What’s Broken in American Healthcare—and How to Fix It | Part One

Is American healthcare truly serving patients—or has the system lost sight of its purpose?

In this powerful episode of TCNtalks / Anatomy of Leadership, host Chris Comeaux welcomes Dr. Don Berwick, former Administrator of the Centers for Medicare & Medicaid Services (CMS), President Emeritus and co-founder of the Institute for Healthcare Improvement (IHI), and one of the world’s foremost experts in healthcare quality improvement.

Together, they explore what’s broken in American healthcare, why healthcare reform is urgently needed, and how leaders can build a system that delivers better patient outcomes, higher quality care, health equity, value-based care, and a more sustainable future for healthcare organizations.  They also discuss the evolution of the Triple Aim into today’s Quintuple Aim, the growing influence of private equity in healthcare, the impact of healthcare policy, and why restoring purpose—not simply profitability—must become the foundation of modern healthcare leadership.

Whether you’re a healthcare executive, hospice leader, hospital administrator, physician, nonprofit executive, or business leader, this conversation offers practical insights into improving healthcare while protecting the mission that first drew so many people into the profession.

In this episode you’ll learn:

✅ Why the Triple Aim evolved into the Quintuple Aim—and why it matters today

✅ How financial incentives can conflict with quality patient care

✅ Why clinician purpose and workforce well-being are essential to healthcare excellence

✅ The growing impact of private equity and financialization across healthcare

✅ What healthcare leaders can do to improve patient outcomes while reducing waste

✅ Dr. Berwick’s vision for meaningful healthcare reform

This conversation challenges conventional thinking and offers a hopeful vision for healthcare leaders who believe patients—not profits—should remain at the center of every decision.

Don’t miss Part Two, where Dr. Berwick outlines the structural changes he believes could fundamentally reshape American healthcare.

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If you enjoy conversations about healthcare leadership, hospice, healthcare innovation, leadership development, healthcare policy, and the future of patient-centered care, subscribe to TCNtalks / Anatomy of Leadership for weekly conversations with the leaders shaping the future of healthcare.

Guest:
Dr. Don Berwick, Former Administrator of CMS

Host:
Chris Comeaux, President / CEO of TELEIOS, author of The Anatomy of Leadership

Teleios Collaborative Network   /   https://www.teleioscn.org/tcntalkspodcast

Transcript

Cause, Purpose, And The Guest

Melody King 0:00

Everything rises and falls on leadership. The ability to lead well is fueled by living your cause and purpose. This podcast will equip you with the tools to do just that. Live and lead with cause and purpose. And now, author of the book The Anatomy of Leadership, and our host, Chris Comeaux.

Chris Comeaux 0:22

Hello and welcome. I'm so excited today. We have a very special guest with us today. We have Dr. Don Berwick, who's the former administrator of CMS. Welcome, Dr. Berwick.

Dr. Don Berwick 0:32

Nice to be with you again, Chris.

