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Berwick Challenges ACOs to Take on Inequity, Racism


ACOs usually concern themselves within issues like attribution, cost of care, quality metrics and shared savings and losses.

But former CMS Administrator Donald Berwick asked the organizations to take on a much different, more fundamental issue today in a keynote talk at the virtual version National Association of ACOs (NAACOS), the main lobbying organization for the accountable care organizations.

Warning that he might be a “little abrasive” Berwick said, “I am at a point where I think we really need to stop kind of admiring this problem of inequity and of racism and do something about it. And I challenge the ACO community to take the lead here.”

“You’ve got some tools in your hands that you could use,” Berwick continued. “You would have to make it a movement. You would have to actually decide that the ACOs of America will be in the lead in American healthcare and society in addressing racism and inequity. And you would actually have to invest in it as you will any area - if I can say-  innovation.”

Like every other health and medical meeting this spring and early summer, NAACOs has moved to a virtual format because of COVID-19. The organization has broken up the meeting so there are online sessions scheduled on Tuesdays and Thursdays the rest of the month.

Berwick, who popularized the Triple Aim as president and CEO of the Institute for Healthcare Improvement before heading up CMS on an interim basis during the Obama administration, also discussed the issues of cost and efficiency that are familiar turf to ACOs. COVID-19 has shown that the healthcare system is capable of changing quickly (“we can move quickly when we need to”), he noted, despite the usually very slow pace of change. Berwick joined the chorus of praise for the move to virtual care and said “it is working great.” And he described the search for answers to clinical questions about COVID-19 as a “search for standards” and a sharing of knowledge, in contrast to needless practice variability that he and others view as a source of waste.

The sudden drop in emergency department visits and elective surgeries shouldn't become a missed opportunity for assessing healthcare value and waste, in Berwick's view. “I hope we have a pause here and say, ‘Wait a minute, wait a minute. What of the stuff that didn’t happen turned out that we really didn’t need to do it in the first place?’”

Excess use of in-person healthcare visits are a form of overtreatment, said Berwick, who referred to his 2012 article in JAMA that estimated that $910 billion annually, or 34%, of U.S. healthcare spending is wasteful, and to a reprise of that article last year by William Shrank, M.D., and his colleagues that arrived at a proportion of 25%. Shrank is Humana’s chief medical officer and a member of the Managed Healthcare Executive® editorial advisory board. “Guys," he said to the online NAACOS audience, "we are looking a trillion dollars that could be redevoted to things that really matter if we really found a way to get rid of overtreatment, if we strongly coordinated care, if we stopped hurting patients with injuries in care and unreliability, if we simplified administration, if we got prices under control, and if we stopped fraud.”

Related:Can Physicians Reduce Waste

Berwick put race in the context of social determinants of health, poverty and COVID-19.

He called healthcare a “repair shop - it doesn't cause health."  Berwick added later, "What we have been doing for decades I can’t call it anything but stupid. We keep fixing the damage instead of moving to the causes." Many health problems are “products of conditions in the environment, including housing, transportation, food security - you know the list - and racism," he said.

Berwick also linked race, inequity and poverty. Berwick showed a slide listing povery rates: 19% among  Latinos, 22% among blacks and 26% among Native Americans. “We live in a country in which there is another country.”

COVID-19 has disproportionately affected African Americans; Berwick mentioned the “COVID window into inequity,” and shared data demonstrating the unequal effect of the disease.  “Inequity was a killer. Racism was a killer in the COVID epidemic,” he said.

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