As CMS transforms how it reimburses for health care, it will need a leader to replace Berwick who can get the agency through the red tape.

Health care reform has become one of the most debated political topics this last year, and Donald Berwick, as the head of the Centers for Medicare & Medicaid Services, was often a face for the reform. Improving the nation's system of paying for the health care needs of millions of Americans is a complicated task that requires patience and a willingness and ability to compromise effectively. The issue itself is entangled in larger issues of budgetary spending and political philosophy, and a leader of reform should not be tied down by too many strong opinions about either. Although there is ample evidence of his pragmatism, Berwick's ideologies were his downfall.

The role of CMS
CMS is at the center of health care reform, and its role is changing. The Medicare ESRD Program is one of the best examples of CMS' evolving role in shaping American health care.

This was said best by two New York nephrologists, Premila Bhat MD, and J. Ganesh Bhat, MD, in the upcoming January issue of Nephrology News & Issues: "In its  'Roadmap for implementing value driven health care in the traditional Medicare Fee-for-Service program,' CMS states that a goal of value-based purchasing is to 'move Medicare away from being a passive purchaser of services to an active purchaser of high quality efficient care.'  In fact, the bundle itself can be considered a type of value-based purchasing, with the QIP representing a sort of checks and balances system to ensure that CMS' defined priorities for high quality care continue to be achieved in the bundled payment system. This represents a fundamental shift in the way that CMS views and pays for health care, and puts the ESRD program at the forefront in a new era." 

As CMS' role has changed, some say Berwick was responsible for a shift in the agency itself. "Berwick conducted the first-ever training to encourage continuous performance improvement throughout the 5,400-employee agency" according to an article from Kaiser Health News. "He sought to shift the agency culture toward teamwork, innovation, speed, and customer focus. Many staffers say they’ve been energized and are working to get information out faster to patients and to states, though some complain this work takes up too much of their time."

Berwick was a proponent of CMS' push towards pay-for-performance, and he helped draft one of the most ambitious plans to streamline health care and move towards value-based purchasing, the rules for accountable care organizations.

As Berwick moved forward with changing CMS, politicians cited his previous writings on his respect for the UK's National Health Service as reason for his removal from office.

"Government is more complex than I had realized," Berwick told The New York Times on his last day on the job. "Government decisions result from the interactions of many internal stakeholders — different agencies and parts of government that, in many cases, have their own world views.”


Navigating the red tape
Although Berwick is now a political casualty, CMS' reform policies are gaining momentum. But there is a lot of skepticism and distrust of CMS and its policies. Nephrologists have called the agency paternalistic and stifling.

"My pessimism revolves around the bureaucracy of CMS knowing what is best, their anti–free market approach to health care, and their paternalistic approach toward the providers of health care," said Robert Provenzano, MD, FACP, FASN in a guest blog post.

The agency might be well meaning, but its policies often have unintended consequences.

"Rather than promote a more relevant and effective care approach, one that provides more value for payers and dialysis patients alike, the QIP will stifle clinical understanding and innovation, raise care costs, and greatly harm patients," said Stephen P. Pollak, PhD, Jonathan A. Lorch, MD, FACP, and Victor E. Pollak, MD, FACP, FRCPE in the upcoming January issue of NN&I.

CMS needs a leader who can learn from mistakes and adjust policy to fit the growing health care system, who cares more about improving the delivery of health care more than any one political agenda or philosophy.