Chris Comeaux 0:34

Oh, it's great. Great to finally have you on the podcast. A mutual friend, Dr. Will Faber, is the one who connected us. This kind of a dream come true. You're, whether you know it or not, you're a bit of a hero in the hospice and powder care space. Definitely a hero in the healthcare space as a whole. Just in case there's someone who's never heard of you, I'll go ahead and read from your bio. But Dr. Don Berwick is a president of emeritus of the Institute of Healthcare Improvement. In fact, Dr. Berwick, we had two folks from IHI at one of our telephone meetings just a couple weeks ago talking about the 4Ms, actually. So he's president emeritus with IHI, an organization he co-founded and led as president CEO for 19 years. He's one of the nation's leading authorities on health care and quality improvement. And in July 2010, President Obama appointed Dr. Berwick to the position of administrator for Centers for Medicare and Medicaid Services. We all know them as CMS. And he held that position until December of 2011. He's a pediatrician by background. He has served as a clinical professor of pediatrics and health care policy at Harvard Medical School, professor of health policy and management at Harvard School of Public Health, and as a member of the staff of Boston Children's Hospital Medical Center and Massachusetts General Hospital and Brigham Women's Hospital. He's also served as a vice chair of the U.S. Preventative Services Task Force. He is their first independent member of the Board of Trustees of the American Hospital Association, AHA, and chair of the National Advisory Council for the Agency for Healthcare Research and Quality. And he's an elected member, I love this, of the American Philosophical Society, the American Academy of Arts and Sciences, and the National Academy of Medicine, which is formerly the uh Institute of Medicine. He has served two terms on the IOM's governing council. He was a member of the IOM's Global Health Board, currently chairs the NAM Board and on Health Care Services, and he served as President Clinton's advisory commission on consumer protection and quality in healthcare industry. He has numerous awards, including the 2007 William Graham Prize for Health Services Research, and in 2006 the John M. Eisenberg Patient Safety and Quality Award, and the 2007 Heinz Award for Public Policy. In 2005, he was appointed honorary Knight Commander of the British Empire by Her Majesty Queen Elizabeth II, which is the highest honor in the UK for non-UK citizens. He is an author and co-author of over 200 scientific articles and six books. And so, Dr. Berwick, I have a friend that he has this great line. Dr. Berwick is a really big deal. He will not like that comment, but he's he's an amazing human being. Dr. Berwick, first off, Kenny, it's amazing to have you here. I told you I'd ask you this question, and I love asking all of our guests, but what is your superpower?

Dr. Don Berwick 3:22

Well, you did give me a heads up on a question. I but it don't doesn't mean I have a great answer. Yeah, well, you know what? I thought of uh uh intersections, seeking intersections. I just always love finding myself in new terrain, meeting new people, people who I who I don't know, and discipline ways of thinking that I I'm not familiar with. And I think that's a lot of well, that's certainly

A Superpower For Finding Intersections

Dr. Don Berwick 3:45

where my fun comes from, whether it's a superpower or not. I have to leave it to others to just that's pretty cool.

Chris Comeaux 3:50

Well, I think that's actually going to lead into a question. First off, having you in a podcast, but asking you this question. I share with you we're the one of the first clinically, we're definitely the first national clinically integrated network in the hospice empowered cure space. And we've used the quintuple aim um as our rallying cry. And so was the quadruple aim, it just morphed

From The Triple Aim To Equity

Chris Comeaux 4:10

into the quintuple aim. And quite often we quote you and say, Dr. Don Berwick was the father of the triple aim. And so it's really began as a framework to improve population health, enhance the patient experience, and reduce per capita cost. Take us back. What was the original insight that that led to the triple aim and explain how you view its evolution now into the quadruple and then the quintuple aim?

