Editor’s Memo

Berwick: Time for a New ‘Era 3’ In American Health Care


Donald Berwick

Donald Berwick’s Triple Aim has been the go-to metaphor of health care reform and attempts to manage care for well over a decade.

In an essay published in JAMA earlier this year, Berwick proposed a new three-infused trope for American health care, organized by eras.

In Era 1, which he dates back to Hippocrates, physicians were autonomous. Era 2 is the welter of data, measurement, and incentives that now dominates. It has become a distressing time, in Berwick’s view. Physicians and other clinicians are feeling angry, misunderstood, and overcontrolled. Payers, government officials, and consumer groups feel suspicious, resisted, and often helpless. Our cover story this month about physician payment echoes some of these sentiments.

So it’s time to usher in Era 3, a “moral era,” argues Berwick, who was briefly head of CMS in the Obama administration during the early days of the ACA. Berwick would bring Era 3 about by, among other things, sweeping away the multitiude of process measures and replacing them with a much smaller set of outcomes. He thinks there should be a moratorium on complex incentive programs and that his former agency should limit its value-based payment models to large groups.

Other Era 3 ingredients: heavy doses of improvement science in health care curriculums and job descriptions; easier access to the troves of data at CMS and commercial payers; and a halt to the current “tolerance for greed” in health care.

The Triple Aim suffers from an aspiration–actuality gap. Taking aim is one thing, hitting the target, another. Berwick’s Era 3 seems like it could be a golden age in health care. Will it ever come to pass? We have our doubts.

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