If a tree falls and no one hears it, does it make a sound? When Donald Berwick fell from his position as the interim administrator of Medicare a few months back, I’ll bet few readers heard the crash. Maybe that’s because Berwick’s demise was less a case of falling timber than it was him falling on his sword. Berwick had hoped to get the CMS administrator gig full-time via Senate confirmation, but with 42 Republican Senators guaranteeing to destroy his bid for the position on the chamber floor Berwick decided to eject from the post 1 month before his temporary recess appointment was scheduled to end.

What could have made those 42 Senators so touchy? Maybe it’s the fact that the hand of the CMS administrator gets to sign checks cut from a federal budget that rivals the Pentagon’s. To those 42 Senators, Berwick’s sketchy profile as a Harvard-trained pediatrician and Honorary Knight Commander of the Order of the British Empire must have made him seem pretty shady.

Maybe it was the five areas Berwick has publicly stated are the sources of Medicare’s “extremely high level of waste.” Those areas include overtreatment, failure to coordinate care, administrative complexity, burdensome rules, and fraud. And doesn’t each of those have a fingerprint on long-term rehabilitation? From mobility to pain management to functional recovery, all five of these concerns have at one time touched a corner of physical rehabilitation, and occasionally cost the profession dearly in dollars and trust.

Every headline that screams “Scooter Fraud!” casts gloom unfairly over the majority of rehab practices and clinicians who are honest and ethical. Given a full term of office, the endorsement of the President, and confirmation by the Senate, Berwick may have done much to counter damaging headlines and the forces of waste. The depth of this waste is highlighted by a 2011 report from the Office of Inspector General that announces 61% of power wheelchairs provided to Medicare beneficiaries in the first half of 2007 were medically unnecessary or had claims that didn’t constitute medical necessity. The cost of those error rates was $95 million. That’s a whole lot of money—much of which potentially could have been saved. Why on Earth would 42 Senators be put off by a leader who seemed committed to divesting the agency of such waste?

Maybe they found him dangerous because of his plan to set guidelines for Accountable Care Organizations, which the Washington Post described as “a pilot program meant to move Medicare away from paying doctors for the volume of services they provide and toward reimbursements based on quality of care.” Let’s take a moment and apply that same approach to Senate compensation: pay them not on the volume of legislation they provide but rather on the quality of legislation they provide. I’ll bet that gives most of those lads on Capitol Hill a case of the jitters.

With Berwick’s exit, Marilyn B. Tavenner appears the heir-apparent of President Obama’s nomination for the CMS administrator. Tavenner was Berwick’s second-in-command during his watch, and the third person to sit at the administrator’s desk in the last 6 years. The New York Times describes Tavenner as “more of a manager and less of a visionary than Dr. Berwick.” Her history as a nurse, nursing supervisor, hospital executive, and board member for hospital associations indicates she is likely to lead CMS on a fantastic voyage of paperwork and coffee breaks at a time when what it really needs is some daring. Maybe I’m wrong, but reading Tavenner’s February 24 Medicare blog entry gives me the uneasy feeling I’m right. In that entry, she ballyhoos the escalation in the recovery of fraud money and the uptick in fraud prosecutions recorded in fiscal year 2011. Those results seem more likely the result of actions set in motion by Berwick at least 2 years ago. The entry hints at a practiced bureaucrat taking credit for someone else’s work. I have a feeling when it comes time to confirm the new CMS administrator, those 42 Senators are going to like Ms Tavenner just fine.

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—Frank Long