Dr. Don Berwick 4:34

Yeah, well, well, your words are extremely generous, Chris, and thank you for what you do. I'm I'm amazed by the by the work that I've I've done, the study once having met you. Um I'm actually not the author, though, of the triple aim. That came from two colleagues of mine named John Whittington, who's was on the faculty of IHI. He's a physician in Fiore, Illinois, but teaching in IHI. And my probably my closest mentor, Tom Nolan, who sadly passed away a few years ago, Tom was uh, in my opinion, one of the greatest experts on quality and systems in the world. Um at that time, we're talking about maybe 2005. Uh, I had already become deeply involved with the National Academy of Medicine report crossing the quality chasm, which I helped to write. And in that report, we laid out uh goals for healthcare improvement, safety, effectiveness, patient-centeredness, timeliness, efficiency, equity. Oh, six goals became canonical. And I was happily working away, saying, well, this is the terrain that we have to play in now if we're going to work on improvement. Pick one of those dimensions of quality and let's get to work. Whittington and Nolan were thinking ahead of the game, and they they I remember they came to me and they said, that's not quite right. Um, you're describing care when you're in care. But uh, how did you get there? How do people, why do people break their arms or get depressed or have heart attacks or or uh strokes? And they knew, as as you know, Chris, that the the sources of illness lie outside healthcare. Healthcare's a repair shop. Uh my my friend and colleague, Lord Nigel Crisp and Crisp in England has written uh a book uh in which he says home is for health, hospitals are for repair. Because we know a ton about where healthcare illnesses come from, where where illnesses come from. And they come from early childhood experiences and education, the way we're educated, and workplace experiences and uh elder care, uh, environmental threats, community infrastructures, all of that determines whether we're healthy or not. And Whittington and Dolan said it improving the experience of care when you're in care, those National Academy of Medicine Demensions, that they're not enough. We have to go upstream. It's our duty to try to produce health, and that's not going to happen through health care. We have to work on the uh factors that affect health and well-being. And it's just said there's a second goal. Goal one, improve the experience of care. Goal two, then improve the health of populations. And then they added a third goal. They said, in the meantime, stop the waste. We we we don't we have to make be careful with every dollar we use in healthcare because that dollar is denied some of their use. It's all coming from workers. Most workers have other places to use their money, send their kids to college, uh, improve their home, uh, go to a movie, and and we're not entitled to it. So they they said it's broader to think, not just of better care, the experience of care of individuals, but we need to talk about the health of populations and the per capita cost. Care of individuals, health of populations, improving per capita cost. That was the triple aim. And uh that was very uh magnetic. It was immediately picked up. The paper we wrote together in 2006 was what became widely cited immediately. I've been all over the world and countries that have picked up the triple Aim as their way to describe the purpose of their healthcare system. But then uh others began to see something really important, which is that if we if we don't attend to the joy and vitality of the workforce, we can't produce the triple aim. And so people began writing about what they called the quadruple aim, better care for individuals, better health for populations, lower per capita cost, and joy in the workforce. And that was the quadruple aim. And then uh a few years later, my colleague Kedar Mate, who had become CEO of IHI, was kind of leading a charge to put equity more squarely on the screen. And although you could argue that's already contained in the triple aim and also in the quadruple aim, he said, no, we have to call it out. It's it's such an embarrassment, especially in our country, that we don't have equitable access to care, equitable outcomes. So they they said, let's let's call it out specifically. So it became better care for individuals, better health for populations, lower per capita cost, joy for the workforce, and equity for everybody. That's the quintuple that you referred to, Chris. And uh so it's it's a work in progress.

Chris Comeaux 9:20

Well, and it makes so much sense to us. And so it just resonated. And usually, you know, we we give you credit, so thank you for actually correcting now who the Yeah, John Whittington and Tom Nolan, those are names people should remember.

Dr. Don Berwick 9:33

They were the real authors.

Chris Comeaux 9:34

And usually what we'll say is that some of the most brilliant people take very complex systems and they break it down very simplistically. And that was the beauty of the triple A and now the Quintuple Aim. It just makes so much sense to us in terms of, you know, when you and I were just kind of in the green room and you asked me, like, you know, I had a background in business, how did I fall into this? I fell in love with the mission of this. But yet, um, how we've

Meaning At Work Versus Profit Signals

Chris Comeaux 10:00

described it is the you deserve a ticket to the future of healthcare if you're working on the quintuple aim. Like there's some people, in fact, I was I didn't know if I was gonna say it, but I am gonna say it out loud to you. I'm a bit of a history buff. Um, you know, Eisenhower warned us about the military industrial complex, the people who will make war because it's profitable. And then after that, he warned about the healthcare industrial complex that this perversity that, you know, the more that you do stuff to people, that's what makes dollars and profits. And there's this weird perversity in the system. And what I love is the quintuple aim kind of brings it back to the pure purpose behind it. I don't know if you want to make any comments to that. And we've quoted that Eisenhower quote. And it's kind of interesting, us being at the end of healthcare. Now, I don't know if I shared this with you, but hospice is interesting. When I came in, 75% were nonprofit, 25% are for-profit. That is now flip-flop. Actually, it's 80 something percent that are for-profit, and only 20 something percent are nonprofit. I'm a capitalist by nature. I'm okay with capitalism, but there's some icky stuff that's kind of come into the hospice space. That's one microcosm of healthcare, but it's really hard, it feels like sometimes to do right, but then also pay out stakeholders, pay out profits, etc.

