Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep86: The future of medical research, with Donald Berwick, M.D., M.P.P., senior fellow at the Institute for Healthcare Improvement
Transcript
- Don Berwick 00:00:00 We know what makes us healthy. And it isn't health care. Health care. Repairs, damage done. But damage comes from elsewhere. Austin Littrell 00:00:19 Welcome to Off the Chart: A Business of Medicine Podcast, featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Littrell, I'm the assistant editor of Medical Economics, and I'd like to thank you for joining us today. In this episode, Medical Economics senior editor Richard Payerchin sits down with Dr. Donald Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement and the former administrator of the Centers for Medicare & Medicaid Services, to talk about the state of medical research. They'll also be talking about a National Academies of Medicine report that he co-authored on making sure that medical research dollars match up with the diseases and patient needs that matter most. Dr. Berwick is also host of IHI's Turn the Lights On podcast alongside former off the chart guest Dr. Kate Mate. Now you can find their show linked in the description down below. Austin Littrell 00:01:06 You can also find the report that they'll be discussing. So you can give it a look for yourself. Dr. Berwick, thank you again for joining us. And now let's get into the episode. Richard Payerchin 00:01:20 Dr. Berwick, thank you for joining us today. Don Berwick 00:01:22 It's my pleasure, Richard. Thank you for having me. Richard Payerchin 00:01:25 And today we're going to talk about the state of American medical research and a new report by the National Academy of Medicine. Before we get to that, can you introduce yourself with a little bit about your education and experience? Don Berwick 00:01:38 Sure. Thank you. Richie. Well, I'm Don Berwick. I'm a pediatrician by training early on, got interested in quality of care and with some colleagues, started the nonprofit institute, the Institute for Health Care Improvement II. And your listeners can tune in and find it. It's now a global organization that tries to work on improving health care all over the world through using modern improvement methods and supporting clinicians and managers. I had a stint after that working in the Obama administration. I was the head of Medicare and Medicaid, the administrator CMS for for a year and a half, 17 months, and then returned to, to Massachusetts, where I live, as a senior fellow and president emeritus at the institute that I founded. Don Berwick 00:02:25 I also do quite a bit of teaching, around the world and, still stay pretty focused on quality of care. Excellent. Richard Payerchin 00:02:34 And as I mentioned, we're here to discuss the new report, Aligning Investments in Therapeutic Development with Therapeutic Need, published by the National Academies of Sciences, engineering and Medicine. Just as by way of introduction, can you explain how did this report come about? Don Berwick 00:02:50 there was a series of meetings going around the country on this question. Are we putting the money where it's needed? In this, in the support of development of new drugs and and therapies. Or is there a mismatch? Eventually that was picked up by Gates Ventures and the Peterson Foundation, Arnold Ventures. I mean, and they, they approached the National Academy and offered to fund an independent study of that question. Richard Payerchin 00:03:20 And the committee came up with recommendations organized around five goals. Can you explain a little bit about what those are? Don Berwick 00:03:29 Yeah, we had a wonderful committee and the, about 16 people from many walks of life, including both the investor community and drug developers themselves, academicians, experts on law and and regulation. Don Berwick 00:03:46 So we, we had the goal of, trying to find out first what is the disease burden in the United States? Where? Where are people really suffering? What conditions and what portion of that burden is unmet? The needs are unmet. In the in the sense that there is still no effective or limited effective medications or treatments for those diseases. We tried to find out the degree of match, mismatch or match between the investments that are going on in both the the public sector, such as NIH and the private sector in, drug developers and, and investors, where that where the investment is going, where the need really appeared to be. And to the extent we discovered and could document that mismatch. Why why is it there or what what is causing us to be off center to that degree in therapeutic therapeutic development and then importantly, to develop a series of recommendations for a policy financed Public action to try to close the most important mismatches. Richard Payerchin 00:04:57 As of year 2025. Sometimes it feels like whether it be about medical topics, health care or any subject matter, sometimes it feels like we have information overload. Richard Payerchin 00:05:06 And yet the committee noted that there was a lack of data needed to produce a comprehensive evaluation to really fully address that mismatch. There were some therapeutic areas of underinvestment that were identified. Can you explain how how you identified those? Don Berwick 00:05:24 well, we had to milk the available public data to discover where mismatches and matches were. I think you began, though, with the most important committee finding. Well, which is we really don't know. We're flying blind. We don't have publicly accessible, pedigree data on the either the disease burden in the country, which is a big surprise to me. I thought we would have tons of data and even more. It's hard to track down where the funding is going. It's a little more transparent with public funding such as the National Institutes of Health. But on the private side, there really is very