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Parting thoughts: Berwick shares views on media coverage of health care and reform Date: 02/09/12

Health reporters, both veterans and novices, know Don Berwick, M.D., M.P.P., as one of the most thoughtful and powerful forces in U.S. health care today. He has worked with reporters as part of his jobs at the Institute for Healthcare Improvement and, most recently, at the Centers for Medicare and Medicaid Services. He has served as a professor at Harvard Medical School and at Harvard School of Public Health and worked as a pediatrician in Boston.

Berwick left CMS in December and agreed to share his thoughts with AHCJ President Charles Ornstein about media coverage of CMS, health reform and his tenure.

In a Newsmaker Briefing at Health Journalism 2011, CMS Administrator Don Berwick unveiled a website on health data.
In a Newsmaker Briefing at Health Journalism 2011, CMS Administrator Don Berwick unveiled a website on health data. (Photo: Len Bruzzese)

Q. What are your overall impressions about the way the media covered CMS during your tenure there?

A. I generally had a favorable impression. Many of the people I dealt with in the press were very, very knowledgeable and asked me tough and deep questions. I’d say the majority of my encounters, especially with the DC-based media, felt like dealing with experts.

I found two things that, as I reflected, may imply suggestions for improvement. One is the amount of in-depth coverage. As we were dealing with very, very complex issues, which is standard for CMS, and the Affordable Care Act, I found the majority of the reports, as opposed to the interviews, shallow. There weren’t a sufficient number of longer in-depth analyses of what really was going on and what were the pros and cons of the choices the government, and our nation, are making.

My job was to think through very, very difficult issues. I would think sound media would be addressing the issues with the same discipline that we were using internally. … That requires longer stories and more print than most reporters are probably able to command.

The other side of it is that there is still more gotcha in the media than I think is productive. This tendency of journalists, not all by any means but some, to kind of wait for the two-word phrase that can become the headline, I think, is unfortunate. I understand why in business terms or commercial terms that might be necessary but it does not support public exploration. What it does induce is extreme caution and pre-packaged answers. One is always thinking about how not to offer the journalist a three-word phrase that will become the misleading headline of what’s happening. I think I learned to do that but I would hope, at least naively, that there could be a different social contract about what the media is doing.

Q. When you first were appointed, you didn’t have media availabilities for some time. What was the rationale behind that?

A. I can only speculate about the rationale. When one joins any administration at a high level, one becomes part of the team and some of the privileges of speaking out as an individual are subordinated to the need to participate in the formulation – and then the articulation –  of policy. Among the members of that team are people whose job is to think about how this complex matter will be made accessible and digestible to the public. For a newcomer, there is probably a testing period. Does this person have the skill to deal with the kind of pressure that happens under the klieg lights and with a very skilled reporter who is able to ask very tough questions? As time went on and I had the opportunity to testify to the [Senate] Finance Committee and to go through interviews, I think that confidence in me probably grew as the administration got to know me better, and over time, they were more and more comfortable letting me undertake more and more interviews.

Q. Did you feel hamstrung by the need to articulate the political positions taken by the administration?

A. Hamstrung is far too strong a word. In deciding to come into an administration as a senior official, I knew full well that I was joining a team, joining something larger than myself. I had every opportunity within the administration – with the privilege of being on the inside – to voice my opinions and my thoughts as policy was formulated, as the internal debates occurred. But then when a decision was made about the direction, my job changed and it was to explain it. … On the sometime occasions when I didn’t agree with policy, if I wanted the privilege to speak out in strong disagreement, I shouldn’t have been part of the team. It doesn’t come with the territory.

Q. What do you think are the stories the media have not covered that you would like to see more of?

A. I’ll give you some examples. This is an urgent time to find ways to reduce health care costs without harming people at all – and it’s clearly possible. There are improvements in care that I am absolutely certain, not from my administration experience, but from my 30 years before, reduce expenses and improve care. I have not seen that grappled with in the way that it really needs to in the media. It’s a social necessity but it’s an important intellectual endeavor. Shannon Brownlee [at New America Foundation] has done a very good job. I don’t think the media has gotten into the "more-is-better" myth enough.

We had, in my opinion, irresponsible and inaccurate claims from the people that opposed my nomination that I was interested in rationing and withholding care. That’s not just slightly inaccurate, it’s 180 degrees wrong. Instead of the media dealing with ways to make sure people really get the care they need and want, instead of the care they don’t need and want, that wasn’t dealt with. Instead they repeated accusations about me that were not accurate.

