By MERRILL GOOZNER
The Obama administration’s commitment to cost control in health care can now be summed up in four words: Not on our watch.
Health and Human Services Secretary Kathleen Sebelius told American women this week that they have nothing to learn from the science that led to the U.S. Preventive Services Task Force guidelines on mammography.Insurance companies won’t change their payment policies, and the independent doctors and scientists who made up the USPSTF task force “do not set federal policy” or determine what services are covered by the federal government.”
What a golden opportunity has been missed to educate Americans about the implications of their health care choices. Otis W. Brawley, the chief medical officer of the American Cancer Society, in an op-ed in today’s Washington Post condemning the USPSTF guidelines, confirms that mass screening would only save at a maximum 600 out of the 4,000 women under 50 who die of breast cancer annually. What he failed to point out is that 1.14 million American women would have to be screened annually for ten years to achieve that goal. To cover the entire cohort (all women between 40 and 49) to replicate that benefit every year would require screening 11.4 million women annually. The cost, at $200 per mammogram (my initial estimate was accurate, according to this New York Times business section article), would come to $2.24 billion annually for the health care system.
I repeat my argument from Tuesday. Let’s start on day one and ask this question: The health care system (you can’t say the government in our mixed public and private payer system) has just come up with an extra $2.24 billion to spend on reducing breast cancer mortality in the U.S. population. Not only that, we get to spend it year after year. Should we spend it on mammography for women under 50? Or should we target that money for free mammograms for women of all ages who smoke, who are obese and who have a family history of breast cancer? Should we target that money to free mammograms for women of color, who have a much higher risk of breast cancer (perhaps because they are more likely to smoke or be obese)?
And as far as the coverage is concerned, I have yet to see a single story that quantified the harms of mass screening. How many false positives and unnecessary biopsies are there for every breast cancer caught early? How many actual, treated positives turn out to be very early stage ductal carcinoma in situ, minor breast duct growths that may dissolve on their own? A recent AHRQ analysis suggested that was about 20 percent of all growths identified during mammograms. According to Greg Pawelski’s most recent comment on GoozNews:
Research by the Nordic Cochrane Centre in Denmark raised questions about the effectiveness of mammography. In a study of 2000 women, they found that one woman would have her life prolonged but 10 would undergo unnecessary treatment and 200 women would experience unnecessary anxiety because of false positive results.
Health care is complex. Most treatments that “work” only work in a fraction of the people who get that treatment. Each has risks, which also affect a subset of those treated. Evaluating value is a trade-off between risks and benefits. Because breast cancer is such a high profile issue, the new mammography guidelines offered the Obama administration a chance to educate the public about the trade-offs involved in making those choices, and how the nation might wring more value out of the money it spends on health care.
Alas, the administration punted. In the midst of a political battle over health care reform, where nihilist Republicans are braying about profligate spending on the one hand and letting nothing stand between you and your doctor on the other, the politicians in charge of health care policymaking saw that offer as one they had to refuse.
Correction: An earlier version of this post mistakenly said there were 4,000 deaths from breast cancer per year among women under 40. I meant women under 50. And Greg Pawelski is not a physian or a Ph.D.
Merrill Goozner has been writing about economics and health care for many years. The former chief economics
correspondent for the Chicago Tribune, Merrill has written for a long list of publications including the New York Times, The American Prospect, The Washington Post and The Fiscal Times. You can read more pieces by Merrill at GoozNews, where this post first appeared.
Filed Under: Merrill Goozner
Tagged: Comparative Effectiveness Research, Costs, Obama administration Nov 20, 2009
Just to follow up on the potential of very high marginal income tax rates and high tax burdens generally to inhibit the economy’s ability to grow and create jobs, I’m reminded of a criticism the late Democratic presidential candidate Paul Tsongas of Massachusetts leveled at his fellow Democrats. He said: “Democrats love employees; it’s employers they can’t stand.” Trying to soak the so-called rich ad infinitum to pay for healthcare and health insurance reform or anything else for that matter, is a dangerous strategy, especially with unemployment and underemployment where it is today. Over the long term, if we as a society really want these programs, the broad middle class will have to pay much of the cost to finance the social programs for the broad middle class and the poor. There are simply not enough rich people to tax at high rates to finance the Democratic agenda while giving the middle class a free ride.
