Fox's Angle baselessly suggested Berwick wants “bureaucrats” to make end-of-life care decisions

Fox News' Jim Angle baselessly suggested that Centers for Medicare & Medicaid Services (CMS) administrator Dr. Donald Berwick wants “government bureaucrats” to make end-of-life care decisions instead of patients. In fact, Berwick has urged doctors to work with patients and families to make those decisions.

Angle pushes baseless claim that Berwick wants “bureaucrats” to decide end-of-life care

Angle advances baseless claim that Berwick wants end-of-life decisions made by government, not patients. On the July 7 edition of Special Report, Angle said that "[s]ome elderly do prepare advance directives should they become incapacitated, but critics say Berwick seemed to be saying something else." Angle then aired a clip of Republican pollster David Winston saying that Berwick “made it kind of sound like those decisions would be made by government bureaucrats and not the individuals.”

In reality, Berwick has urged doctors to work with patients on end-of-life decisions. Speaking at the 1999 meeting of the American College of Physicians, Berwick proposed "20 Improvements in End of Life Care," which are guidelines for doctors to help their patients make end-of-life care decisions. Among them:

  • “To eliminate anxiety and fear, chronically ill patients must understand what is likely to happen. When you see a patient who is 'sick enough to die' -- tell the patient, and start counseling and planning around that possibility.”
  • “To understand your patients, ask (1) 'What do you hope for, as you live with this condition,' (2) 'What do you fear?,' (3) 'It is usually hard to know when death is close. If you were to die soon, what would be left undone in your life?,' and (4) 'How are things going for you and your family?' Document and arrange care to meet each patient's priorities.”
  • “Comprehensive and coordinated care often breaks down when providers don't have all the facts and plans. The next time you transfer a patient or a colleague covers for you, ask for feedback on how patient information could be more useful or more readily available next time.”
  • “Unsure how to ask a patient about advance directives? Try: ” If sometime you can't speak for yourself, who should speak for you about health care matters?" Follow with: 1) 'Does this person know about this responsibility?' 2) 'Does he or she know what you want?' 3) 'What would you want?,' and 4) 'Have you written this down?' "
  • “To identify opportunities to share information with patients and caregivers, ask each patient who is 'sick enough to die:' 'Tell me what you know about ________(their disease).' Then: 'Tell me what you know about what other people go through with this disease.' ”

Berwick has encouraged “involvement of patients and families in decision making” on end-of-life care. Contrary to the suggestion that Berwick supports allowing the government to cut off end-of-life care in order to save money, Berwick has actually encouraged the “involvement of patients and families in decision making” on end-of-life care, and pointed out that the responsibility for making that idea a reality “rests squarely on the shoulders of clinicians.” According to Berwick, such involvement, such involvement “ha[s] been shown to reduce inappropriate care at the end of life, leading to both lower costs and more human care from the patients' point of view.” From Berwick's book Escape Fire: Designs for the Future of Health Care:

AIM 4: Reduce the use of unwanted and ineffective medical procedures at the end of life.

Only a minority of patients, families, and clinicians support prolonged use of life-sustaining procedures and dramatic interventions in the terminal stages of illness, yet substantial use of the procedures continues. In human terms, using unwanted procedures in terminal illness is a form of assault. In economic terms, it is waste. Several techniques, including advance directives and involvement of patients and families in decision making, have been shown to reduce inappropriate care at the end of life, leading to both lower costs and more human care from the patients' point of view.

It is, of course, hard to know in advance that this month or this week is the last month or week of a patient's life. That is, in fact, one of the main reasons why this particular improvement challenge rests squarely on the shoulders of clinicians. It requires our highest skills to help patients and families balance the factors of uncertainty, dignity, risk, and reward involved in using medical procedures appropriately as life ends. We must begin be recognizing that today the appropriate balance is badly missing.

Angle rehashed distortions of Berwick's comments on rationing

Angle cites Berwick statement that “the decision is whether we will ration with our eyes open.” Angle claimed that Berwick “laments the amount of money spent on people in their final weeks of life,” then quoted Berwick's statement that access to a new drug or medical intervention can be “so expensive that our taxpayers have better use for those funds. We make those decisions all the time. The decision is not whether or not we will ration care -- the decision is whether we will ration with our eyes open.”

Angle cropped out portion of statement in which Berwick noted that rationing is already occurring. In quoting Berwick's statement that “The decision is not whether or not we will ration care -- the decision is whether we will ration with our eyes open,” Angle did not note what Berwick said immediately after that: “And right now, we are doing it blindly.” Indeed, the insurance industry has readily admitted to using cost-benefit analyses in coverage decisions. For instance, during the July 15, 2009, edition of NPR's Morning Edition, WellPoint chief medical officer Dr. Sam Nussbaum told co-host Steve Inskeep that “where the private sector has been far more effective than government programs is in limiting clinical services to those that are best meeting the needs of patients.” Moreover, in Senate testimony, Wendell Potter, a former senior executive at CIGNA health insurance company, detailed ways in which the insurance industry makes cost-based coverage decisions, including how “insurers routinely dump policyholders who are less profitable or who get sick” and “also dump small businesses whose employees' medical claims exceed what insurance underwriters expected.”

Berwick's statement on rationing was echoed by Republican Rep. Ryan. In a February 2 interview with The Washington Post's Ezra Klein, Rep. Paul Ryan, ranking Republican on the House Budget Committee, said: "Rationing happens today! The question is who will do it? The government? Or you, your doctor and your family?"

Angle regurgitated claim that Berwick blindly supports British health system

Angle ignored Berwick's criticism of Britain's NHS in passing along right-wing talking point. Angle also said that “Berwick also praises one of the world's most famous examples of socialized medicine,' followed that with a clip of Rep. John Barrasso (R-WY) saying, ” He said he's in love with the British health care system, which is known for rationing health care."

Berwick also criticized elements of NHS. In a 2008 speech widely cited by right-wing critics in which Berwick praised Britain's National Health Service (NHS), Berwick acknowledged that the NHS is “far from” perfect, and specifically cited “cancer outcomes” as an area in which the program has had “less progress” :

BERWICK: Is the NHS perfect? Far from it. Far from it. I know that as well as anyone in this room, from front line to Whitehall, I have had the privilege of observing performance and even to help to measure its performance.


There is less progress in some areas, especially with comparison to other European systems, such as in specialty access, in cancer outcomes, in patient centeredness, in life expectancy and infant mortality for socially deprived populations. In other words, in improving its quality, two facts are true: The NHS in en route, and the NHS has a lot more work ahead.

Berwick then listed “ten suggestions” for how the NHS “can do even better.”

Angle reiterates claim that Berwick's “redistribute wealth” comment is unusual

Angle suggests Obama made recess appointment to avoid criticism of Berwick's comment. Angle reported that “Berwick has said some things that are definitely not part of the administration's pitch on health care,” then aired Berwick's 2008 comment that “Any health care funding plan that is just equitable, civilized and humane must -- must -- redistribute wealth.” Angle added, “Republicans suggest President Obama didn't want a confirmation hearing where such statements were bound to come up.”

But health programs such as Medicare and Medicaid are inherently redistributive. Medicare and Medicaid -- which Berwick will oversee as CMS administrator -- redistribute wealth from those who can afford private insurance to those who cannot. Even Fox News' Laura Ingraham has acknowledged that Berwick's comments are “right,” telling Bill O'Reilly that “you and I are both in favor of there being a safety net where people don't go untreated, where people who need help get help. Obviously to pay for those people, it's obviously going to involve taxes and taxes come from people who make a living and make income.”