Dr. Don Berwick 11:20

Well, you're I couldn't agree with your comments uh more, Chris. Uh so let I'll pick it up two ways. First is what's the nature of quality itself? That is what what what is goodness in healthcare? And I have a pretty romantic view of that. I think we are in a very uh lucky profession and enterprise when we when we say, well, our purpose is to help people live long and healthy lives. And in the case of the your your the hospice movement, uh uh the the best deaths possible. Um the end of life should be another meaningful part of life. But all of this is about meaning. And when you go to the um the the triple aim and the dimensions of the National Academy of Medicine, these are efforts to write down in words why we do what we do. Safety. Don't hurt people with a care that's supposed to help them. Effectiveness, give them the best shot at getting better or preventing illness, uh, safety, effectiveness, patient-centeredness. You know, we work for them. We're guests in their lives. That's when we're doing our best. Timeliness, delay is waste, uh, efficiency, waste is waste. We can we can we don't have infinite resources, and we need to conserve the resources we have, and then equity. These are the names of dimensions that have meaning. And in the quality improvement movement that I have been lucky to be part of, meaning in work is everything. We we we tend to be very disrespectful of our workforce by assuming that their motivations are extrinsically provided with salaries and wages and rewards and punishments when I think the well, the older I get, uh, the more I think. No, most people want to be proud of their work and they they they they they know that life is short and they only get one, and they they want it be have it meaning meaningful. Yes, of course, we need resources to do that work, but it's all about meaning and law and work. What's happened in healthcare though, and that's the second point, is uh the financialization that you referred to. It certainly has is taken over too much of the hospice and palliative care world. But that but you're you're in very good company. I mean, uh the majority of uh physicians now find themselves involved in working for organizations that I think put much too much emphasis on profit, even if they're nonprofit on margin. Um and there's an assumption that you know if we just have enough competition, things will get better. No, the competition's against disease, not each other. So, I mean, be a capitalist if you wish, but don't fool yourself to think that the pursuit of profit is the answer to meaning in life or excellence in healthcare. It's not.

Chris Comeaux 14:14

Both.

Dr. Don Berwick 14:15

So um we've dug ourselves in a pretty deep hole, and we're we're we're way in it now. Private equity is owning more and more of hospitals. And those people who pool their money into private equity resources, yeah, they provide capital that we need, but their goal has frankly nothing to do, or little to do with the the meaning of the experience for patients, families, and communities. They want to make a profit. And I really think we've gone way, way down that uh pathway, and uh, and it's hurting us. It's hurting us badly.

Chris Comeaux 14:47

Well, we did a podcast. I don't know if you know Laura Katz Olson. She wrote a book called Ethically Challenged, well-researched book about private equity, not only in actually a very specific segment, hospice and healthcare, air ambulance, autism schools, um, I think it was substance abuse medicine. So she had a chapter for each of these different verticals and basically treating it like a vending machine. It's not like quality is not even in the idea. It's just all about outsized returns. And the downside is you then don't even have the transparency you typically would have in a publicly traded company. So it was a well-researched book. The other thing I wanted to mirror back to you, you may know my mentor, Quint Studer. And so I we had Quint on our podcast about a year ago. And um, Quint sold the Studer Group, and he now owns a multitude of different businesses. He's actually just getting back into healthcare consulting now. And so he's got restaurants, a baseball team, all these different businesses. So it was a wide-reaching podcast. We talked about leadership, but I asked Quint and I said, what's the easiest business? And he said healthcare, and he saw the look on my face, and I wanted to almost say BS. And he said, Chris, I see the look on your face. And his answer was so profound. He said, the purpose is so close to the work in healthcare, it's unlike any other business. And therefore, it makes it one of the easiest businesses because purpose is so just intrinsic into the heart of the work of what you do. I just thought that was so profound because now, you know, but he's a hospital administrator by trade, done healthcare, consulting everywhere. And it was just such a profound answer to me.