little opportunity of aggregating information on where the where the funding is going. So all of the conclusions we we come up with thereafter are kind of like inhibited by this fundamental lack of lack of data. Don Berwick 00:06:19 And our first and most important recommendation is that should be there should be established by Congress, an interagency consortium in the Department of Health and Human Services, and an appropriate agency which has the charge of tracking and assessing unmet therapeutic need associated with the burden of disease in the US, and also tracking current investments in innovation to identify areas of mismatch. In other words, there should be a standing body which can carry out the tasks that our committee. what was assigned. Without that information, it's going to be very tough to make sure that we have the alignment we're after. Richard Payerchin 00:06:56 I definitely want to get into some of those conditions, because, you know, we're talking about actual patients in a real human cost when people are dealing with illness and disease. But maybe to elaborate a little bit more on that point. There was the recommendation regarding establishing an interagency consortium to track those unmet therapeutic needs, research, investments and disease burden. Can you explain more about how that would work? Don Berwick 00:07:21 we envision, a a function within the Department of Health and Human Services. Don Berwick 00:07:27 It's not clear, as the Trump administration is changing the configuration of HHS exactly where that would land. But there should be under the secretary of HHS guidance. a group that pulls together, especially the federal side of, expertise from CDC, NIH and other federal agencies that have knowledge about disease burden, and also with private sector participation. So we can aggregate the information in one place. And, and most importantly, make it accessible to, to potential investors, to the public that has an interest in where the resources are going. right now, there's no such aggregation and very little transparency, especially on the private investment side. We recommend that there be actually a report issued by the this consortium on, every three years on a three year basis so we can track what the needs are, how they're evolving and what the investments are and how they're evolving. Richard Payerchin 00:08:28 In the United States. Why is there such a misalignment between research, investment and alignment with the disease burden and unmet need? How did that happen and why did that grow? Don Berwick 00:08:41 there's probably two big categories of reasons. Don Berwick 00:08:45 On the one hand, science missing missing science that allows the drug developers to get to work to find the molecules that will help combat disease. And second, markets and market forces. The economics of this and both both do matter, especially recently with what are, in my view, very, very unfortunate cuts in our investments through the National Institutes of Health, through the centers for Disease Control and Prevention and others. These are extremely important investments in developing the underlying platform sciences that allow. Biomedical developments to occur for therapies. there are numerous areas of gap in those investments. Now they're getting worse with the current trend in policy. sometimes it's just that they're difficult scientific issues that we have to put a lot of work into. And that's really important to understand that the basic sciences that underlie the development of drugs. There's some uncertainty. You don't you can't really know right at the start that a particular basic science investment is going to lead to a drug. But if you don't take the risks, you don't get the medications. Don Berwick 00:10:01 There are also, with the modern AI world, some opportunities now on the research side to aggregate information and then digest it so that artificial intelligence can help us triangulate and find the areas that we should be investing in and the the possible new therapies on the market side there. You know, right now a lot of drug development is in the private sector, of course. And they look at return on investment. They want to see that the the investments that they put in are within their capacities and that where necessary, where the drugs to be developed won't pay off economically, that there be for the forms of subsidy and support to allow them. Nonetheless, the private sector nonetheless to invest in in innovations. and there can be misalignment at that level because, for example, it may be the case that, the, the pricing, strategies for drugs to acquire, to be acquired can, can lead to anomalies in pricing where, either the prices are too high for people to have access to those drugs, or in a very interesting subset of cases where there are very important disease burdens, where there exist a lot of generic drugs and low cost drugs. Don Berwick 00:11:21 Right now, the incentive to develop the frontier of such, research can be very low because there's too much generic competition. that, of course, means that if we want to have drugs for which there's not a sufficient market case, then we need government intervention to make the market case more attractive. I. Multiple Speakers 00:11:44 Say, Keith. That's all well and good, but what if someone is looking for more clinical information? Multiple Speakers 00:11:50 Oh, then they want to check out our sister site, Patient Care Online. Com the leading clinical resource for primary care physicians. Again, that's patient care online. Com. Richard Payerchin 00:12:02 It may seem in our conversation we're bouncing back and forth between the science and some of those financial forces. And yet this is one of those instances where it's there so uniquely intertwined that, again, I just I think this is this is really great food for thought and hopefully will translate into