New Medicare Chief Termed “Rationer”: Is This Fair?

The Centers for Medicare and Medicaid Services (CMS) has a new chief.  Donald M. Berwick M.D. was appointed by the president to take over CMS.  A “recess appointment” was made during the absence of Congress, as there was concern that the formal hearing process would be used to stall or delay the nomination.

Dr. Berwick is a pediatrician with decades of experience, the CEO of the Institute for Healthcare Improvement, and a professor at Harvard.  He is well qualified for this challenging post. 

The emerging backlash is centered on his views concering utilization of healthcare resources.  One comment noted in many news items  is the following, made by Dr. Berwick during an interview in the June 2009 issue of Biotechnology Healthcare.  He said this:

We make those decisions all the time.  The decision is not whether or not we will ration care – the decision is whether we will ration with our eyes open.  And right now, we are doing it blindly.

The complete interview is here

Most criticism has focused on taking pieces of the above comment, usually sentence two, and honing in on the issue of “rationing”.  Naturally, lawmakers do not like recess appointments, which is part of the reason for the criticism.  Other groups have opposed his appointment, using terms I will not repeat.  Is this justified? 

There is no doubt that the healthcare system is under significant stress.  It suffers from imperfect competition, and costs are rising beyond our ability to contain them.  Something has to change, and forces are underway to that effect.  But terming Dr. Berwick a “rationer” makes little sense.  What he and most sensible observers advocate is for care options to make clinical and financial sense. 

Considering this quote in full, there is all sorts of rationing in healthcare just in reaction to the economic forces that shape the system.  And since this is imperfect competition, that sort of rationing doesn’t always help patients.

The system simply cannot provide everything to everyone, and one way or another, decisions will have to be made.  The medical education system has chosen to largely ignore considering the cost of care when training doctors and other providers.  This is because taking on the cost issue is very difficult and brings up many ethical conflicts.  Ignoring it is far easier.  But the problem has never gone away.  Now, with costs out of control, it must be tackled.

“Blind rationing” is not an appropriate way to reduce cost.  Improving the system requires considering incremental benefit and cost of new treatments, confirming that new treatments are effective, and reducing the moral hazard issues prevalent throughout the system.  Leading CMS is a big challenge, moreso now than at any time in the recent past.  Dr. Berwick doesn’t need accusations of being a “rationer”, he needs support and best wishes.


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