Dr. Don Berwick 16:22

Yeah, he's a deep thinker, and his investments in leading us in healthcare to listen to patients better and better and really go where they are are second to none. Uh but I would agree with him that, you know, look at this uh opportunity we have as leaders or coaches in healthcare to just begin by reminding people of the meaning of in what they do, of how important it is. Uh when I went to CMS uh as administrator, I mean, look, CMS had every reason to look at itself just as a financing agency. It just cut checks and tried to do it responsibly. But my my message there was no, that's just not who we are. We we are a major force and need to be a trustworthy partner for the continual improvement of health and health care for all Americans. That's what you're doing here at CMS. I don't care if you're cutting checks, that's part of that game. And so you're part of something much, much bigger than you think. And um it was no surprise to me, but was a real source of um uh uh satisfaction that people people immediately rose to that to be told what you do is healing, and you're part of that. It's it's a great foundation for getting things done.

Chris Comeaux 17:43

We we just had a podcast that dropped a couple weeks ago with one of the key guys who actually taught leadership at Chick-fil-A. And we actually we've well before I met this guy, his name is Mark Miller, he's written a book with Kim Blanchard called The Secret, and um we have an article in our orientation to our team members. It's a Chick-fil-A article, and there's a there's one great line in it. It says you're either either serving chicken or you're serving someone who is serving chicken. And we use that line because yeah, we've got team members that are doing billing for many of our hospices, credentialing, but yet you are serving someone who's by the bedside, and that way it couches everyone's job in terms of cause and purpose. So I just appreciate the fact that it sounds like you did exactly the same thing at CMS.

Dr. Don Berwick 18:27

Yeah, and that uh, you know, as Quint Studer pointed out to you, it was easier for me than perhaps the CEO of Chick-fil-A. Although people do want to be proud, even if they're if what they're doing is serving customers' meals. This secret that people want to be proud of their work. And your job as a leader is to make it possible for them to be proud of their work, is uh it's a very powerful uh lesson.

Chris Comeaux 18:53

I'm loved that we started here. So here's a

What Worries Him And What Gives Hope

Chris Comeaux 18:55

this is a probably a good segue question. Then when you step back and look at American health care today, what concerns you the most and what gives you the greatest hope?

Dr. Don Berwick 19:05

What concerns me the most, what concerns me the most, we've talked about which is financialization, that we we we have we've uh developed American healthcare into probably the largest generator of wealth in a nation. And it's regressive. It's it's a the way we're doing it right now, it's actually a machine for the transfer of resources from people who have the least to people who have the most. It's uh the rich get richer and uh it's hurting us. The the language that's surfaced in the past few years um is moral, moral injury when you look at the workforce. When people become aware that they're they're they are attract working in a system as a doctor or a nurse or a pharmacist or anyone whose prime whose leaders are primarily focused on margin, uh it alienates them from their work. It puts them in a position where they have to do things that they know are wrong. Uh and um that worries me a ton. I just think it's erosive and the the the the with the tills in the bank are not infinite. You know, eventually we're gonna that that'll come home to haunt us. You mentioned the the sectors affected hospice. Uh I'm a pediatrician and studied autism for years. I think most of the autism services now offered are are by for-profit companies that I don't think are putting the kids first or the families. Um we have you know over 10% of hospitals are now owned by private equity, and we have very, very good research showing that when private equity takes over a hospital, quality goes down and costs go up. It's almost uh it's almost a sure thing. So this is a trend that's it's very, very difficult to stop. It's greed, and it appears in every single sector. We could talk about hospital consolidation to get control of prices, uh pharmacy pricing, which is crazy. Um the insurance company behaviors like in Medicare Advantage, which are just taking money right out of the system and putting it in pockets. That worries me. Most optimistic. Um I am basically optimistic. I guess a couple things. One is that I think there is a growing awareness of what's going on here that the the the research we've had on, say, Medicare Advantage or on uh uh hospital consolidation, we have people in Congress, both sides of the aisle, who are really raising their eyebrows now. They're saying, whoa, wait a minute, what are you telling me? And I don't think that's stable. I think there's going to be some pushback uh in policy. Uh and even more important, I think there's going to be pushback from patients. Patients are really, patients and families are really distressed right now. Uh they're distressed about out of pocket costs, which continue to go up and up and up. Distressed that they can't find a doctor when they need one. They're distressed that the system is impossibly opaque. They can't understand what I feel that when I go to a pharmacy counter, I feel like I'm playing roulette. I have no idea what they're going to say about whether the drug is approved and whether, if it's approved, what I have to pay for it. It feels like a game because it is a game. And I think people are finding out. I've just uh on the threshold with several colleagues of starting a nonprofit organization called Power to Patients. And what we're going to do is aggregate leaders from patients and communities and the clinicians who say enough is enough, we're not putting up with it, and then turn that into a political voice that doesn't currently exist, the mobilization of patients. So in a way, I'm optimistic about the degree of anxiety right now, the degree of anger in there can buy some solutions. I think the other thing is it's like we know what to do. It's not like, you know, it takes a genius to describe a healthcare system, behavior, performance, quality that we want and can afford. Like you get someone to help you when you need the help. Like you don't have to repeat your story over and over and over again as if the system had no memory, where um you don't have to fear bankruptcy because you get ill. We we know what those systems look like. They exist around the world. And maybe we'll be smart enough finally to say, nope, that's what we're gonna have.