actual policy going forward. And when we talk about that financial element, the report underscores the role of Medicare and CMS as a powerful potential influence on therapeutic development. Richard Payerchin 00:12:32 Can you explain why that financial element of CMS coverage, reimbursement and drug price negotiations is so important. Don Berwick 00:12:42 yes. Well, on the public side. The center for Medicare and Medicaid Services is one of the largest purchasers of medications in the world, and the prices that they can set for purchase and medication have enormous effect on where drug producers and developers put their energies. Recently, with the expansion under the Inflation Reduction Act, CMS has acquired new authorities to negotiate drug prices that it never had before. Now the question is how will CMS use those authorities? Right now, the main application has been very high volume drugs, drugs which are costing CMS a lot of money. But in an ideal world, you might think that this consortium idea that we have of of actually having data on MT need could be translated by CMS into extra payment for drugs, where which would close those unmet need gaps so CMS could become an instrument for drawing attention both of the public sector, but also private sector, into where they're putting the money for drug development simply by adjusting their pricing frames in accordance to the unmet need. Richard Payerchin 00:13:50 And to maybe continue along the lines of thinking about the federal government's role. You know, in the scientific research here, there always has to be a balance among patient safety research, medical effectiveness, and the ability to bring new medicines to market. The report recommends the Food and Drug Administration maintain and uphold strong regulatory approval standards. How could the FDA realign research, you know, based on disease burden needed treatments and cures, and unmet need? Don Berwick 00:14:21 Great question. Let me go back to a point that I think is crucial. And this is me speaking, not the committee. The current trend to decrease investments in research and development at at the Food and Drug Administration and NIH is going to be very toxic to the goals we have as a country. We are talking about draconian cuts at the National Institutes of Health, which fund and also intramural produce research that becomes the basis for drug development. So I'm extremely worried about what's happening now with funding of these agencies. It's a very big backward step in drug development. The Food and Drug Administration is interesting. Don Berwick 00:15:00 Obviously a key agency. and it has when I went into this project, not being an expert in this field, I expected that we would discover that the Food and Drug Administration is actually a one that that failures that the FDA explains some of the gaps in, in new drug development. That didn't turn out to be the case. The more we looked at the FDA, I'll say, the more I impressed I was on and the committee as a whole, how diligent and expert the FDA is in in carrying out its tasks. Again, that will depend on ongoing FDA funding, which is very much at risk right now. But it's an agency that's done. Overall a very good job. Now they, like we are, are aware of gaps both because of missing science and and market forces. and they have mechanisms in the FDA to accelerate the, the approval of a drugs accelerated approval in different forms. we have, we came down as committee saying that we we need that we there have to be ways to fast track drugs with, with due diligence to the evidence base. Don Berwick 00:16:19 But in the in the accelerated approval world, the FDA relaxes somewhat the standards for approval. For example, instead of requiring studies that show the ultimate outcome of treatment, They sometimes allow the use of of surrogate measures or intermediate measures, which may or may not actually be related to the long term fate. But we're talking about other diseases for which there are no treatments or populations that are kind of left high and dry with no drugs. It makes sense to us for the FDA to have these accelerated approval mechanisms subject to a condition. And that's what you were talking about. So the way this works now is the FDA can say to a drug developer, yeah, that's really badly needed. There's a population window treatment now subject to these somewhat relaxed standards of approval, you can go ahead and will approve the drug conditionally condition on post-marketing confirmatory studies, which do restore the full burden of proof with better design research, larger sample sizes, and true outcome measures. So for now, you can market the drug, but there have to be ongoing confirmatory studies, are underway, and should those confirmatory studies not confirm the safety and efficacy of the drug, then that drug will be withdrawn from the market. Don Berwick 00:17:39 That's the that's the condition. Now, however, it turns out it's not. It's more honored in the breach. A lot of confirmatory studies are never done. The there are even drugs in which there are confirmatory studies which show the drug to be ineffective or unsafe, and then the drug is not withdrawn from the market. This has to do with capacities within the FDA. And so our recommendations are that the FDA reinvest in the use of this of these accelerated approval, subsequent confirmatory studies with much more diligence than it's been able to muster so far. Again, that will take extra resources in the FDA at a time when the administration is cutting back on FDA personnel and funding. And so that's another kind of mismatch. We think that correctly implemented. This accelerated approval with confirmatory studies is safe enough that the public can be assured that their long run interests are being protected. Richard Payerchin 00:18:40 No, that that is something that whether it be a physician or patient perspective. Obviously, if