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REPLY
My Right Knee
Donald M. Berwick, MD, MPP
2 August 2005 | Volume 143 Issue 3 | Pages 237-238
IN RESPONSE:
I understand Dr. Sapers' skepticism, given how poorly designed health care is today. My vision, however, is hardly that of a "Wal-Mart." It is of a health care system that seeks to address each individual patient on his or her own terms, so far as possible. I believe that dedicated clinicians indeed try to do that as a matter of personal mission, and I also believe that modern understandings of health care as a system (not "aping business models") with open-minded, scientific redesigns, can go a long way toward that vision. For example, waiting times can be reduced dramatically with relatively simple changes in time-honored, but illogical, scheduling systems (1). Much safer care is within our reach, if only we will commit to new levels of reliability in our processes.
Dr. Fleming accurately notes the toxicity of current financing systems with respect to the changes we need for truly patient-centered, reliable care (2). I disagree, however, about the promise of making patients more "cost sensitive," which usually means shifting costs to individuals. I find little evidence that that helps, and besides, illness and poverty are too closely correlated to make that ethical social policy (3). Indeed, nations with globally funded, often government-sponsored health care with universal access seem in important dimensions to outperform our system at far lower cost (4). "Total quality," in my view, will be found sooner in a health care system with clear mandates, policy guidance, universality, flexible funding, and public accountability than in one relying on the invisible hand of a market to care for the sick.
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Author and Article Information
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From Institute for Healthcare Improvement, Cambridge, MA 02138.
Potential Financial Conflicts of Interest: None disclosed.
1. Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care. JAMA. 2003;289:1035-40. [PMID: 12597760].
2. Leatherman S, Berwick D, Iles D, Lewin LS, Davidoff F, Nolan T, et al. The business case for quality: case studies and an analysis. Health Aff (Millwood). 2003;22:17-30. [PMID: 12674405].
3. Galvin R. A deficiency of will and ambition: a conversation with Donald Berwick. Health Aff (Millwood). 2005;12 January. [Epub ahead of print].
4. Davis K, Schoen C, Schoenbaum SC, Audet AM, Doty MM, Tenney K. Mirror, Mirror on the Wall: Looking at the Quality of American Health Care through the Patient's Lens. New York: The Commonwealth Fund; 2004.
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