Chris Comeaux 23:30

You would we actually did a podcast last year with T.R. Reid, who wrote the book The Healing of America. And I'm sure you'd yeah, great book. Yeah, great book. He went research healthcare systems all over the world. And and then we actually, I knew we kind of were apolitical here. One of my great mentors said, You're a hospice CEO, you always should be apolitical. So we actually went and found also Rita Numerof, who's maybe a little bit more right-lean, a little bit more free market, and she writes for Forbes. And it's so interesting because both there you literally could take both of those podcasts and overlay. And I think it really did kind of create a roadmap, if you will, of how to fix health care as a whole, which is maybe a good segue. If if you had the authority, and my God, it would be so cool if it was. If you can make three structural changes tomorrow to fix health care, where would you

Three Big Fixes For The System

Chris Comeaux 24:15

start?

Dr. Don Berwick 24:19

It's a complicated system. I'm not sure three is enough or a large change. Don't feel limited by three. I guess I mean, yeah, we have yeah, I think for one thing, I first I divide the question into two. We have healthcare financing insurance, which right now is not doing its job. It's taking money out of our pockets and putting it into more concentrated wealth. It plays games. We have to change the financing system. And I, you know, I there's nothing perfect, but I've come to believe that we should have a single uh health insurance system in the country, a national health insurance that I don't think the uh variety of all of these complicated uh uh insurance companies and pay-in systems, I just don't think it's adding value to people. I mean, uh it's not a political position, it's a technical one. I want to make sure every dollar that we that is is spent on health care is spent to help someone, a patient. And I think uh a consolidated national health insurance system is more likely to do that. Would it be uh perfect? No. I ran Medicare and Medicaid. That's uh that's a health insurance system for 110 million people. And I know the warts, I understand what happens politically and so on, but I'd rather start there uh so that we have an insurer who is a nonprofit and unified in the way they think about serving a population and one way or another accountable for serving that population. End of story. Um I think we tried the other and the highly fragmented, highly complex, opaque uh system with you know a few massive insurers and a lot of small ones, and it just doesn't work. Drives you nuts, drives you crazy. So that I I change financing that way. I would make sure it's highly transparent and very accountable. So that's why I think a national system, government isn't perfect to say the least, but I want accountability for that single insurance system, and so I guess it would be governmental, would be the best choice, or maybe there's a way to do it with uh some kind of uh uh you know uh uh agency system where at arm's length from the political winds of government. But I think we've had it with private insurance as the best way to offer coverage, I don't think. Along with that, we need goals. We can't have it's not an infinite resource. The money that goes out through healthcare insurance is coming from somewhere. As I said earlier, every it always will trace back to a worker's pay. It's all every dollar we spend in healthcare is coming out of the pay of workers. And so I want to protect them. I want them to have that money to spend in other ways that they like. So we're gonna have to have some sense of um responsibility for reducing waste in healthcare. So that's payment. On the delivery side, I mean, we've had our experiments with a highly fragmented systems, you know, hospitals that, you know, focus on acute care and laboratories that do laboratory work, emergency rooms, freestanding or otherwise, that take care of emergencies and a mental health system and a hospice system. And the the by building this in fragments, we what we do is we lose the patient. The patient doesn't come in fragments. The person that ends up in hospice care, as you well well know, has been through a journey back. They've been chronically ill for a while, and they and they haven't been yet close to death, but they've been certainly compromised. Before they were chronically ill, they were a person at risk, someone whose hypertension could have been controlled or whose whose uh depression could have been better treated. Before that day they were a child who was learning habits and being supported for vitality. So I personally would prefer a healthcare delivery system that's organized around population that says, you know, I'm in Omaha, Nebraska, and I'm going to take care of, if not all the people in Omaha, this segment of the people in Omaha or in Lincoln or in Chicago. And I'll and I'm and I'm like accountable for their their journey, their journey, not for this little piece of their journey. So that leads us to systems that people call integrated delivery systems or holistic delivery systems where you're not chopping up the care into little pieces. People don't come that way. So I would configure care that way and have this payer say, hey, out there, we want people that will take responsibility for the journeys of people, of patients, no matter where they happen to be, and so that people don't get forgotten. I think that's that's kind of a much too long two-part answer.

