ORLANDO — In his keynote address closing out the 24th Institute for Healthcare Improvement National Forum, Donald Berwick, M.D., former head of both the IHI and the Centers for Medicare and Medicaid Services, urged attendees to take the lead in defeating what he termed "monsters," or the sizeable political and systemic barriers to improving care while reducing costs.

Berwick repeatedly took aim at systemic issues that allow for more expensive procedures to prevail over less costly approaches that achieve similar results, and implored those in the audience to join the battle.

"The operating principle… is get all you can," Berwick said. You can act differently. Aim for fairness. Abandon the plan of keeping all the money you can get. As citizens you can ask the government to draw lines between fair profit and cynical greed."

During the year of travel that followed his departure as chief administrator for CMS, Berwick said he was impressed by quality improvements from the spread of central-line infection bundles in the United States to PDSA work in Dublin. But he said the U.S. health care system still faces sizeable barriers in the long-term challenges of improving care and lowering costs.

"From the viewpoint of scale, getting the changes that will get reeling economies, angry payers and fretful politicians to calm down, we are miles from home," Berwick said.

So what stands in the way? He cited examples ranging from the use of stents when patients have stable coronary artery disease to cost differences in drugs for Medicare patients to argue that the current health care system is still designed to reward volume over value.

"It's much easier to sell the American public on the claim that we need more anything — fill in the blank — than less," Berwick said.

After a contentious year in Washington, of course, that ended after President Obama could not muster the votes in the Senate to get Berwick's permanent appointment approved, Berwick was blunt in his analysis of the political barriers to better care. He argued that many of the improvements needed to improve care and lower costs, from palliative care to Affordable Care Act provisions that incentivize prevention strategies, have been demonized to the extent that they are no longer mentioned as policy solutions. He also took aim at the controversy that erupted after his critics seized on his praise of the United Kingdom's National Health Service.

"Politics isn't going to help us. It's polarized, it's contentious," Berwick said. "Using national exceptionalism as an excuse to blindfold ourselves makes no sense."

Still, Berwick ended his remarks with a charge to attendees to embrace the challenges he laid out, citing the success the Anchorage-based Southcentral Foundation's Nuka model of care as a potential national model for improving care and reducing costs.

"Right now, there's stranded capital, a misaligned workforce and a public belief that confuses volume and technology with healing and solace," Berwick said. "I know U.S. health care leaders are starting to get it, but very few know how to navigate the transitions. Keeping the revenue stream coming and trying to be the last man standing— this cannot work for American [health care] in the years ahead."

I talked to Berwick a few hours before his speech, and he had this to say about the challenges facing the quality improvement community: