Don Berwick, something of a folk hero to journos covering health care, had a heart-to-heart with the Association of Health Care Journalists the other day, and the story deserves a close read. The idea apparently was to vent about his short tenure heading the vast agency that oversees Medicare and Medicaid. Berwick, you may recall, had a recess appointment from the president and was up for confirmation in December. But he had no prospect of being confirmed; he was largely done in by the favorable remarks he once made about Britain’s National Health Service. Conservatives politicized his comments and portrayed Berwick as someone who would ration health care. Undoubtedly gun shy now, Berwick seemed to hold back a bit, and sometimes he spoke in tangled language. But some of his remarks were spot on. Others raise questions for another Q and A.
On rationing. Berwick tackled the conservatives’ argument that he was in favor of withholding care. “That’s not just slightly inaccurate,” he said. “It’s 180 degrees wrong.” Berwick had talked about rationalizing care—that is, getting the right care to the right people at the right time. Who would quarrel with that? The press, however, missed that notion at the time and instead repeated allegations about how Berwick would let people die on the streets. Berwick said the media should have focused on ways to get people the care they need and want instead of care they don’t need or want. A follow-up, asking for an example, would have helped drive home the point.
On politicizing stories. Yes, Virginia, Medicare stories today are politicized, and Berwick doesn’t like that, citing the contrived controversy over death panels during the health reform debate. “Tragically deceptive nonsense,” he called it, but “it attracts the public’s eye.”
“When something sounds like nonsense like death panels, journalists should be brave enough to say so. When someone says something quite silly, the journalists should say, ‘that’s quite silly,’” he advised. During the death panel brouhaha, reporters were slow to push back on the nonsense.
On health care costs. Stories about reducing medical costs and improving care need to appear more frequently. “I have not seen that grappled with in the way that it really needs to in the media. I don’t think the media has gotten into the more-is-better myth enough,” Berwick noted.
On Medicaid. He thinks the press ignores Medicaid, and he’s right about that. Few editors want stories about the poor and the ongoing saga of their states’ inability to pay for their health care. “Although Medicare inside the beltway attracts the most attention, I lost much more sleep about Medicaid than about Medicare.” He “dearly” hopes the country will continue to “embrace the idea that the most vulnerable people need us to help them.”
On the Affordable Care Act. Here is where the interview got really muddy. Berwick said he did not understand why the administration has not been able to explain what the health reform law can do for people. “I don’t know if it’s a communication strategy failure for which the administration needs a mulligan here, or if there’s something dyadic going on between the administration and the journalistic community that has been unable to explain it,” he said. Whew! I had an editor once who would write “mego” next to a phrase like that. “Mego” stands for “my eyes glaze over,” and mine certainly did. Berwick does not think journalists should sell the law, but he does think “the positive aspect of it has been too sotto voce in the reports.” Huh? So are we intentionally keeping our voices too low on the positives of the law? But, then again, it’s not our job to sell health reform.
On transparency. Berwick was clearer when it came to transparency. He’s all for it, even though he doesn’t think patients will open Consumer Reports to decide where to go when they have a heart attack. He doesn’t think the country is where it needs to be on the matter of transparency. “If we can make more information more transparent, almost everything will get better, cost and price,” he noted. “I have become more and more a fan of transparency.” Maybe it’s easy to be one when you don’t have the health care establishment (which doesn’t like transparency) pressuring you at every turn.
There were two topics I wish the interview would have touched on—Berwick’s position on the future of Medicare and the underuse of medical services, which exist alongside overuse. It’s a paradox of American health care. Decisions about the shape of the program made this year or next will have far-reaching financial consequences for every American. Knowing what the ex-head of Medicare thinks might be helpful. Does he think vouchers or premium support are a good idea? Then there’s the matter of underuse of medical services. In mid-November, I checked with Berwick’s agency to find out whether seniors were getting preventive care benefits available from Medicare. Of the four million or so new beneficiaries who had signed up for Medicare at that point, only 3.6 percent had had their “Welcome to Medicare” exam, and of the more than 40 million seniors already on Medicare, only 1.7 million had had their “Annual Wellness Visit.” Perhaps someone can ask Berwick about that in the next interview.
Berwick said he would “not knowingly turn down any request for an interview from press that I know about.” Spoken like a battle-scarred politician. Who, then, will he talk to next?