The Moral Test, a speech delivered by Dr. Donald Berwick, the outgoing Administrator of the Centers for Medicare & Medicaid Services (CMS) at the MDIHI National Forum, Orlando, Florida: December 7, 2011
Let me begin by thanking the Picker Institute for this honor. I am
touched to be in such good company, and especially for a theme
so close to my heart – patient-centered care. And let me also say
a word of personal reverence for Harvey Picker. He was a man of
grace, vision, and action. He changed forever our understanding
about the proper relationship between the people who get care
and the people who give it.
And, I need to say a word about Maureen Bisognano. For years, I
have known that the luckiest step in my entire professional career
was Maureen’s joining IHI in 1995. She made into the
organization it has become. She is the best colleague I have ever
had – bar none. Now, I know that that was the second luckiest
step. The new luckiest step was Maureen’s willingness to
become IHI’s President and CEO. Thanks to her, I can see after
this time away, IHI has soared to entirely new heights with
stronger patient voice, wider global reach, an Open School that 2
now includes 74,000 students, and a whole new level of presence
and gravitas in the global health care scene. Maureen, you are a
treasure – a global treasure, and it is an honor to have you as our
leader.
It is good to be back. For me, the past 16 months have been
quite an expedition; I feel like Marco Polo. Never having
expected it, I journeyed into the world of national policy and
politics at the most tumultuous time for both modern American
health care and the modern global economy. To keep things in
perspective, I also watched grandson #1 – Nathaniel – grow to 2
½ years old, and we welcomed grandson #2 – Caleb – into the
world 8 weeks ago.
The time at CMS has been a privilege. I got the chance to work
with thousands of career public servants, and to learn how much
these people do for us all, unsung and too often unappreciated.
These are the people who translate laws into regulations and
regulations into deeds. In CMS these are the people who keep
the lights on – they see that providers get paid, they protect the
public trust, they help the most vulnerable people in America, and
make sure that they get the care they need.
And, I got the chance to help pilot toward harbor the most
important health care policy of our time – the Affordable Care Act. 3
A majestic law. I learned that a law is only a framework; it’s like
an architect’s sketch. If it’s going to help anyone, it has to be
transformed into the specifications that regulations and guidance
documents. Only then can become real programs with real
resources that reach real people. On my expedition, that, mostly,
was what I was doing.
I would have loved to keep at that job longer. But, as you know,
the politics of Washington, and especially the politics of the United
States Senate, said, “No.” But, overall, I don’t feel an ounce of
regret. What I feel is grateful for the chance I had to serve, and for
the generous support I felt, including from so many of you.
I want this afternoon to share with you a little of what I learned on
the expedition; and what I think it means for you – for all of us.
It’s a sort of good-news-bad-news situation. The good news: the
possibility of change has never been greater – not in my lifetime.
The bad news: if it’s going to be the right change, the burden is
yours.
When I first got the job, my brother, Bob, a retired middle school
science teacher and a very wise man, gave me a sign to put on
my desk. It read, “How will it help the patient?” It was there from
the minute I arrived until the minute I left. Maureen gave me the
same sort of advice just before I left IHI. I asked her how I could 4
succeed at CMS, and she said, “That’s easy; just mention a
patient five times a day.”
Bob’s advice and Maureen’s was the best I got – hands down –
from anyone else anywhere else. Remember the patient.
As it turns out, that’s not easy in an office just a few hundred
yards from the US Capitol Building – less than a mile from the
White House. Every morning at breakfast, the stewards of
national policy and politics rush to scan the Washington Post and
Politico and to wolf down the day’s Capitol Hill newsletters and
blogs. What they are finding out is what each other says. Which
Senator has raised an eyebrow? Which lobbyist has cried foul?
Which Committee is launching which outraged inquiry into which
shocking development. In Washington, a day without a shocking
development is hardly worth getting up for. And, of course, who is
ahead? Always, who is ahead? My son, Dan, when he first knew
I was going to Washington, and who had lived there, said to me:
“Just remember, Dad, Washington is a city where everyone is
trying to get into a room they aren’t yet in.”
In that self-absorbed culture, the question, “How does it help the
patient?” isn’t always the first one asked. In fact, it can seem
naïve – not on point. And yet, I learned that, in Washington, DC,
just like here, it is exactly the right question. The best public policy 5
and the best public management answer it. This is only Harvey
Picker’s idea reframed – from patient-centered care to patientcentered policy.