There is a great communication paradox around the Affordable Care Act. Before I went there, I saw this relatively complex legislation take shape. Reputationally, it was kind of a quilt, many things happening in it. I was very glad to see expansion of coverage, but I didn’t really understand the details of the new law. Then I went to Washington and it became the center of my work. It is really quite a terrific bill. There’s a lot in it that helps people. Sure it could be better, but this law contains welcome news for the vast majority of Americans. But many don’t seem to know that. Almost everybody says, “What’s wrong here. Why hasn’t the administration, the government, been able to explain the Affordable Care Act in a way that explains what really can be done for them?” I don’t have the answer for that. I don’t know if it’s a communication strategy failure for which the administration needs a mulligan here or if there’s something dyadic going on between the administration and the journalistic community that has been unable to explain it. I don’t think it’s journalism’s burden to sell the law. Their job is to analyze it. But the positive aspect of it has been too sotto voce in the reports.

Q. Any others?

A. I don’t think Medicaid could get too much focus. It is such a vulnerable and crucial part of the system and must be somehow navigated into its future. Although Medicare inside the beltway attracts the most attention, I lost much more sleep about Medicaid than about Medicare and I dearly hope this country continues to embrace the idea that the most vulnerable people need us to help them.  That commitment – that social commitment – we simply cannot back down from, and, unfortunately there are those who would. The complexity of the Medicaid situation is enormous because it involves basic questions about federalism and at a time when states are under such pressure. It’s just such a complicated terrain. I think journalists would be well advised to keep the Medicaid story alive and see if the country can get to a solution for care and coverage of vulnerable people that really can work. That story is not going to go away. It’s very important. I would never let up on it.

Q. Do you have different thoughts about broadcast media than you do for print?

A. Print, you at least have the option for an expansive feature story or a broad investigation. … that’s a very important resource. Broadcast doesn’t have that. You’re always dealing with a very, very short, remarkably short, period of time. I’m trying to think in my mind about when there was a broadcast experience that felt extremely important to public understanding or health care improvement and when it was, I don’t know. Sometimes when a broadcast journalist is interviewing me, you actually have a feeling that the person on the other end is authentically curious. Sometimes it’s just a setup. They’re just waiting for you to make a mistake. It’s a frustrating field, broadcast journalism, because of the small amount of time into which you have to compress very complex matters.

Q. What are your thoughts about the transparency initiatives to make data available to the public? Is the public equipped to deal with it?

A. I have come to think that transparency is one of the most important aspects of policy in the nation. I don’t think we’re where we need to be and I think if we can make more information more transparent, almost everything will get better, cost and price. I have become more and more a fan of transparency. In the Affordable Care Act, there are more and more tools for this. I think transparency, by which I mean the ready availability of data while protecting patient privacy, at low costs helps everyone. It helps providers compare their quality to one another. It helps buyers look at pricing. It helps consumers know more about the care they get or could get. Some of the consumers that want that information will make good use of it, but many will not. They’re too busy with other things. But overall the effect of transparency will be entirely favorable. Do I think patients will open Consumer Reports to decide where to go when they have a heart attack? Of course not.

Q. Reporters are exposed to an increasingly politicized environment. How can they avoid that type of reporting if it’s becoming more of a reality in the world we live in?

A. I would have loved to have been a journalist. It’s a fascinating field.

Someone makes an irresponsible statement for political purposes, it can be on either side of the aisle. If someone says President Obama appointed this person to this position and Sen. Pat Roberts says he’s the rationer-in-chief, that’s nonsense. Or go back to the death panels conversation. Nonsense. It’s tragically deceptive nonsense but it attracts the public’s eye, so the game begins. What comes back is usually reaction from the other side that is in some sense not quite right. It’s silence or mincing words – tip-toeing to stay off the land mines. The journalists get into this by looking for the three-word sound bite so that’s going to be the next part of the game. I don’t think that’s journalism. Journalism is a responsible guy who stands up and says, “Hold on guys, this sounds like nonsense to me” and doesn’t become a party to this combat. The best journalists do that. They really get beneath the surface and they don’t let either side get away from that. They’re looking for facts and realities. When someone says something quite silly, the journalists should say, “That’s quite silly.”

Journalism is here to help us think, not necessarily to help us record the next shot. That’s very tough. The lesson I saw was that it induces the same behavior on both sides. You end up in a game instead of an inquiry.

Q. I know many journalists want to know what you’re going to do next. Do you want to break the news to me?

A. You’d be the first to know. I don’t know. The 16 months I was at CMS were the most exciting and professionally engaging part of my whole career. I love being a doctor and I loved running IHI but this was a level of excitement and intensity that exceeded anything I had done. I wish I could have stayed but I know it’s behind me now. My mission is to help health care get better globally, both here and abroad. I’m in a contemplative period. I’m with my family and thinking about it. I’m giving speeches and want to speak out and have many thoughts I want to share.

It is a firm decision on my part to be available to press. I will not knowingly turn down any request for an interview from press that I know about.