By DONALD BERWICK
Time www.time.com web exclusive
Monday, Apr. 24, 2006
Donald Berwick is a Massachusetts pediatrician and president of the Institute for Healthcare Improvement.
Ask a doctor what’s wrong with America’s healthcare system, and be prepared to pull up a chair. You’ll hear a litany of complaints about Kafka-esque bureaucracies, litigious patients, unreasonable insurance companies, too few nurses, never enough time, too much testing and not enough talk. But complaining gets us nowhere–we need solutions. Here are my top seven reforms for health care.
1. Make Health Care in America a Human Right
The US spends almost twice as much in health care as the next most costly nation, and our system is not even close to the best on earth. The assertion that making health care a human right isn’t feasible — isn’t affordable — makes me mad. It’s just not true; in fact, we are the only developed Western country that fails to view health care as a human right. Leadership for change must come from the President and Congress. Without the promise of health care for all, we aren’t likely to muster the energy and political will we need to meet the needs of our entire population. We’ll limp along, instead, with defects in care and gaps in management that we have trained ourselves to regard as inevitable.
2. Pay for the Care of Populations, Not Events
Our current system of fragmented payment — for hospital stays, office visits, lab tests, drugs, and therapists — destroys the patterns of care that patients need, and leaves them confused and, too often, simply abandoned. Funding care for people over time, instead of for specific medical events, reduces the burden of illness by focusing on high quality preventive care. We need “managed care” as it was originally intended to be — the good kind, not the evil, mutant twin that just tried to cut costs, restrict choice, and limit available care. Correctly conceived, “managed care” addresses the real needs of patients over time and place, guiding them through the technological thicket of modern medicine, and making sure that they get exactly what they want and need, exactly when and how they want and need it.
3. Put the Patient in the Driver’s Seat
The more control patients have over their own care–the more they know, the more involved they are in the design of their care–the better. We haven’t even begun to plumb the real potential of patients who have been taught how to become their own physicians (to the extent that they want to). Despite the rhetoric, most people can’t even get access to their own medical records, and it’s often next to impossible to find data on how one’s own hospital or physician performs compared with others. Some people fear that, given choices, patients will not choose wisely or will demand too much. I doubt it–one study found that when patients actively shared in decisions about whether to have surgery, the rate of surgery fell 23% and satisfaction and outcomes both improved.
4. Computerize Medical Records, Once and for All
My pizza parlor is more thoroughly computerized than most of health care. It’s high time to put the paper medical record where it belongs — in the Smithsonian, next to the typewriter. Proper use of modern information systems for medical records will support much more integrated care, and will allow patients to feel better supported and remembered as they move from place to place and over time. Importantly, a computerized medical record [could] be, and should be, accessible to patients directly, and under their control.
5. Use Modern Engineering Science to Make Health Care Safer and Smoother
The same sciences that allow airplanes to fly safely, that keep the lines moving at Disney World, and that continually reduce the costs and improve the reliability of computers and consumer goods, can help in health care too. To a large extent, health care systems were not designed with any scientific approaches in mind. Too often there are long waits, high levels of waste, frustration for patients and clinicians alike, and unsafe care. A bold effort to design health care scheduling systems, process flows, safety procedures, and even physical space will pay off in better, less expensive, safer experiences for patients and staff alike.
6. Re-Energize Primary Care and Nursing
Our current care system is hospital-centric and physician-centric. We cannot have excellent, coordinated, patient-centered, economical health care without a strong backbone of primary care, and without a vibrant, proud, and joyful nursing workforce. Yet fewer and fewer young people are choosing to go into primary care careers (instead, we are getting an oversupply in specialties like ophthalmology, radiology, anaesthesiology, and dermatology) and the average age of an American nurse is now over 47 years.
7. Give Up the “More Is Better” Myth
Good evidence now shows that the areas in the US with the highest rates of use of hospital beds, intensive care units, specialist consultations, and invasive testing don’t have the best quality of care and outcomes. In fact, they often have the worst. It would be a great advance in both quality and cost if somehow the American public came to understand that “more care” is not by any means always “better care,” and that new technologies and hospital stays can sometime harm more than they help. Patients need to ask more, “Are you sure I need that?” and to trust that, often, the best care is the most conservative care.