And that leads me to a second big lesson. I can best explain it to
you by describing a visit I made in the fall of 2011 to a small rural
hospital – Lower Umpqua Hospital in Reedsport, Oregon. I was
on a so-called “Rural Road Trip” visiting rural hospitals to learn
from them.
At a meeting there, one of the doctors spoke up – Dr. Robert Law
– and he captivated me. Dr. Law, I learned, was the Oregon
Academy of Family Practice’s “Family Physician of the Year” in
1999. And two sentences into his remarks at the meeting, I could
see why. He spoke from his heart. He said how deeply he cared
about his community, his patients, and his professionalism. He
told why he felt lucky to be serving, and how willing he was to try
out new ways to meet needs, even while resources get tighter.
He said how offended he was by waste in the health care system
– even in Reedsport – and how hard he wanted to work to make
sure that every single thing done to, for, and with patients and
families would actually help them – on their terms, not his. And –
most importantly – he asked for help – for a context of policy,
payment, and information that, simply put, would help him get his 6
work done with pride and joy. “If things don’t change soon,” he
told me last week, “I am not sure how we can keep going.”
Cynicism grips Washington. It grips Washington far too much…
far too much for a place that could instead remind us continually
of the grandeur of democracy. I vividly remember my first trip
ever to Washington, DC. I was twelve years old, and friends took
me to the Lincoln Memorial just after sunset. I looked from the
statue of Abraham Lincoln, past the Reflecting Pool and the
Washington Monument, to the glowing Capitol Building in the
distance – the same Capitol that I saw outside my office window
every day for the past 16 months. And, twelve years old, I cried in
awe and admiration for – what shall I call it? – majesty.
Two weeks ago, Congress’s approval rating fell to an all-time
low: 9%.
How did that happen? It happens when the cynics are winning.
In a city where everyone wishes to be in a room they are not yet
in, it is easy to see everyone as on the make, everyone
maneuvering, everyone with elbows sharpened. It becomes too
easy to lose hope and confidence, and to forget what can be
noble in human nature.
When the lens through which one sees the world magnifies
combat, dissembling, and greed, then trust decays and those who 7
deserve to be trusted feel bad – misunderstood, confused, and
impeded in their good works.
Dr. Robert Law is not cynical, and he is not on the make. He is
dedicated to a life of service to a community he loves, and in
which he raised his own three children – Alison, Brian, and
Duncan. The job of public servants is to serve him so that he can
better serve others. He needs help, resources, encouragement,
voice, and respect. His promise – what he can offer our nation –
has nothing to do with preventing fraud, holding his feet to the fire,
or audits, and it has little to do with payment for performance,
public measurement, incentives, or accountability. He is a good
person who needs dignified assistance to do good work… and he
is legion. He can be the future. He, in fact, can and will rescue
us, if we will help him help us.
If lesson one for me is, “Remember the patient,” then lesson two
is this: “Help those who help others.” Those thoughts – not the
negativity – guided my in DC, and they made my time there
meaningful.
They are reminders of what is truly important; not the noise, but
simply this: to help the people who need our help the most.
Inscribed on the wall of the great hall at the entrance to the
Hubert Humphrey Building, the HHS Headquarters in Washington 8
where my office was, is a quotation from Senator Humphrey at
the building’s dedication ceremony on November 4, 1977. It says:
“The moral test of government is how it treats those who are in
the dawn of life, the children; those who are in the twilight of life,
the aged; and those in the shadows of life, the sick, the needy
and the handicapped.”
I believe that. Indeed, I think that Senator Humphrey described
the moral test, not just of government, but of a nation. This is a
time of great strain in America; uncertainty abounds. With
uncertainty comes fear, and with fear comes withdrawal. We can
climb into our bunkers, each separately, and bar the door. But,
remember, millions of Americans don’t have a bunker to climb into
– they have no place to hide. For many of them, indeed, the crisis
of economic security that we all dread now is no crisis at all – it is
their status quo. The Great Recession is just their normal life.
