“Peeling the Onion” is a monthly column by Harvey Abrams, PhD.
About 18 months ago, I came across an interesting letter to the editor in the Journal of the American Medical Association (JAMA). The author was Donald Berwick.For those of you unfamiliar with this distinguished health care policy expert, Dr. Berwick is a former administrator of the Centers for Medicare and Medicaid Services (CMS) but is probably better known as the President and CEO of the Institute for Healthcare Improvement.
His work has focused on improving the quality of health care, including the reduction in medical errors, through the aggressive and judicious use of evidence-based medicine. He is the author of several books on health care quality improvement, the latest being Promising Care: How We Can Rescue Health Care by Improving It.
Changing the Audiology Regime
The title of Dr. Berwick’s letter to JAMA was “Era 3 for Medicine and Health Care” in which he argues for the need to move beyond the past and current approaches to health care into a new era characterized by 9 fundamental changes to the current regime. At the time I read the letter, I was struck by how many of these changes could, and should, apply to the audiology profession.
Given the recent developments brought about by the PCAST and NASEM reports, recent legislation leading to a new class of OTC hearing aids and, what many consider, an existential crisis facing the profession, I re-read Dr. Berwick’s letter with a renewed sense of urgency.
The 2 Eras of Health Care
Berwick describes era 1 as the ascendancy of the medical profession with roots going back to Hippocrates. It is characterized by beneficence, self-regulation and, with society’s full blessing, the authority of the profession to judge the quality of its own work.
Era 2 was born out of emerging evidence that demonstrated large and disturbing unexplained variations in practice, growing numbers of costly medical errors, profiteering, and documented injustices in the delivery and quality of health care related to race and social class. This current era is characterized by a tension between the medical establishment which desires to maintain the privileges it enjoyed in era 1 and the payer, governments, and consumer groups which advocate for more inspection and control.
Berwick maintains that “the tactics of eras 1 and 2 reflect deeply held beliefs” and that this “clash will continue unless and until those beliefs change and stakeholders act differently as result.” He advocates for a new era in health care, era 3, “guided by updated beliefs that reject both the protectionism of era 1 and the reductionism of era 2” and suggests 9 changes that must characterize this new era.
Era 3 – 9 Changes Are Required
- Reduce Mandatory Measurement: Those of us working in hospital-based clinics are all too aware of the requirements associated with measuring just about everything we do. This era 2 reaction to era 1 shortcomings has, according to Berwick, resulted in excessive measurement and reporting leading to unnecessary waste and inefficiencies. Berwick suggests that CMS, insurers and regulators should commit to reducing the volume and cost of measurement by 50% in 3 years and 75% in 6 years.
- Stop Complex Individual Incentives: Berwick argues for a moratorium on complex incentive programs for individual clinicians which, he claims, are “confusing, unstable, and invite gaming.” He supports an approach characterized by a simple salaried practice as part of a patient-focused organization.
- Shift the Business Strategy from Revenue to Quality: Berwick argues that the current focus on maximizing revenue dominates the business model of most health care organizations. He maintains that a commitment to quality health care improvement, as opposed to maximizing revenue, is a better strategy for long-term sustainability.
- Give Up Professional Prerogative When It Hurts the Whole: A feature of era 1 health care is the belief that the clinician’s prerogative supersedes the needs and interests of others. Are our patients best served when we maintain that “Only an audiologist can…” “A hearing instrument specialist should only …” “An audiology assistant can never …”?
- Use Improvement Science: Despite decades of quality improvement implementation in other organizations, health care has still not fully mastered the tools of quality improvement such as process control charts and the “plan-do-study-act” cycle of testing. When was the last time we evaluated a clinical process to determine if it yields the best outcome at the lowest cost?
- Ensure Complete Transparency: Berwick maintains the best rule for transparency is, “Anything professionals know about their work, the people and communities they serve can know, too, without delay, cost, or smokescreens.” Naturally, the issues associated with bundling vs. itemizing our hearing aid related fees and services immediately come to mind.
- Protect Civility: ASHA vs. AAA vs. ADA vs. HIS. Berwick quotes Robert Waller, M.D., former president and CEO of Mayo Clinic who said, “Everything possible begins in civility.”
- Hear the Voices of the People Served: Most of us would agree with Dr. Berwick’s assertion that “The more patients and families become empowered, shaping their care, the better that care becomes, and the lower the costs.” We often talk about the importance of a patient-centered focus to our care but how many of us fully engage our patients and their families as part of the clinical encounter?
- Reject Greed: Berwick observes that health care has “slipped into tolerance of greed” fueled by “rapacious pharmaceutical pricing, hospitals’ exploiting market leverage…, profiteering physicians, and billing processes that deteriorate into games…” He argues that professional organizations and academic medical centers should “articulate, model, and fiercely protect moral values intolerant of individual or institutional greed in health care.”
As we begin to explore and seek our way through a dramatically changing hearing healthcare landscape, let’s adopt the principles of the 3rd era of health care – what Berwick describes as the “moral era.” Without a moral ethos, Berwick argues, there will be no winners.
Harvey Abrams, PhD, is a consulting research audiologist in the hearing aid industry. Dr. Abrams has served in various clinical, research, and administrative capacities in the industry, the Department of Veterans Affairs and the Department of Defense. Dr. Abrams received his master’s and doctoral degrees from the University of Florida. His research has focused on treatment efficacy and improved quality of life associated with audiologic intervention. He has authored and co-authored several recent papers and book chapters and frequently lectures on post-fitting audiologic rehabilitation, outcome measures, health-related quality of life, and evidence-based audiologic practice. Dr. Abrams can be reached firstname.lastname@example.org