Where's the Fat?

When a 65-year-old pediatrician retires, it may be a sad moment for him and the community he has served, but it usually isn’t an event that makes the New York Times. However, Don Berwick is not your usual pediatrician. For the last 17 months, he has been head administrator of the Centers for Medicare and Medicaid Services. He entered the job under a dark political cloud, and what followed has been a frustrating year and a half. Formal confirmation by the Senate is unlikely to occur, and his temporary status will expire at the end of 2011.

I met Don when we were fellow house officers. From that point, our paths couldn’t have been more divergent. I chose to practice small-town primary care, and he focused on health care delivery on a much larger scale. However, after 40 years of very different careers, we seem to have retained surprisingly similar perspectives on health care delivery.

On his last day on the job, he observed that 20%-30% of spending on health care is "waste." He included on his list of waste categories burdensome rules, the administrative complexity of the system, and the failure to coordinate care. While he feels that computerizing medical records will ameliorate these issues, I am not quite so sure now is the best time. More than a decade of daily use has convinced me that electronic medical records (EMRs) aren’t ready for prime time.

While I tend to favor free market solutions, when it comes to EMRs the immediate need is for standardization and concentration on hard data (lab work, immunization records, vital signs). These are areas in which the government should take a lead role, and then let free enterprise fine-tune the system.

I also believe that creating large health care delivery networks is not going to create the efficiencies I think he believes can be achieved. However, where Don Berwick and I see eye to eye is the issue that has been at the heart of his frustration. He has observed, "Much is done that does not help patients at all, and many physicians know it" (Health Officer Takes Parting Shot at Waste, by Robert Pear, N.Y. Times, Dec. 3, 2011). Please count me in as one of the "many." How about you?

Do you see the same 20%-30% of lab work, imaging studies, medications, and consultations that we are ordering as unnecessary? I haven’t figured out what more I can do to encourage us to trim these excesses. When I used to go to meetings I would speak out from time to time, and I continue to grumble to my colleagues in the hall. After awhile, one begins to feel like a curmudgeonly old-schooler. I am lucky enough to have this column as a soapbox to climb on when the frustration gets too great. But from your responses, I feel that often I am preaching to the choir.

The problem seems to have become woven into the system. The recent responses to the new recommendations about more-rational screening for prostate cancer are just one example. To some extent, the undercurrent of antiscience is to blame. But when people who call themselves "scientists" misbehave badly, we can’t be too surprised.

Speaking out about waste can leave one vulnerable to being labeled as an advocate of rationing, a tag that has dogged Dr. Berwick during his short public service career. But, as he wrote in 2009, "The decision is not whether we will ration care – the decision is whether we will ration with our eyes open."

Although Dr. Berwick was often frustrated by the system he hoped to change (more quickly than it was ready for), I suspect he is the same quick learner that he was as an intern. I am sure we will hear from him again, seasoned by the hard knocks of public service. Will we be ready to join him in speaking out against waste? I am interested to hear what waste you see around you, and what you think we can do about it.

When a 65-year-old pediatrician retires, it may be a sad moment for him and the community he has served, but it usually isn’t an event that makes the New York Times. However, Don Berwick is not your usual pediatrician. For the last 17 months, he has been head administrator of the Centers for Medicare and Medicaid Services. He entered the job under a dark political cloud, and what followed has been a frustrating year and a half. Formal confirmation by the Senate is unlikely to occur, and his temporary status will expire at the end of 2011.

I met Don when we were fellow house officers. From that point, our paths couldn’t have been more divergent. I chose to practice small-town primary care, and he focused on health care delivery on a much larger scale. However, after 40 years of very different careers, we seem to have retained surprisingly similar perspectives on health care delivery.

On his last day on the job, he observed that 20%-30% of spending on health care is "waste." He included on his list of waste categories burdensome rules, the administrative complexity of the system, and the failure to coordinate care. While he feels that computerizing medical records will ameliorate these issues, I am not quite so sure now is the best time. More than a decade of daily use has convinced me that electronic medical records (EMRs) aren’t ready for prime time.

While I tend to favor free market solutions, when it comes to EMRs the immediate need is for standardization and concentration on hard data (lab work, immunization records, vital signs). These are areas in which the government should take a lead role, and then let free enterprise fine-tune the system.