The rate of poverty in this country is rising. Over 100 million
Americans – nearly one in every three of us – is in poverty or
near-poverty today – 17 million of them children. I will tell you –
state by state, community-by-community, and in the halls of
Washington, itself – the security of the poor – their ability to find
the health care they need, and the food, and the housing, and the
jobs, and the schools – all of it, hangs by a thread. The politics of 9
poverty have never been power politics in America, for the simple
reason that the poor don’t vote and the children don’t vote and the
sickest among us don’t vote. And, if those who do vote do not
assert firmly that Senator Humphrey was right, and if we do not
insist on a government that passes the moral test – the thread will
break, and shame on us if it does.
Cynicism diverts energy from the great moral test. It toys with
deception, and deception destroys. Let me give you an example:
the outrageous rhetoric about “death panels” – the claim,
nonsense, fabricated out of nothing but fear and lies, that some
plot is afoot to, literally, kill patients under the guise of end-of-life
care. That is hogwash. It is purveyed by cynics; it employs
deception; and it destroys hope. It is beyond cruelty to have
subjected our elders, especially, to groundless fear in the pure
service of political agendas.
The truth, of course, is that there are no “death panels” here, and
there never have been. The truth is that, as our society has aged
and as we have learned to care well for the chronically ill, many of
us face years in the twilight our lives when our health fades and
our need for help grows and changes. Luckily, palliative care –
care that brings comfort, company, and spiritual and emotional
support to people with advanced illness and their families – has 10
grown at its best into a fine art and a better science. The principle
is simple: that we can and should offer people the very best of
care at all stages of their lives, including the twilight.
The truth is, furthermore, that patient-centered care demands that
the ways in which a person is cared for ought always to be under
his or her control. The patient is the boss; we are the servants.
They, not others, should direct their own care, and the doctors,
nurses, and hospitals should know and honor what the patient
wants. Some of us want to be guaranteed that, no matter how
sick or close to death we are, every single machine, drug, and
device that could help us live even a moment longer should be
used; and that is, therefore, exactly what they should have. And,
other if us want not to spend our final days in an intensive care
unit, attached to machines, but rather, say, to be at home, in our
own bed surrounded by our loved ones in a familiar place, but still
receiving world-class treatment for pain and complications; then
that is, therefore, exactly what they should have. It is one of the
great and needless tragedies of this stormy time in health care
that the “death panel” rhetoric has denied patients the care that
they want, denied caregivers the information they need to give
that care, and denied our nation access to a mature, open,
informed, and balanced discussion of the challenge of advanced
illness and the commitment to individual dignity. It is a travesty.11
If you really want to talk about “death panels,” let’s think about
what happens if we cut back programs of needed, life-saving care
for Medicaid beneficiaries and other poor people in America.
What happens in a nation willing to say a senior citizen of
marginal income, “I am sorry you cannot afford your medicines,
but you are on your own?” What happens if we choose to defund
our nation’s investments in preventive medicine and community
health, condemning a generation to avoidable risks and unseen
toxins? Maybe a real death panel is a group of people who tell
health care insurers that is it OK to take insurance away from
people because they are sick or are at risk for becoming sick.
Enough of “death panels”! How about all of us – all of us in
America – becoming a life panel, unwilling to rest easy, in what is
still the wealthiest nation on earth, while a single person within our
borders lacks access to the health care they need as a basic
human right? Now, that is a conversation worth having.
And, while we are at it, what about “rationing?” The distorted and
demagogic use of that term is another travesty in our public
debate. In some way, the whole idea of improvement – the
whole, wonderful idea that brings us –thousands – together this
very afternoon – is that rationing – denying care to anyone who
needs it is not necessary. That is, it is not necessary if, and only 12
if, we work tirelessly and always to improve the way we try to
meet that need.
The true rationers are those who impede improvement, who stand
in the way of change, and who thereby force choices that we can
avoid through better care. It boggles my mind that the same
people who cry “foul” about rationing an instant later argue to
reduce health care benefits for the needy, to defund crucial
programs of care and prevention, and to shift thousands of dollars
of annual costs to people – elders, the poor, the disabled – who
are least able to bear them. When the 17 million American
children who live in poverty cannot get the immunizations and
blood tests they need, that is rationing. When disabled Americans
lack the help to keep them out of institutions and in their homes
and living independently, that is rationing. When tens of
thousands of Medicaid beneficiaries are thrown out of coverage,
and when millions of Seniors are threatened with the withdrawal
of preventive care or cannot afford their medications, and when
every single one of us lives under the sword of Damocles that, if
we get sick, we lose health insurance, that is rationing. And it is
beneath us as a great nation to allow that to happen.