I’m not sure about the right percentage of taxes. I guess it depends on what you get for all the taxes you pay. It is tempting to say that we should keep more of our earnings and have the freedom to decide how to spend it.
That may be true for most goods and services, but it cannot be true for things like education for example. A certain optimal level needs to be provided even to those that obviously cannot pay for it.
Why? If you are a liberal, you would say that it is a social service and everybody has a right to a decent education and a fair chance to succeed and so forth and so forth.
But education for all is also something that serves the rich very well. Without an educated workforce, it wouldn’t be so easy to amass fortunes, so you don’t hear much about socialized education.
How about health care? It is less obvious that universal health care is a necessity for business to thrive. Even on this blog, people often suggest that the poor, which really includes middle class nowadays, should forgo buying fancy goods and pay for their health care first. So instead of buying big screen TVs, or cell phones or a new car, people should prioritize responsibly and buy health care insurance.
Does this sound like a boost to the economy? I don’t think so.
This is why the rich and the large corporations should pitch in and bear a disproportionate part of health care costs. An impoverished population is not good for business. Short term greed is bound to come back to roost in the long term future.
I don’t think that the shrinking middle class can finance much anymore. I wish it could, but for the last few decades the minuscule upper class has been consistently improving its lot at the expense of everybody else and the well is just about dry.
“…everybody has a right to a decent education and a fair chance to succeed…”
Margalit – Of course, they do. The problem here is what do you do when the public education monopoly chronically fails the kids, especially in our inner cities? Suppose Catholic schools, for example, are achieving better results educating low income students at half the cost or less that public schools are spending? If they have extra capacity to take in more of these kids, why can’t we use tax dollars for vouchers to give these students a viable alternative to the failing schools that they’re currently trapped in? The teachers unions staunchly oppose this and their Democratic allies in the Congress back them up. The same is largely true at the state level.
Our Federal Trade Commission expends a lot of effort to ensure that private markets are reasonably competitive. Proposed mergers between companies in the same business have to pass muster with the FTC to proceed. It’s too bad that we don’t apply the same standard to public K-12 education. There is plenty of competition between public and private colleges. Low income students can spend their Pell grants at any school they can get into. Why isn’t the same standard applied to elementary and secondary education? I don’t know about you but I frankly resent having to pay ever higher taxes each year to the State of NJ to support and sustain failure in our inner city schools with no viable alternatives available because of opposition from teachers unions.
As for economic progress or lack of it among the middle class, employer provided health insurance benefits, along with pensions, 401-K plans and other benefits are part of total compensation. The rapid rise in healthcare costs leaves less money available for wage increases. Total compensation (wages plus benefits) grew far faster than wages alone over the last few decades. A considerably higher percentage of compensation is now accounted for by health insurance benefits. Most employees don’t have a clue about how much their employer is spending on their behalf to provide these benefits. If they knew, they might show more interest in shining a light on doctors, hospitals, drug companies, device manufacturers, labs and other providers and ask hard questions about why the cost of these services, tests and procedures are increasing so much faster than everything else we buy.
OK, Obama and congress control my healthcare costs. Just don’t take control of my health, I care. There needs to be a balance of cost cotainment and freedom of choice.
jd
Please tell me you are smarter than this. Texas does not have tort reform. They have caps on awards. Well BFD!! The doc still got sued to get to that point. That is the problem!! Every doc that did not get sued tried to be bullet proof (Lawyer proof). Tests keep docs out of court. Court is not about the truth. It is about shading the truth your way. A normal CT scan or cardiac cath kills a lot of law suits, but they cost a whole bunch. Let me be the doc making reasonable choices and I’ll spend a lot less. Leave me out on the freeway and I’ll spend whatever it takes not to get hit.
Barry,
Public education is not failing because it’s public. There are excellent public schools out there. There are other reasons for inner city failure and those indeed need to be addressed. I am not sure that vouchers to Catholic schools are the answer and I wouldn’t want to see for profit schools.
Since you mentioned vouchers for schools, why not use the same mechanism for health care? Have the government collect taxes, set a minimum acceptable coverage (I’m sticking with basic FEHBP) and provide everybody vouchers to pick the private insurer of their choice. Private insurers will be mandated to accept all comers and provide the minimal coverage in return for the voucher. Anything above the minimum costs money. The government will regulate this one plan only and insurers will be barred from offering anything less, but free to offer more.
