Discusses the Affordable Care Act and its Impacts

Donald M. Berwick, MD, MPP, FRCP was appointed by President Obama to the position of Administrator of the Centers for Medicare and Medicaid Services in July 2010, a position he held until December 2011. Prior to that time, Dr. Berwick was President and CEO of the Institute for Healthcare Improvement (IHI) for nearly 20 years. He was formerly Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School, and Professor in the Department of Health Policy and Management at the Harvard School of Public Health. An elected member of the Institute of Medicine (IOM), Dr. Berwick served two terms on the IOM’s governing Council and was a member of the IOM’s Global Health Board. He served on President Clinton’s Advisory Commission on Consumer Protection and Quality in the Healthcare Industry. 

With the implementation of the Affordable Care Act (ACA), many previously uninsured patients will gain access to care. How are physicians adapting to this change? For instance, will they start accepting greater numbers of Medicaid patients than they currently do?

I think the response will be great, and I expect a lot of my professional colleagues to step up.

We have some sources of strength—the community health centers, also known as federally qualified health centers–and their star is rising. There are more of them, and they are better supported in the ACA. They have new opportunities, so that will help fill some of the gaps. There are investments in trying to make primary care more attractive to physicians, and I think we very much need to continue that.

I think there are some levers, or “force multipliers” that we really need to be thinking about in order to solve the problem. There are two that are most important to me. First is telemedicine and ways to project knowledge, information, and support to people in their homes so that every problem doesn’t need a visit to deal with it. The second is non-physician providers. There is such a reservoir of people who are very skilled, and who could be even more skilled than physicians to deal with primary care needs. We need to get out of our own shadow and view the problem not as one of primary care physician supply but primary care supply, and I think we’ll get better care overall.

In articles you have written, like “What ‘Patient-Centered’ Should Mean,” you addressed the need for the culture of healthcare to become one in which the patient is put first. Does the ACA answer the need for patient-centered care, as you’d hoped?

Culture changes are much, much bigger than the implementation of federal policies. You can’t legislate spirit, and people will do what makes sense to them. We can change laws and payment to make it more sensible to be gentle, dignified, and responsive. I can think of all sorts of ways to put doctors, nurses, and pharmacists in a position where they don’t have the time or energy to connect, but this type of change is going to have to come from a different place.

In my own view, and what I hope is true, is that a new breed of professionalism is what we’re really talking about here. The professions will get back in touch with the importance of the element of care as caring and support the young—doing this in such a way that medical students, nursing students, anyone who’s preparing for health professions are really encouraged to connect to what I call “authentic patient-centered care.”

How has the ACA allowed this conversation about patient-centered care to take place?

I think it’s helping. For example, if the affordable care organizations (ACOs), which are in the ACA, thrive, then you’ll find healthcare delivery systems that will be really interested in things like behavioral medicine, reinforcing primary care, and effective encounters; they’re going to look for new ways to meet needs. Because, remember in an ACO, the patient doesn’t enroll, their provider does, so the patient can go wherever they want. So the ACO is going to have to be attractive. If I were running an ACO, I would really work hard and say, “Look, people need to have such an exceptional experience here that even though they could walk and go somewhere else, they won’t because they want to be here.”

How can healthcare professionals in training best implement changes to create a healthcare system that emphasizes patient-centered care?

Stay together. IHI’s phrase is “never worry alone,” and I think the dynamics of the Open School, for example, will help. Because when you get aggravated and can’t act the way you’d like to, you can go to a buddy who shares that feeling, and that will build your confidence.

Maureen Bisognano would say, and I’d agree with her, “Get the patient in the room.” Whenever you’re wondering what to do, talk to the person you’re trying to help, and ask him how he’s doing. If the people in training exercise around that kind of contact with patients, families, and their communities, they’ll guide you and give you more energy.

You’ve spoken many times about your concerns with fragmented systems in healthcare, and through the ACA one more, insurance exchanges, will be added. Do you have any advice or recommendations for how states can best approach their implementation?

Absolutely. The original concept behind the exchanges was “no wrong door.” I love that phrase—it was Cindy Mann who developed it.

So you have Mrs. Smith, a single mom with two young kids, who’s struggling to keep a job. She can possibly get health insurance, but she’s never tried before and she’s not sure if she qualifies. So she goes into some place and they sort it out for her. They tell her what she’s eligible for, provide her with choices of plans, and help her sort through all of it. That requires an integrated approach—integrating information systems, enrollment procedures, Medicaid, and exchange processes. It means the exchange is an active exchange, not a passive exchange; so it’s not just posting the availability of products but also providing information about how good they are.

Some states, the ones that are supportive of the ACA and been moving in this direction, will have “no wrong door” exchanges. Others that are resistant, haven’t gotten started, haven’t built the information systems, they’re not going to be able to give the patient this type of experience. That may be what they want because a confused patient may just take a walk and not enroll.

But I think the challenge is that “no wrong door” itself is a challenge, and I’m concerned because I don’t know how this will play out. The other thing is at least a third or more of the states will default to choose a federal exchange. The federal exchange is set up as “no wrong door,” which is very important. I’m certain my former colleagues at CMS are working as hard as they can to set up an effective system, but it’s going to be hard, particularly among the states that are being very passive aggressive about this.

Feature photo: cc/kenteegardin