And that brings me to the opportunity we now have and a duty. A
moral duty: to rescue American health care the only way it can be
rescued – by improving it. 13
I have never seen, nor had I dared hope to see, an era in
American health care when that is more possible than this very
moment. The signs are everywhere. In the past two years, major
hospital systems are asking at last how they can coordinate care.
Specialty societies are coalescing around plans for more
evidence-based care, the use of clinical registries, serious
recertification, and reduction of overuse of unhelpful care. The
patient safety movement is maturing, with numerous national
efforts to bring excellence to scale, including the billion-dollar
Partnership for Patients that we launched in HHS. Insurers are
experimenting with much more integrated payment models, of
which Accountable Care Organizations are only one breed.
Transparency is, I believe and hope, about to leap forward.
Patients’ and consumers’ groups are more active and more
sophisticated, and they are gaining the footholds they need in
governance. Employer groups and labor unions are uniting in
their demands. And states are on the move – states like Oregon,
Arkansas, and Massachusetts – where courageous and visionary
governors – like John Kitzhaber, Mike Beebe, and Deval Patrick –
are catalyzing transformation.
And, though no sane person would have wished on us the most
serious economic crisis since the Great Depression, the global
downturn has added tons to the pressure for change. We are 14
headed for a cliff, and we need to change course. And that
means health care needs to change course.
To be clear, we have not changed course yet. Not enough. Not
hardly. All the unfreezing has not yet moved health care into its
new and needed state. In truth, we have only been getting ready.
The Affordable Care Act helps, but, a law is not change – it set
the table for change. A Constitutional provision for a free press
does nothing until a press turns somewhere. And a law that
provides support for seamless, coordinated care has done
nothing until some person who needs it gets it.
This is the threshold we have now come to, but not yet crossed:
the threshold from the care we have to the care we need.
We can do this… we who give care. And nobody else can. The
buck has stopped. The Federal framework is set by the
Affordable Care Act and important prior laws, such as the
HITECH Act, and, quite frankly, we can’t expect any bold statutory
movement with a divided Congress within the next year or more.
The buck has stopped; it has stopped with you.
Now comes the choice. To change, or not to change.
It is not possible to claim that we do not know what to do. We
have the templates. 15
If you doubt it, visit the brilliant Nuka care system at Southcentral
Foundation in Anchorage, which just won the Baldrige Award. I
visited in October. Thoroughly integrated teams of caregivers –
physicians, advanced practice nurses, behavioral health
specialists, nutritionists, and more – occupying open physical
pods in line-of-sight contact with each other all day long, weaving
a net of help and partnership with Alaska Native patients and
families. The results: 60% fewer Emergency and Urgent Care
Visits, 50% fewer hospitalizations, and 40% less use of
specialists, along with staff turnover 1/5
th
as frequent as before
the new care.
If you doubt that we know what to do, visit Denver Health or
ThedaCare or Virginia Mason, and see the Toyota principles of
lean production learned, mastered, adapted, and deployed
through entire systems and into the skills and psyches of entire
workforces. The result, over $100 million in savings at Denver
Health while vastly improving the experience and outcomes of
patients.
If you doubt that we know what to do, contact George Halvorson
at Kaiser Permanente and ask him how they have reduced sepsis
mortality – sepsis is the cause of death in 24% of seniors who die
in California hospitals. Kaiser-Permanente has driven down
sepsis mortality by nearly half – to 11% in less than three years.16
Let me put it simply: in this room, with the successes already in
hand among you here, you collectively have enough knowledge to
rescue American health care – hands down. Better care, better
health, and lower cost through improvement right here. In this
room.
The only question left is: Will you do it?
When we entered the world of health care improvement as our
life’s work, we didn’t ask for the burden we now bear. We did not
ask to be responsible for rescuing health care.
But, here we are, and, as intimidating as the fact may be, that
burden is ours. Our nation is at a crossroad. The care we have
simply cannot be sustained. It will not work for health care to
chew ever more deeply into our common purse. If it does, our
schools will fail, our roads will fail, our competitiveness will fail.
Wages will continue to lag, and, paradoxically, so will our health.