Would that pass the free enterprise litmus test? This way all employees are going to know exactly how much health care costs and maybe act to reduce the tax burden.
This would be in addition to all cost cutting measures that everybody is bringing up, and I would include negotiating brand name drug costs on behalf of all insurers.
Margalit – Believe it or not, we’re not far apart. I’ve always liked vouchers conceptually, and if I were starting with a clean sheet of paper, that’s what I would do. As I’ve said before, financing needs to be transparent so people understand exactly how much they are paying for health insurance. I like Dr. Emanuel’s idea of a dedicated VAT, but I don’t think his proposal of a 10% tax rate will raise anywhere near the amount of money he suggests it will after inevitable exemptions for food and other necessities are factored in. We would probably also need a flat tax of 5%-6% or so that I would apply to all income including investment income above the federal poverty level but would cut it off at $250-$300K of income or so. I would ensure that the top marginal ordinary income tax rate above $300K was at least 40%. It is scheduled to return to the 39.6% rate that prevailed under Clinton once the Bush tax cuts expire at the end of 2010.
There are two areas we differ, I think. One is the scope of coverage. I would want to know more about what’s covered and what isn’t in what you call the basic FEHBP. I’m more inclined toward a catastrophic insurance only approach with, say, a $5K deductible for an individual and $10K for a family, though I’m well aware of the arguments regarding the inability of lower income people to afford the deductible. I think it’s more important to keep the overall cost that needs to be covered with tax revenue as low as possible. Also, rather than one size fits all, I would allow people with sufficient income or assets, to be defined, to opt for a higher deductible than the coverage mandate calls for and, in effect, receive change for their voucher if they buy a lower cost policy. People can buy additional coverage if they want to and can afford to.
I note that we almost had national health insurance in 1974 before organized labor prevailed upon Senator Kennedy to kill the bill. Democrats wanted basically what you are proposing in terms of coverage but with a $1K deductible and Republicans wanted a $1,500 deductible. Multiply by a bit over 5 times to translate those numbers to today’s dollars. Since President Nixon was weakened by the Watergate scandal, however, organized labor anticipated a landslide election win in the 1974 elections and thought it would be able to ram a single payer system through over Nixon’s veto. Instead, Nixon resigned in August, 1974, a severe recession set in, and suddenly there was no longer any money for new entitlement programs. In short, Democrats and organized labor overreached and wound up with nothing. Kennedy later regretted not making that deal with Nixon when he had the chance. The message from this saga: don’t overreach.
I would hate to say I agree with MD as Hell (OK, just poking fun), but he is actually correct about Texas. People don’t understand that it is not losing the lawsuit that drives defensive medicine, it is the fear of being sued in the first place, and the undeniable fact that the legal system is a lottery. It is this fear that drives the “unnecessary” testing, plus the fact that medicine is inherently a needle in a haystack phenomenon. That is, in a large haystack of people with headaches, there will be one needle where the HA is caused by something serious like an aneurysm or a brain tumor. When a patient comes in with a HA and literally demands a CT scan, how does the Dr. know if he is the needle or the haystack? And what will inevitably ensue if he is the needle but the CT scan is not done?
That is why tort reform does not reduce costs.
Bev M. D. – Regarding the patient who presents with a headache but there is only a 1 in 1,000 chance or less that it is anything serious, I wonder how physician behavior might change if (1) they had robust safe harbor protection from lawsuits if they follow evidence based guidelines, (2) disputes were handled by special health courts and not lay juries, and (3) insurance didn’t pay for MRI’s under these circumstances.
If a doctor could tell a patient who wanted an MRI that (a) the situation doesn’t call for it, (b) insurance won’t pay for it and (c) there had already been a few cases where patients who turned out to be the 1 in 1,000 that had the brain tumor but didn’t get the MRI sued but health court judges ruled in favor of the defendant(s) on a Summary Judgment basis and (d) those rulings carried the power of legal precedent. If a doctor can’t refuse to order an MRI under those circumstances unless the patient is prepared to self-pay, I would throw up my hands regarding the ability of tort reform to reduce defensive medicine related healthcare costs.
