The Moral Test by Donald M. Berwick

The point is, with costs rising a great deal faster than that, no matter what your goal is, you’ve got a sustainability triangle to fill — the growing, cumulative difference between unsustainable “business as usual” costs and the sustainable ones.

The social imperative for reducing health care cost is enormous. And, to meet that enormous need, I suggest, just as with the environmental triangle, for the health care cost triangle, nothing works. Only everything works. It’s all or none, or we head straight on and over the cliff. Andy Hackbarth and I took a stab at defining the “wedges” for health care costs. These are the names of the forms of waste whose removal from the system both helps patients thrive and reduces the cost of care.

We found six wedges, for starters, and we estimated their size.

Overtreatment — the waste that comes from subjecting people to care that cannot possibly help them — care rooted in outmoded habits, supply-driven behaviors, and ignoring science.

Failures of Coordination — the waste that comes when people — especially people with chronic illness — fall through the slats. They get lost, forgotten, confused. The result: complications, decays in functional status, hospital readmissions, and dependency.

Failures of Reliability — the waste that comes with poor execution of what we know to do. The result: safety hazards and worse outcomes.

Administrative Complexity — the waste that comes when we create our own rules that force people to do things that make no sense — that converts valuable nursing time into meaningless charting rituals or limited physician time into nonsensical and complex billing procedures.

Pricing Failures — the waste that comes as prices migrate far from the actual costs of production plus fair profits.

Fraud and Abuse — the waste that comes as thieves steal what is not theirs, and also from the blunt procedures of inspection and regulation that infect everyone because of the misbehaviors of a very few.

We have estimated how big this waste is — from both the perspective of the Federal payers — Medicare and Medicaid — and for all payers. Research and analytic literature contain a very wide range of estimates, but, at the median, the total annual level of waste in just these six categories (and I am sure there are more) exceeds $1 trillion every year – perhaps a third of our total cost of production.

This is our task … our unwelcome task — if we are to help save health care from the cliff. To reduce costs, by reducing waste, at scale, everywhere, now.I recommend five principles to guide that investment:

1. Put the patient first. Every single deed — every single change — should protect, preserve, and enhance the wellbeing of the people who need us. That way — and only that way — we will know waste when we see it.

2. Among patients, put the poor and disadvantaged first — those in the beginning, the end, and the shadows of life. Let us meet the moral test.

3. Start at scale. There is no more time left for timidity. Pilots will not suffice. The time has come, to use Göran Henrik’s scary phase, to do everything. In basketball, they call it “flooding the zone.” It’s time to flood the Triple Aim zone.

4. Return the money. This is the hardest principle of them all. Success will not be in our hands unless and until the parties burdened by health care costs feel that burden to be lighter. It is crucial that the employers and wage-earners and unions and states and taxpayers — those who actually pay the health care bill — see that bill fall.

5. Act locally. The moment has arrived for every state, community, organization, and profession to act. We need mobilization — nothing less.

One evening shortly before I left Washington, I visited the Lincoln Memorial again — standing at the same spot that I had stood at as 24a twelve-year-old boy 53 years ago. The majesty was still there — the visage of Lincoln, the reach of the Washington Monument, the glow of the Capitol Dome. It was still unbearably beautiful. Still majestic.

But, there was one change. Chiseled in the very stone where I was standing is now the name of Dr. Martin Luther King and the date — August 28, 1963, when he gave his immortal “I have a dream…” speech.

When I first stood at that spot, the Montgomery Bus Boycott was only three years in the past, and Dr. King’s speech lay five years in the future. Rachel Carson’s book, Silent Spring, was four years in the future. And it would be six years before the phrase, “Women’s Liberation,” would first be used in America.

I thought, standing there, of something I once heard Dr. Joseph Juran say: “The pace of change is majestic.” And I mused about that majesty, and its nature.

It occurred to me that the true majesty lay not just in the words — not just in the call — but also in the long and innumerable connections between the ideas that stir us — the dreams — and the millions and millions of tiny, local actions that are the change, at last. A dream of civil rights becomes real only when one black child and one white child take one cooling drink from the same water fountain or use the same bathroom or dine together before the movie they enjoy together. An environmental movement becomes real only when one family places one recycle bin under one sink or turns off one unneeded light out of respect for an unborn generation. Women’s rights are not real until one woman’s pay check stub reads the same as one man’s, and until my daughter really can be anything she wants to be. The majesty is in the words, but the angel is in the details.

And that is where you come in. Here is the lesson I bring you from 16 months in Washington, DC. Your time has come. You are on the cusp of history — you, not Washington, are the bridge between the dream and the reality — or else there will be no bridge. Our quest — for health care that is just, safe, infinitely humane, and that takes only its fair share of our wealth — our quest may not be as magnificent as the quest for human rights or for a sustainable earth, but it is immensely worthy. You stand, though you did not choose it, at the crossroads of momentous change — at the threshold of majesty. And — frightened, fortunate, or both — you now have a chance to make what is possible real.

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The Moral Test by Donald M. Berwick

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