The choice is stark: chop or improve. If we permit chopping, I
assure you that the chopping block will get very full – first with
cuts to the most voiceless and poorest us, but, soon after, to more
and more of us. Fewer health insurance benefits, declining
access, more out-of-pocket burdens, and growing delays. If we
don’t improve, the cynics win.17
That’s what passes the buck to us. If improvement is the plan,
than we own the plan. Government can’t do it. Payers can’t do it.
Regulators can’t do it. Only the people who give the care can
improve the care.
What’s the strategy? Let me show you one. I owe much of this to
my friend and colleague, Andy Hackbarth, who has been
collaborating with Joe McCannon, others, and me for much of the
year to develop a set of lenses clear enough to let us see the
pathway to success.
We began with work far from health care – the work of a
Princeton economist and environmental expert named Robert
Socolow. Professor Socolow published an important article in
2004 in Science magazine, trying to answer a very important
question: “What is the way to slow the rate of atmospheric carbon
production enough to avert catastrophic carbon levels in the
future.”
Here is his answer: “There is no way.” That is, there is no single
way to do it. Automobile emission control can’t do it. Solar power
can’t do it. Conservation can’t do it. The only way we can do it is
to do, not one thing, but everything. When I read Socolow’s
article, I thought instantly of Göran Henrik’s answer to me when I
asked him a few years ago how Jönköping County in Sweden 18
was achieving such pace-setting results in total health system
performance. Göran said, “Here’s the secret: We do everything.”
“Do everything” – that’s Socolow’s answer to the global warming
problem. Luckily, nothing more than everything is necessary,
and, unluckily, nothing less than everything is sufficient. Socolow
diagrammed “everything” as what he called, “wedges.” In his
chart, the lower line is the line of “sustainability.” It shows the
highest levels of atmospheric carbon that do not lead to runaway
warming. It’s the goal. The top line is the “business as usual” line;
it shows how fast carbon levels rise if we stay on the current
course.
The “wedges” – Socolow proposes 15 of them – 15 changes that
affect carbon output – fill what Socolow calls the “sustainability
triangle.” The “wedges” framework looks a lot like a strategic plan,
or at least a system of strategic goals, whose cumulative effect –
all together – is a sustainable level of carbon, so that we don’t
cook Planet Earth.
Solving the health care crisis has wedges, too. We don’t have as
crystal clear a target – a sustainability level that works for total US
health care spend – but for sure our business-as-usual line isn’t it.
Pay on that line over time, and schools suffer, roads suffer, 19
museums suffer, and private consumption suffers because, as
Tom Nolan said years ago, “It’s our money.” It is all wages.
Now, I probably owe you an apology for talking about costs. I
know that, among the important dimensions of quality – safety,
effectiveness, patient-centered care, timeliness, efficiency, and
equity – I am not sure any of us would have chosen “efficiency” –
the reduction of waste – as our favorite. It’s not my favorite.
Nonetheless, it is the quality dimension of our time. I would go so
far as to say that, for the next three to five years at least, the
credibility and leverage of the quality movement will rise or fall on
its success in reducing the cost of health care – and, harder,
returning that money to other uses – while improving patient
experience. “Value” improvement won’t be enough. It will take
cost reduction to capture the flag. Otherwise, “cutting” wins.
But, I am not going to apologize. That’s because if you are a
student of lean thinking or quality, itself – if you have taken the
time to study the work of Noriaki Kano, or Jim Womack, or Taichi
Ohno, or Dr.Deming, you know that great leverage in cost
reduction comes directly – powerfully – exactly from focusing on
meeting the needs of the person you serve. “Waste” is actually
just a word that means, “Not helpful.” So, that initial wave of
reaction – “Who wants to work on efficiency” – is actually off the 20
mark. In very large measure, improving care and reducing waste
are one and the same thing.
How much cost reduction? Well, If we look to Europe for ideas,
then a target of, say, 12% of our GDP, far below our current 17%
would look plausible. If you want to stay at home for signals, find
the lowest cost quartile of American health can economies –
hospital referral regions or HRRs – and we’d be somewhere in the
neighborhood of 15% of GDP. Or, maybe that looks tough, and
you’d be more comfortable if health care began to behave just as
well as, but no better than, the rest of the economy – that is, rising
in synch with the GDP, itself, and just staying where it is – 17% or
so.
The point is, with costs rising a great deal faster than that, no
matter what your goal is, you’ve got a sustainability triangle to fill
– the growing, cumulative difference between unsustainable
“business as usual” costs and the sustainable ones.