With tort reform, I think doctors also need to be prepared to accept more accountability including being grouped into tiers based on cost-effectiveness and quality with patients being responsible for higher co-pays if they choose doctors and hospitals outside the preferred tier.
Barry Carol,
You are missing the point. I don’t want to be appearing in any court. Period. I also will test any patient to my satisfaction regardless of the tort environment. I have to believe in what I do for each patient. Also part of what I do is decrease anxiety in patients (or parents).
In the dark days when the CT scanner at my hospital was mobile and was only here half the time, there were fewer scans, despite the mantra “if you need it then the distance is no reason not to get it.”
Parents now really demand a CT scan for their child with a head bonk. They would not be in the ED if they had any thought to the contrary. It is starting to be that way with abdomenal pain. The other day I told a mother her child was fine and needed nothing. She was very unhappy. The next day her pediatrician got some normal lab work on the child. The child was fine but the mother never will believe I did enough for her child. No one paid me for the negative impression I made. I would have been the hero getting unnecessary lab work and a CT, all of which would have been normal. This way I am the goat.
If the patient had to pay for the test, they would not be clamoring for unnecessary care.
Don’t empower 50 million more people to stampede the system with their brand new coverage and expect costs to go down.
Barry:
“With tort reform, I think doctors also need to be prepared to accept more accountability…”
MD:
” I don’t want to be appearing in any court. Period.”
And that’s the arrogance of doctors. When Texas instituted it’s tort “reform” it gave more power to the medical board, so guess what happened – doctors didn’t like that oversight as well.
http://www.dallasnews.com/sharedcontent/dws/news/texassouthwest/stories/102007dntexmedboard.31cdc72.html
Does anyone think that if docs were given absolute immunity they would say; gee I can survive on less income, let’s stop doing all this unnessesary fee for service stuff that buys me the vacation homes and strip malls. Does anyone think that hospital budgets could take the hit from the all of a sudden ethical practice of medicine by their doctor staff.
Uh, hang on Peter; we’re talking about CT scans and stuff that have no effect on the doctor’s income. I hear you about marginal surgeries and such, but most defensive medicine has to do with laboratory and imaging tests that do not make any more $$ for the doc – and that’s what the last few comments have been addressing. Don’t go overboard!
Annonymous;
I struggle to come up with one example of a test/procedure that has been proven (with unanimous support) to be of no benefit or harmful in every case
That’s a pretty tough challenge since “proven” and “unanimous” are moving targets (i.e. as evidence comes in, opinions change). However, I would suggest you read about the history of x-ray pelvimetry in difficult labor. There’s a test that at one point in time was widely accepted as a way to prevent significant neonatal and maternal harm. In the long run it was a useless test (no better than a coin flip) and it lead to maternal harm (i.e. unnecessary c-sections) and neonatal harm (i.e. unnecessary radiation exposure)
In support of c3; medical history is littered with such examples. In the 30′s and 40′s for example, the “ideal” contrast medium for x-rays, Thorotrast, was found. Unfortunately it was discovered that it gave patients cancer up to 30 years after its administration…….100x risk for liver cancer, 20x for leukemia, etc.
Just because we are theoretically more advanced now does NOT mean the next Thorotrast is not already upon us.
(I did not find the anonymous statement that c3 quotes, so this may be out of context.)
http://www.washingtonpost.com/wp-dyn/content/article/2009/07/30/AR2009073004285.html
Not including the income needed by hosptials for doing unnessessary tests.
Next time you come to your doctor with a seemingly simple complaint and he/she offers a test to rule out a certain diagnosis tell them no thank you because there is no possibility that you are the needle in the haystack. The only way this will work is when american society is ok with a certain rate of missed diagnosis for these conditions and say if it does happen its bad luck it happened to you, end of story. Life aint fair, cant have it all folks
Yeah Peter, I take the Post and read that article when it came out. Once again, I am not disputing you that some docs are just out to make $$. This is a different issue than defensive medicine practices, however. If you didn’t allow docs to own their own CT scanners or anything else, you would still have a problem with defensive medicine, so stick to the issue.
