Berwick’s Rules, Wennberg’s Windfall and the Quality-Industrial Complex

Quality and value are important. But are they best achieved through professionalism or regulation? In 1996, Donald Berwick co-authored an important book, “New Rules,” which set forth the manifesto for how and why health care was to be regulated. The following statements, grouped into paragraphs, are from that book.

 BERWICK:  “Physician control of knowledge has allowed practitioners to shape both the demand for medical technology and its supply. One motivation for doing so may have been that the monopoly of knowledge and the inhibition of the patient’s role furthered the profession’s own economic interests. Another, and more probable explanation is that the espoused ethic of medicine eliminated all influences on the healing relationship except for the physician’s commitment to the patient.

Today, this isolated relationship in no longer tenable or possible.  No longer is the physician, paternalistically committed to the patient, the driving force in medical care. Health care has become an industry, with numerous loci of authority well beyond the doctor’s office. Traditional medical ethics, based on the doctor-patient dyad, must be reformulated to fit the new mold of the delivery of health care. The relationship of the patient to the doctor is less important. In these circumstances, the need for regulation is greater, not less.

Regulating for improved medical care involves designing appropriate rules invested with authority. Their primary function is to constrain decentralized, individualized decision making. Strict regulations reduce the autonomy of health care professionals and thereby improve safety.” 


Health care reform has created myriad rules invested with authority. It has strengthened the QUALITY-INDUSTRIAL COMPLEX. The Society of Actuaries has published a list of more than 100 organizations, many of which are proprietary, that are profiting from “quality.” Investors in Health Dialog, the company associated with John Wennberg and the Dartmouth Atlas, have profited already – the company was sold for $772M, giving investors an 880% profit, and the cash keeps rolling in.
In mid-July, there will be a meeting in Boston of the Physician Advisors Congress. Its goal will be to enhance the role  of physician advisors in an era of increasing regulation. A new career track now exists, simply to help physicians cope with the voracious appetites of quality-regulators. More such consultants will be needed if Berwick’s regulatory zeal lays claim to CMS, and even more if the Dartmouth Atlas remains President Obama’s road map for health care. Quality is good. Profit is good. But beware of profit in the name of quality.

One comment

  1. Dana Wilson

    Your point was brought home to me in the late ’70’s when our social worker began to refer to our patients as “clients”; it was viscerally offensive and denigrated the dyad: the private relationship between doctor and patient.

    S.I Hayakawa pointed out long ago that the word is not the thing, the map is not the place.

    Semantics shape our decisions and propel our actions. “Patients” should and do get more commitment than “Clients”. Words do matter; as has our Hippocratic oath.

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