Notes from Don Berwicks 24th IHI National Forum Keynote: 11 Topics which are monsters under the

bed we need to confront in healthcare, but are often politically off the table: 1. The Uses of Knowledge a. Confidence in science as a basis for action i. Treat patients according to facts, not myths or legends. ii. Public thinks scientific thought is elitist. Evidence based medicine sounds like rationing or eugenics. iii. Use PDSA cycles. b. Using global brains i. Its okay to have differences (between nations). We should use them. ii. Berwick had praised parts of the British National Health System and was criticized for this. iii. Dont use American exceptionalism to blindfold ourselves. c. Learning in large systems i. Evaluation and learning are different. You dont tell spouse you are evaluating your marriage. But can ask, What can I learn every day to do better? ii. You can use a sample to learn about a still pond but not for a rushing river. To do so, need to predict. iii. Learn improvement science. Use control charts. 2. The Nature of Waste a. Naming the excess. i. The U.S. spends much more healthcare than any other industrialized nation, but its much easier to sell Americans on the idea that we need more healthcare than less healthcare. ii. Hard to say enough is enough even if its true. iii. Dr. Bernard Lown a distinguished cardiologist. Studied overuse of cardiac procedures. At least 50% of catheterizations are not beneficial for the patient. Medical management can have at least as much success with conservative approach. Theirs is a minority view, but what if they were right? What if what we do a lot of doesnt help nearly as much as we like to believe? This is scary to face. iv. Addressing overtreatment takes courage. b. Profit vs. Greed i. We accept unbridled pursuit of revenue as okay. ii. American marketplace entrepreneurship but also people use loopholes. 1. Makena Loophole used to patent this for high cost. Cost 1 billion per year to Medicaid. 2. Lucentis vs Avastin intraocular injection for wet macular degeneration is marketed as Lucentis, costs 2000 vs 50 per dose. So many opthamologists dilute. Others use Lucentis. Costs 1.4 billion per year.

Colchrys colchicine used for gout for thousands of years but originally put on unappoved (not yet approved) list. One company did trial to get exclusive rights. In 2007, 50 million instead of 5 million. 4. Epo originally included in bundled payment for dialysis patients. But high hemoglobin was then associated with worse outcomes, so revision. Dialysis units got 500 million in payments even though they didnt use the drug. They kept the money. 5. Not everything legal is proper. The rules are wrong, leaving too much room for harmful yet legal behaviors. 6. The operating principle: Get all you can. Instead, you can aim for fairness. c. Not all innovations help. i. Some have negative marginal effectiveness. Worse care at higher cost. ii. Vendors selling wares. Public policy can do little about this. Authorities are weak. iii. Provision in affordable care act to reimburse preventative care with scores of A or B by preventative care taskforce has been criticized as government run medicine. iv. We should have healthy skepticism. Use lean thinking. Who does the new gadget really help? d. The behavior of guilds i. They could support new models of care that have new roles for nonphysicians and telemedicine. 1. Echo project in New Mexico. Achieving results for Hep C in rural New Mexico via telemedicine. 2. The AFHCAN 3. DHAT program Treatment without dentist. ii. Legacy payment : resource relative value systems are way behind the times. iii. E.g. guilds trying to stop expanding roles of nurses. iv. Ask, How can we make new roles better and more reliable? 3. Priorities in Care a. Defending the Poor The moral test of government. Hubert H Humphrey. i. Defending the safety net is a hard sell nowadays. Nowadays we are focused on helping the middle class. But we are at risk of failing this moral test. ii. Healthcare is a human right. b. End of life care. i. Palliative care and advance directives. ii. Join the Conversation Project. c. Authentic Prevention i. Hospitals dont prevent disease. They cure disease once its started. ii. Prevention has no cathedrals. Massive misallocation of resources. We dont have sufficient institutional infrastructure for prevention. 4. Transition Plans a. Business transition models.

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b. Nuka system for Alaskan natives. Team-based, population-minded, prevention-oriented total care system. c. That system is obviously better but how do we get there from here? Stranded capital, misaligned workforce. Confusing volume and technology with healing and solace. Revenue models and business models.

So Voldemort in healthcare (things that need to be named, not avoided) is: 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Assaults on science Blindfolds of exceptionalism Evaluation orthodoxy that impedes learning Excess The amount of care that does not help Harmful profiteering Innovations without proof of worth Obstructive behaviors of guilds Weakening commitment to the poor Silence about end-of-life care Inauthentic commitment to prevention Absent business transition models for care