a drug is ineffective, I mean, let's face it, that can be a waste of time and money. Richard Payerchin 00:18:47 And if it's harmful, then goodness gracious. I mean, you know, you don't necessarily even want that going out in the first place. So that is is just vitally important I would think. Don Berwick 00:18:57 Yeah. But you can understand the patients, some patients point of view would be I have a disease, it's fatal or it's going to hurt me badly. There's no treatment now. And here's a treatment that might work. please let that drug get to market in a way that I can start to use it even while the confirmatory studies are underway. That makes some sense. As long as there's real, serious commitment to the science in the longer run. Richard Payerchin 00:19:19 We've talked quite a bit about the role of some of those federal agencies that could, you know, that they could have in correcting the misalignment here between unmet need and In research, how do you see the role of private funders evolving in the effort to realign medical research with disease burden? Don Berwick 00:19:36 Well, two, 2 or 3 ways first. Remember the earlier assertion we're kind of flying blind. Don Berwick 00:19:44 We don't have a public database showing us the disease burden and the degree of gaps that anyone can access so that they could decide what to buy, what to invest in, whether they be a member of Congress or a private investor. So this idea. Recommendation number one, about a publicly available database that dealing with disease burden and unmet needs and current levels of investment, I think it's essential. That may mean some new level of transparency on the private sector side who want to protect their their intellectual property, of course. But I think we all, We feel we'll all be better off if the if the data are, are made available, at least in aggregated form, so that we can look at gaps, that those gaps will become a business opportunities for organizations once they're aware of it, that they can move into it. which, you know, we don't we don't have now. It's just it's very difficult to do that. There are, by the way, an interesting subset of medications where a particular drug companies develop a medicine that would be effective if brought to market, but that medicine doesn't fit that drug company's business model. Don Berwick 00:21:02 And so it remains on the shelf, an intellectual asset, a molecule or or promising molecule that remains on the shelf. Part of the policy changes that could be made would be to have better mechanisms to get those off the shelf and into other hands, so that they can be developed to help the people that could benefit from those medications. I think the willingness of the drug developers to participate in this level of transparency would be a big asset if we could pull that forward into the into the models for the future. Also, remember that a lot of drug developers are following up on public investments. They're using knowledge gained by, say, the National Institutes of Health to then develop the drugs that they that they can make money on. So, you know, there's a bit of a what should I call it, a kind of, agreement here that I think we need as a matter of social policy, which is when our public dollars are being put into developing the basic sciences upon which drugs will be developed. We, the public, owned part of that asset and can make some rules about how that asset can be used. Don Berwick 00:22:08 the, the other, theme in the report that's pretty big is public private partnerships. It's not possible to put all of the burden for this entire trajectory of addressing unmet need. Doing the basic science, and bringing a drug to market on the government. Government is a player, a crucial player. But we need better and stronger relationships between the government and private investors and private developers in public private partnerships, which again can be guided by the priorities that could be developed with a better database. Multiple Speakers 00:22:49 Hey there, Keith Reynolds here, and welcome to the P2 Management Minute. In just 60s, we deliver proven real world tactics you can plug into your practice today, whether that means speeding up check in, lifting staff morale, or nudging patient satisfaction north. No theory, no fluff, just the kind of guidance that fits between appointments and moves the needle before launch. But the best ideas don't all come from our newsroom. They come from you got a clever workflow hack and employee engagement win, or a lesson learned the hard way. Multiple Speakers 00:23:16 I want to feature it. Shoot me an email at Kay Reynolds at Life sciences.com with your topic, quick outline or even a smartphone clip. We'll handle the rest and get your insights in front of your peers nationwide. Let's make every minute count together. Thanks for watching and I'll see you in the next part. Two Management Minute. Richard Payerchin 00:23:39 I'm curious about your perspective because some primary care physicians, we I mean, we know their situation. They're swamped. They and they are treating some of the conditions that are chronic conditions that are a huge disease burden in the United States. And some of them might look at a study like this and say, okay, well, that's great for the pharmaceuticals, the drug companies, the doctors and researchers who are working in academia. Can you discuss maybe some of those connections and conditions in primary care and how how this research actually actually translates to medicine out there going on in exam rooms or even right now? Don Berwick 00:24:15 Well, I, I, a primary care doctor, practiced for 20 years in general pediatrics and like, I think all doctors, nurses, clinicians, I want to be able to offer my, patients. Don Berwick 00:24:28 drugs that can help, the medications that really do work and that are affordable for them. And we haven't talked