The social imperative for reducing health care cost is enormous.
And, to meet that enormous need, I suggest, just as with the
environmental triangle, for the health care cost triangle, nothing
works. Only everything works. It’s all or none, or we head
straight on and over the cliff.21
Andy Hackbarth and I took a stab at defining the “wedges” for
health care costs. These are the names of the forms of waste
whose removal from the system both helps patients thrive and
reduces the cost of care.
We found six wedges, for starters, and we estimated their size.
Overtreatment – the waste that comes from subjecting people to
care that cannot possibly help them – care rooted in outmoded
habits, supply-driven behaviors, and ignoring science.
Failures of Coordination- the waste that comes when people –
especially people with chronic illness – fall through the slats.
They get lost, forgotten, confused. The result: complications,
decays in functional status, hospital readmissions, and
dependency.
Failures of Reliability – the waste that comes with poor execution
of what we know to do. The result: safety hazards and worse
outcomes.
Administrative Complexity – the waste that comes when we
create our own rules that force people to do things that make no
sense – that converts valuable nursing time into meaningless
charting rituals or limited physician time into nonsensical and
complex billing procedures.22
Pricing Failures – the waste that comes as prices migrate far from
the actual costs of production plus fair profits.
Fraud and Abuse – the waste that comes as thieves steal what is
not theirs, and also from the blunt procedures of inspection and
regulation that infect everyone because of the misbehaviors of a
very few.
We have estimated how big this waste is – from both the
perspective of the Federal payers – Medicare and Medicaid – and
for all payers. Research and analytic literature contain a very
wide range of estimates, but, at the median, the total annual level
of waste in just these six categories (and I am sure there are
more) exceeds $1 trillion every year – perhaps a third of our total
cost of production.
This is our task… our unwelcome task – if we are to help save
health care from the cliff. To reduce costs, by reducing waste, at
scale, everywhere, now.
I recommend five principles to guide that investment:
1. Put the patient first. Every single deed – every single
change – should protect, preserve, and enhance the wellbeing of the people who need us. That way – and only that
way – we will know waste when we see it.23
2. Among patients, put the poor and disadvantaged first –
those in the beginning, the end, and the shadows of life. Let
us meet the moral test.
3. Start at scale. There is no more time left for timidity. Pilots
will not suffice. The time has come, to use Göran Henrik’s
scary phase, to do everything. In basketball, they call it
“flooding the zone.” It’s time to flood the Triple Aim zone.
4. Return the money. This is the hardest principle of them all.
Success will not be in our hands unless and until the parties
burdened by health care costs feel that burden to be lighter.
It is crucial that the employers and wage-earners and unions
and states and taxpayers – those who actually pay the
health care bill – see that bill fall.
5. Act locally. The moment has arrived for every state,
community, organization, and profession to act. We need
mobilization – nothing less.
One evening shortly before I left Washington, I visited the Lincoln
Memorial again – standing at the same spot that I had stood at as 24
a twelve-year-old boy 53 years ago. The majesty was still there –
the visage of Lincoln, the reach of the Washington Monument, the
glow of the Capitol Dome. It was still unbearably beautiful. Still
majestic.
But, there was one change. Chiseled in the very stone where I
was standing is now the name of Dr. Martin Luther King and the
date – August 28, 1963, when he gave his immortal “I have a
dream…” speech.
When I first stood at that spot, the Montgomery Bus Boycott was
only three years in the past, and Dr. King’s speech lay five years
in the future. Rachel Carson’s book, “Silent Spring,” was four
years in the future. And it would be six years before the phrase,
“Women’s Liberation,” would first be used in America.
I thought, standing there, of something I once heard Dr. Joseph
Juran say: “The pace of change is majestic.” And I mused about
that majesty, and its nature.
It occurred to me that the true majesty lay not just in the words –
not just in the call – but also in the long and innumerable
connections between the ideas that stir us – the dreams – and the
millions and millions of tiny, local actions that are the change, at
last. A dream of civil rights becomes real only when one black
child and one white child take one cooling drink from the same25
water fountain or use the same bathroom or dine together before
the movie they enjoy together. An environmental movement
becomes real only when one family places one recycle bin under
one sink or turns off one unneeded light out of respect for an
unborn generation. Women’s rights are not real until one
woman’s pay check stub reads the same as one man’s, and until
my daughter really can be anything she wants to be. The majesty
is in the words, but the angel is in the details.