I also believe that creating large health care delivery networks is not going to create the efficiencies I think he believes can be achieved. However, where Don Berwick and I see eye to eye is the issue that has been at the heart of his frustration. He has observed, "Much is done that does not help patients at all, and many physicians know it" (Health Officer Takes Parting Shot at Waste, by Robert Pear, N.Y. Times, Dec. 3, 2011). Please count me in as one of the "many." How about you?

Do you see the same 20%-30% of lab work, imaging studies, medications, and consultations that we are ordering as unnecessary? I haven’t figured out what more I can do to encourage us to trim these excesses. When I used to go to meetings I would speak out from time to time, and I continue to grumble to my colleagues in the hall. After awhile, one begins to feel like a curmudgeonly old-schooler. I am lucky enough to have this column as a soapbox to climb on when the frustration gets too great. But from your responses, I feel that often I am preaching to the choir.

The problem seems to have become woven into the system. The recent responses to the new recommendations about more-rational screening for prostate cancer are just one example. To some extent, the undercurrent of antiscience is to blame. But when people who call themselves "scientists" misbehave badly, we can’t be too surprised.

Speaking out about waste can leave one vulnerable to being labeled as an advocate of rationing, a tag that has dogged Dr. Berwick during his short public service career. But, as he wrote in 2009, "The decision is not whether we will ration care – the decision is whether we will ration with our eyes open."

Although Dr. Berwick was often frustrated by the system he hoped to change (more quickly than it was ready for), I suspect he is the same quick learner that he was as an intern. I am sure we will hear from him again, seasoned by the hard knocks of public service. Will we be ready to join him in speaking out against waste? I am interested to hear what waste you see around you, and what you think we can do about it.

When a 65-year-old pediatrician retires, it may be a sad moment for him and the community he has served, but it usually isn’t an event that makes the New York Times. However, Don Berwick is not your usual pediatrician. For the last 17 months, he has been head administrator of the Centers for Medicare and Medicaid Services. He entered the job under a dark political cloud, and what followed has been a frustrating year and a half. Formal confirmation by the Senate is unlikely to occur, and his temporary status will expire at the end of 2011.

I met Don when we were fellow house officers. From that point, our paths couldn’t have been more divergent. I chose to practice small-town primary care, and he focused on health care delivery on a much larger scale. However, after 40 years of very different careers, we seem to have retained surprisingly similar perspectives on health care delivery.

On his last day on the job, he observed that 20%-30% of spending on health care is "waste." He included on his list of waste categories burdensome rules, the administrative complexity of the system, and the failure to coordinate care. While he feels that computerizing medical records will ameliorate these issues, I am not quite so sure now is the best time. More than a decade of daily use has convinced me that electronic medical records (EMRs) aren’t ready for prime time.

While I tend to favor free market solutions, when it comes to EMRs the immediate need is for standardization and concentration on hard data (lab work, immunization records, vital signs). These are areas in which the government should take a lead role, and then let free enterprise fine-tune the system.

I also believe that creating large health care delivery networks is not going to create the efficiencies I think he believes can be achieved. However, where Don Berwick and I see eye to eye is the issue that has been at the heart of his frustration. He has observed, "Much is done that does not help patients at all, and many physicians know it" (Health Officer Takes Parting Shot at Waste, by Robert Pear, N.Y. Times, Dec. 3, 2011). Please count me in as one of the "many." How about you?

Do you see the same 20%-30% of lab work, imaging studies, medications, and consultations that we are ordering as unnecessary? I haven’t figured out what more I can do to encourage us to trim these excesses. When I used to go to meetings I would speak out from time to time, and I continue to grumble to my colleagues in the hall. After awhile, one begins to feel like a curmudgeonly old-schooler. I am lucky enough to have this column as a soapbox to climb on when the frustration gets too great. But from your responses, I feel that often I am preaching to the choir.

The problem seems to have become woven into the system. The recent responses to the new recommendations about more-rational screening for prostate cancer are just one example. To some extent, the undercurrent of antiscience is to blame. But when people who call themselves "scientists" misbehave badly, we can’t be too surprised.

Speaking out about waste can leave one vulnerable to being labeled as an advocate of rationing, a tag that has dogged Dr. Berwick during his short public service career. But, as he wrote in 2009, "The decision is not whether we will ration care – the decision is whether we will ration with our eyes open."

Although Dr. Berwick was often frustrated by the system he hoped to change (more quickly than it was ready for), I suspect he is the same quick learner that he was as an intern. I am sure we will hear from him again, seasoned by the hard knocks of public service. Will we be ready to join him in speaking out against waste? I am interested to hear what waste you see around you, and what you think we can do about it.