much about affordability. So I think the primary care voice here is really important to insist that the research and the developments are going where the patients I see need them to go. it borders a little bit on political comments, but we but, you know, we really do need, outspoken physician communities, beginning with primary care, insisting that the use of science today is the is the necessary foundation for the development of therapeutics of the future. I also think there are probably, even more opportunities in the future for primary care physicians to participate in consortia for, research and development of drugs in the public sector by becoming participants in research projects and others that can benefit their patients. So both as potential beneficiaries of drug development and potential drivers of drug development, primary care can play a very big role here. Right now, the concerns I've expressed several times as interview about what I believe to be this is me personally speaking, extremely unwise cutbacks in our investment in research and development in NIH and FDA and elsewhere. Don Berwick 00:25:43 That's something I think the physician community should be standing up loud and clear about and saying, absolutely not. Science is the foundation of good care, and we insist that that science be supported fully and expanded in some cases. Richard Payerchin 00:25:59 I I'm going from memory, and to be perfectly candid, I don't remember every page of a 245 page report, so I just don't remember. Don Berwick 00:26:07 Making you feel better with that. Richard Payerchin 00:26:08 Thank you. You know, and I and where I'm going with that is I just don't remember if it explicitly did mention about the efforts to make America Healthy again and the leadership of HHS Secretary Robert F Kennedy Jr. How do you want the report to contribute to the new national conversation about making America healthy again? Don Berwick 00:26:27 Well, at a specific level, there is information in the report that you've referred to which shows some areas where we do appear to be underinvested. and for example, if you look at public sector investment, chronic lung disease, low back pain, ischemic heart disease, you know, a very, very common burdens, these don't have investment in public research at the level that you'd think they would. Don Berwick 00:26:58 If you look at, overall disease burden, the reasons are complicated, but I think, Congress, I think, needs to take under advisement where the gaps appear to be. And so should the agencies. the federal agencies right now, the across the board cuts that are occurring in NIH are just going to are going in the wrong direction. So there is some detail in the report on particular conditions that probably deserve more attention. Now, if you look at the private sector, remember that private investment is more difficult to track than public investment. But there are some hints that we are under investing in maternal and neonatal disorders and treatments of those nutritional deficiencies, substance abuse disorders, mental disorders in general, very high burden conditions where the investments in the private sector don't appear commensurate. there is an interesting subcategory we've mentioned before that I'll highlight also again, which is that for some really common diseases like cardiovascular disorders or hypertension, the current drugs available are now commoditized. They're generics. And that decreases the willingness of the private sector to invest. Don Berwick 00:28:21 And if in its wisdom, Congress and the administration say no, we ought to be investing hypertension, still the biggest killer among us in many ways. We're going to have to put money behind that so that it can become interesting for new drug development in terms of where things are now. Again, speaking for myself, I'm extremely concerned about the administration and the HHS secretary contravening science, being willing to support things that are not scientifically validated, and and decreasing investment and trust in really important areas of development, for example, vaccines. So, I guess I have to say, Richard, I'm really worried right now about the direction that things are going. And I'm speaking for myself now, not for the committee. Let's make that really clear. we know what makes us healthy. And it isn't health care. Health care. Repairs, damage done. But damage comes from elsewhere. So if we really wanted to make America healthy again, we would be putting extensive resources where other countries often do. They have much longer life expectancy than we do, for example, into things like early childhood, early childhood education and development, safe birthing, things like education, the, our schools. Don Berwick 00:29:44 That's the source of health. As young people get educated and acquire a talent and self-confidence. Workplace protections, strong unions, adequate, minimum wage structures, reaching out to the elderly so that people who are lonely in their older years have have company, and there are community based resources to help them, safe communities, communities that work on, food security. housing security. communities that work on environmental protections. the biggest threat to human health and the planet. Now, according to the World Health Organization, is is climate change and global warming? Well, unfortunately, as you look at those determinants of health, early childhood, schools, workplaces, eldercare, community resources, this administration is going backwards on the total policy. So it's not in this case, drug policy or medical policy we're talking about. It's the total package of policies. And we are now we are backing away as a country from investing in the things that actually would make us healthy. We need two things. We need health care when we need it, including medications. Don Berwick 00:30:57 But we also need investments in