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Another important battle over the future of Medicare and Medicaid

Posted by Rob Anderson  April 20, 2011 01:23 PM

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berwick.JPGGiven the broader Republican attacks on Medicare and Medicaid, the confirmation of the administrator for the Centers for Medicare and Medicaid Services (CMS) may not seem like a big deal. But as the Senate decides between two candidates — Dr. Donald Berwick, President Obama’s recess appointment for the post, and Marilyn B. Tavenner, the current CMS deputy administrator — the stakes are quite high. At issue is how the most important government health care programs will be run and how closely its administrator will be tied to the very health care companies CMS regulates.

The professional histories of Berwick and Tavenner could not be more different. Berwick is a Harvard trained pediatrician and co-founder of the Cambridge-based Institute for Healthcare Improvement, the nation’s premiere patient safety and quality improvement organization. Although the institute tends to promote its agenda among the hospital industry’s top leaders, it has focused on teamwork in health care and nursing initiatives like the Transforming Care at the Bedside project. It has also helped the hospital industry implement “best practice” initiatives that help protect patients from harm. At CMS, Berwick has backed programs that link hospital pay to patient satisfaction, streamlined operations to reduce bureaucratic hassles, and argued that physicians should have discussions with patients about end-of-life care.

Berwick has wide support from the American Medical Association, as well as from many in the hospital industry and corporate America. But, from the perspective of Tea Party Republicans, other conservatives, and some Democrats, he has several fatal flaws. Berwick has acknowledged that all health care systems ration care and has argued for transparency and accountability as we decide what we can afford. When working for greater global patient safety, he has argued that we need to learn from other health care systems, like the United Kingdom's. Indeed, he’s even expressed these views in print, in (Heaven help us!) foreign medical journals like the British Medical Journal. To some, this constitutes proof positive that the relatively mainstream pediatrician favors “death panels” for the old and infirm and major cuts in services for the rest of us.

In July of 2010, President Obama used a recess appointment to place Berwick at the head of the CMS. With this appointment, the president seemed to recognize that the health care law he’d promoted — the Patient Protection and Affordable Care Act — promised Americans more than access to health insurance. Now the president and some Congressional Democrats seem about to buckle under conservative pressure by abandoning Berwick and supporting Tavenner, a nurse who has spent 25 years working for Health Care Corporation of America and the nation’s largest for-profit hospital system. Ordinarily I’d rejoice at the idea of seeing an RN at the helm of CMS. But this particular RN has worked for a for-profit hospital system that, as research studies report, spends 11 percent less on patient care — mostly by stinting on nursing care.

While Tavenner worked for HCA, the company was busily enhancing its profit margin by defrauding the Medicare, Medicaid, and TRICARE systems. Terry Leap’s new book, "Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What To Do About It," details HCA’s sorry history. In 2000, for example, HCA paid fines of $840 million for improperly billing the government and in 2003 HCA had to fork over another $631 million.

Although Tavenner may not have been personally involved in these scandals, it hardly seems wise to put her in charge of the government system her company helped defraud. The job of CMS administrator is to protect patient safety and quality, something that federal officials with close ties to the industries they are supposedly regulating and monitoring seem to have a hard time doing.

The fact that Berwick’s candidacy is now in jeopardy has prompted an Internet and letter writing campaign that includes some of the most prominent patient safety advocates and organizations in the country, including physicians and patient safety gurus Lucian Leape and Robert Wachter.

As legislators judge the qualifications of candidates for one of the top health care jobs in the country, they shouldn’t be sifting through medical journals to find out of context comments about health care systems in other countries. They should instead be asking what candidates for this high office have done to assure patient safety and quality services right here at home. In any contest between Tavenner and Berwick, Berwick’s decades long record of initiating some of the most important patient safety campaigns in the country should make him the clear winner. If someone with Berwick’s record and stature cannot win the nomination, perhaps we should simply just take the two P's — patient and protection — out of the PPACA.

Suzanne Gordon is editor of the Culture and Politics of Health Care Work series at Cornell University Press and co-editor of a forthcoming book on patient safety.

Globe file photo: Donald Berwick, administrator of the Centers for Medicare and Medicaid Services, testifies before the Senate Finance Committee last year.

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ABOUT THE ANGLE Online commentary and news analysis from the Boston Globe. The Angle is produced by Rob Anderson and Alan Wirzbicki. You can follow Rob on Twitter at @rcand.

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