And that is where you come in. Here is the lesson I bring you from
16 months in Washington, DC. Your time has come. You are on
the cusp of history – you, not Washington, are the bridge between
the dream and the reality – or else there will be no bridge. Our
quest – for health care that is just, safe, infinitely humane, and
that takes only its fair share of our wealth – our quest may not be
as magnificent as the quest for human rights or for a sustainable
earth, but it is immensely worthy. You stand, though you did not
choose it, at the crossroads of momentous change – at the
threshold of majesty. And – frightened, fortunate, or both – you
now have a chance to make what is possible real.
It is good to be back. For me, the past 16 months have been quite an expedition; I feel like Marco Polo. Never having expected it, I journeyed into the world of national policy and politics at the most tumultuous time for both modern American health care and the modern global economy. To keep things in perspective, I also watched grandson #1 – Nathaniel — grow to 2 ½ years old, and we welcomed grandson #2 — Caleb — into the world 8 weeks ago.
The time at CMS has been a privilege. I got the chance to work with thousands of career public servants, and to learn how much these people do for us all, unsung and too often unappreciated. These are the people who translate laws into regulations and regulations into deeds. In CMS these are the people who keep the lights on — they see that providers get paid, they protect the public trust, they help the most vulnerable people in America, and make sure that they get the care they need.
And, I got the chance to help pilot toward harbor the most important health care policy of our time — the Affordable Care Act. A majestic law. I learned that a law is only a framework; it’s like an architect’s sketch. If it’s going to help anyone, it has to be transformed into the specifications that regulations and guidance documents. Only then can become real programs with real resources that reach real people. On my expedition, that, mostly, was what I was doing.
I would have loved to keep at that job longer. But, as you know,the politics of Washington, and especially the politics of the United States Senate, said, “No.” But, overall, I don’t feel an ounce of regret. What I feel is grateful for the chance I had to serve, and for the generous support I felt, including from so many of you.I want this afternoon to share with you a little of what I learned on the expedition; and what I think it means for you – for all of us. It’s a sort of good-news-bad-news situation. The good news: the possibility of change has never been greater — not in my lifetime. The bad news: if it’s going to be the right change, the burden is yours.
When I first got the job, my brother, Bob, a retired middle school science teacher and a very wise man, gave me a sign to put on my desk. It read, “How will it help the patient?” It was there from the minute I arrived until the minute I left. Maureen gave me the same sort of advice just before I left IHI. I asked her how I could succeed at CMS, and she said, “That’s easy; just mention a patient five times a day.”
Bob’s advice and Maureen’s was the best I got — hands down — from anyone else anywhere else. Remember the patient.
As it turns out, that’s not easy in an office just a few hundred yards from the US Capitol Building — less than a mile from the White House. Every morning at breakfast, the stewards of national policy and politics rush to scan the Washington Post and Politico and to wolf down the day’s Capitol Hill newsletters and blogs. What they are finding out is what each other says. Which Senator has raised an eyebrow? Which lobbyist has cried foul? Which Committee is launching which outraged inquiry into which shocking development. In Washington, a day without a shocking development is hardly worth getting up for. And, of course, who is ahead? Always, who is ahead? My son, Dan, when he first knew I was going to Washington, and who had lived there, said to me: “Just remember, Dad, Washington is a city where everyone is trying to get into a room they aren’t yet in.”
In that self-absorbed culture, the question, “How does it help the patient?” isn’t always the first one asked. In fact, it can seem naïve — not on point. And yet, I learned that, in Washington, DC, just like here, it is exactly the right question. The best public policy and the best public management answer it. This is only Harvey Picker’s idea reframed — from patient-centered care to patientcentered policy.
And that leads me to a second big lesson. I can best explain it to you by describing a visit I made in the fall of 2011 to a small rural hospital — Lower Umpqua Hospital in Reedsport, Oregon. I was on a so-called “Rural Road Trip” visiting rural hospitals to learn from them.
At a meeting there, one of the doctors spoke up — Dr. Robert Law — and he captivated me. Dr. Law, I learned, was the Oregon Academy of Family Practice’s “Family Physician of the Year” in 1999. And two sentences into his remarks at the meeting, I could see why. He spoke from his heart.