health production. And that's important for the public to understand. We're going the wrong direction right now. Richard Payerchin 00:31:06 This is a question, frankly, I think like literally every interview now we ask about Make America Healthy Again. And then the other question that we ask for every interview is how AI might get involved. And interest in artificial intelligence and large language model programs has really taken off in the last few years. How do you think these new technologies could be used, either in medical research that's needed to fill unmet needs, or maybe determining the greatest areas of need for more study? Don Berwick 00:31:37 With respect to artificial intelligence, I'm kind of bullish on it. I actually think there's some real promise here in the area of therapeutic therapeutic development. the use of AI, including generative AI with very large databases can produce findings and results that no human mind could ever discover. And we in the course of our committee's work, we heard testimony from people from the oncology community, from a rare disease community and others that show that we have adequate, large, privacy protected databases. Don Berwick 00:32:12 AI can point out things and discover things we never could have known before. This is independent of AI's opportunity to help me as a doctor or make better choices. Because I can't read all the medical literature, 30 or 40,000 randomized trials a year. I can't read them, but AI can. And so I think the potential here for bringing artificial intelligence to bear on priorities, on new relationships that could lead to therapies and supporting decision making at the bedside. I think all is very, very promising. Richard Payerchin 00:32:45 I just wanted to ask, sort of an open ended question, if there were any points that we didn't talk about yet that you'd really like to bring to the table. Don Berwick 00:32:53 Yeah, I don't want to again get too technical, but there's a very important part of this report. So when people open this report, they expect to see the list of things we should invest in but aren't. And there are some of those I've mentioned some. And you can find that in the report. But no, we we we did not really swing the bat the whole way, saying, okay, America, here's the ten diseases we should be investing. Don Berwick 00:33:14 The reason is a complex one has to do with values and value structure. For example, there are a lot of rare, very, very serious diseases for which, you know, the number of people that actually have them are measured in the hundreds or thousands, not the millions. If you simply take a utilitarian view and say, well, we're just going to maximize the disability adjusted life years, then then you don't put money into rare diseases. That doesn't sound right to me. People with rare diseases need a shot at that. Cure is being found for them too. So this is a value judgment. And what if you read our report carefully, you'll see we're opening the questions of what are the values that you want to see expressed in new drug development? beyond, you know, some simple, blunt calculation of years of life saved or lost. so there's some subtleties here about the kind of country we want to be. Do you want to be a country in which, if you have a rare disease, this nation is still behind you and still going to invest in in finding cures when rare cures are lacking? My answer is yes. Don Berwick 00:34:16 But, it's a it's a it's a public policy issue that needs to be addressed. Richard Payerchin 00:34:22 Our main audience is primary care physicians. You are one yourself. What would you like to say to them, or what would you like them to know? Don Berwick 00:34:30 They say thank you. Primary care is every successful health system I know in the world, and I've traveled all over the world. It is fundamentally founded on its primary care system, which isn't necessarily just doctors. There are many others that help in the primary care world. So first, thank you. Keep at it and encourage others to keep at it. I but I think my main message overall has got to be now speak up. Speak up for science, speak up for supports to the, dedicated federal agencies that provide the Foundational support and the resources through which we can discover the drugs that are yet undiscovered and find the biochemical by medical mechanisms that we have to use, is foundational for further drug discovery. If the medical community stays silent. Bad things will happen and they are happening now. Don Berwick 00:35:20 So I guess my plea for the primary care community is speak up and speak up. We need your voice more than ever before. Richard Payerchin 00:35:29 That's a great message. And again, I've just really enjoyed our conversation. Doctor Berwick, thank you so much for joining us today. Don Berwick 00:35:35 Thank you. It's been a pleasure speaking with you. Austin Littrell 00:35:46 Once again, that was a conversation between Medical Economics senior editor Richard Payerchin and Dr. Donald Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement and former administrator of CMS. My name is Austin Littrell, and on behalf of the whole medical economics and physicians practice teams. I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with experts sharing strategies, stories, and solutions for your practice. You can find us by searching off the chart wherever you get your podcasts. Also, if you like the best stories that Medical Economics and Physicians Practice published delivered straight to your email six days of the week, subscribe to our newsletters at Medical Economics and Physicians Practice Off the Chart, A business and medicine podcast is executive produced by Chris Mazzolini and Keith Reynolds, and produced by Austin Littrell. Austin Littrell 00:36:33 Medical Economics, Physicians Practice and Patient Care Online are all members of the MJH Life Sciences family. Thank you.