Chris Comeaux 28:59

That's a great answer.

Dr. Don Berwick 29:00

Integrated delivery system and a consolidated financing system that's no longer wasting our money in billboards and games.

Chris Comeaux 29:10

And great quality outcomes, right? That uh kind of measures the outcomes of the system. I know that's in your sweet spot.

Dr. Don Berwick 29:17

Not just quality, but continual improvement, which is we've got innovation after innovation that could be brought in, that by the way, often can reduce costs if we're smart about it, instead of just another way to line the pocket of some billionaire. I think that um uh possibly artificial intelligence, AI, and large language models that we're all kind of looking at with appropriate skepticism and a little bit of fear, maybe, maybe if those are correctly guided, can become real cost reducers and improvers so that we're you know, we're not relying on people's frail memories all the time. We have better ways to think about it. Yeah, because it's I'm aware of your comment, Chris, about capitalism. And yes, I mean undoubtedly many of us, maybe you believe that capitalism generates the best outcomes, by which we mean private ownership and competition. I don't know yet that. Uh we it's really hard to find an example, as TR Reid's wonderful book shows, where in the healthcare space where we're really trying to make healthy communities where where competition among providers or uh has won the day, it doesn't appear to be, yes, for my computer or my car, let well let the capitalists reign, but uh maybe not for my health.

Chris Comeaux 30:42

I agree with you wholeheartedly. And so when I talked about that as as a general belief as how you build an economy, but now I've come full circle and probably start my young career, my naivete, that maybe that applies to any business, not to healthcare. And I didn't fully explain, like, you know, T.R. Reid that was such an incredible podcast, and then bringing Rita Numerof, it's interesting. For me, it was like an Easter egg kind of like what's their answers. But I feel like if I smush those two podcasts together, it's your answer that you just said. Um, and that's the conclusion I've come to as well. You've got to cover everybody in a healthcare system. And that perversity of um doing more stuff to people that drives profits is not aligned with actually what's doing best for people to have good health.

Dr. Don Berwick 31:27

Yeah, you know that. That's right. Uh sometimes more is better. Uh I am about to have a hip replacement. I've waited till I'm very old, but that hip needs to be replaced. And I'm and now I'm sure I'm sure that I'll assuming I get through all the risks involved, I'll be better off. But that doesn't mean that everything you could do, you should do. You have to stop and pause and say, is this is this gonna help? Is this really what matters to the person I'm seeing before us? And right now, too much of the thinking is is driven by can I make a book? No, it's not it's not quite that vital. It's not, I don't think there's a lot of evil people out there doing it, but it's certainly what the signals are in the moment.

Part Two Tease And Closing

Jeff Haffner 32:13

Don't miss part two of this episode coming this Friday.