Tapped by President Obama in a recess appointment, Donald Berwick, MD, will lead the CMS at least till the end of next year. Here, selections from our Berwick file.

A history of silence on key issues? That may mark the ideal Supreme Court nominee, but it scarcely characterizes the new administrator of the Centers for Medicare and Medicaid Services (CMS).

Donald Berwick, MD, MPP, nominated to the post by President Obama in April and then placed in the job through a controversial July 6 recess appointment, has been pondering health policy questions for years — occasionally in the pages of MANAGED CARE.

Here’s Berwick — longtime CEO of the Institute for Healthcare Improvement — on the record, from our past articles:

Not A System

“Our so-called health care ‘system’ is designed to fail, not to work. We don’t even have a real system of care. We have fragmentation to the point that the public remains without the basic information necessary to either demand what it needs or to get it.”

—2004, quoted in a feature article titled “Do We Really Have the Best Health Care in the World?

Improper Focus

“Suppose you went to the senior executive suite at Boeing and you listened to what they’re talking about. Many of them today would be talking about mergers and Wall Street and capital. But they’d also be talking about airplanes. The leadership is knowledgeable about … the actual core product. In health care, when you go into the executive suite, especially on the lay side, you often find that the conversations are not about care, they’re not about the core product, they’re about deals. Patients may not even be mentioned. That’s a disabling characteristic.”

—1999 “Q&A” interview

Leaning Too Much on Docs

“The more I study the subject of quality, the more I become concerned that a major problem in our health system is the fragmentation of care that results in part from overreliance on physician discretion. Involving patients more deeply adds value to care. Outcomes are better, and patients are more satisfied.”

—2004, in an article titled “Plans Go Directly to Patients, Describing Treatment Options

Just What Is Managed Care?

“I have no idea what it means. Whenever you’re in a conversation with someone about managed care, you’d better spend about half the conversation defining your terms. Otherwise you’ll be lost. In the United States, we have a breed of well-led, prepaid organized systems. The traditional ones are staff- and group-model HMOs, the Kaiser Permanentes and Harvard Pilgrim Health Care, Fallon, Group Health Cooperative. In our work in the institute, we are always looking for the best we can find. We search the country and the world for the best care of back pain we can find, the best asthma care, the best intensive care units or the best obstetrical management. It is exceedingly rare that, after picking a topic and searching hard, we don’t end up with some of the famous and important managed care systems in the country on our list of the best we can find. I think it’s no accident. I think they’re the places that had the leadership and information and systems. The best of managed care is often the best we have. Many people don’t seem to realize that.”

—1999, “Q&A” interview

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.