Bev MD and MD as HELL,
I would be interested in your gut feel level estimate of the percentage of U.S. healthcare costs that are driven by a combination of defensive medicine and trying to placate often unreasonable and inappropriate patient expectations. The liberals would have us believe that it is a very low single digit percentage. My own guess: 10% at a minimum. Throw in Medicare and Medicaid fraud and futile end of life care and we’re talking real money before we even deal with comparative effectiveness and cost-effectiveness research in trying to determine coverage and payment policy.
The caps on damages in Texas are effective at keeping victims out of court. Good luck finding a lawyer in Texas to take a med mal case. Your suggesstion of “health courts” presided over by judges with a medical background smacks of the cronyism that already exists in every regulatory agency involved in the health care industry. From medical boards to the Joint Omission, nobody is protecting the patient from harm. N O B O D Y.
Defensive medicine? Unreasonable patients? And still nobody is discussing the cost of medical errors. Let’s all just ignore that problem and pretend it doesn’t exist.
C3 and bev, all good points and examples. I’m not a clinician (I’m one of those evil insurance types- hopefully I’m an Enlightened Insurer) so defer to your experience.
Your examples raise an interesting thought about the effect that lag of information and practice changes have on healthcare. At a single point in time, a medical service’s value/benefit can be 1. unknown, but believed to be beneficial, 2. confirmed to have known value/benefit and in current use, 3. of dubious value or harmful, and no longer used, or unfortunately 4. of dubious value or harmful and still used. There was a gov’t study (I can’t find it) that estimated that it takes 17 years from the time of a medical discovery to be incorporated to the bedside. I believe it meant it takes 17 years for outdated practices to disappear from the healthcare system entirely too.
It would be a good doctorate study to plot out the universe of medical services to see where they are on this lifecycle of evidence-based validation and utilization and use it to identify ways to speed up this cycle, therefore reducing the time a harmful or useless product/service. I am afraid there are too many serivces out there that are stuck in the the “unproven but believed to be of value” and “disproven but still in use” categories for many many years.
MD as HELL,
I was asking a question because I haven’t dug into the details myself, but have heard that reform was enacted and that it reduced med mal lawsuits, but that practice patterns hadn’t changed.
Peter and LisaLindell raise I think the most relevant point related to costs: if the lawyers have a low-enough cap on their fees, they aren’t going to take many/any lawsuits where they are paid based on the award.
Here is a link on the effect of the legislation that indicates the malpractice reform in Texas went way beyond caps on damages and had a major effect on lawsuits:
http://docisinblog.com/index.php/2009/07/27/texas-tort-reform/
What would it take for clinicians and patients to know with a reasonable degree of certainty whether a particular test, procedure, medication or other action–for a particular patient with a particular condition (or conditions/co-morbidity)–is worth the money (i.e., is cost-effective)? Yes, we already have such knowledge in some situations, but ignorance often (usually?) prevails.
We ought to engage in earnest in an evolutionary, interdisciplinary, worldwide collaborative process of knowledge building, guideline dissemination, and ongoing assessment & revisions that is guided by sound science. And we ought to continue as long a humanity exists. The current day controversy, imo, simply points to that need!
LisaLindell:
You are no longer correct about medical errors. Although it is (too) slow, attitudes concerning these errors are changing. There is movement toward and even some federal and state mandates regarding full disclosure and quality improvement. I just read “Josie’s Story”, by Sorrel King, concerning her daughter’s death by medical error, and the foundation for patient safety which she set up with the settlement money from Johns Hopkins. (www.josieking.org, I believe, is the website). I recommend you read this book. I am retired now but am fairly well read on the patient safety movement and can vouch for the people and events cited in her book, such as Dr. Peter Pronovost, Dr. Don Berwick, and others. In addition, the appendix to the book gives useful information regarding progress and resources in this arena.
Another useful resource is Beth Israel-Deaconess CEO Paul Levy’s blog, “Running a hospital”, which contains several posts regarding quality improvement and patient safety. (Check the archives; I am not sure how to pick out those specific posts).
As I said, it is happening too slowly, but it IS happening.
Bev MD thanks for trying to be helpful but you are not telling me anything I don’t already know. I’ve been a pt safety advocate for the past 6 years, I know who and what everybody and everything is in this movement. I am correct about medical errors. Progress has been painfully slow, way too slow, and medical errors are a significant cost driver. As I have said in other posts, I have a real problem being mandated to finance this industry. You should, as well. We should all be outraged by the amount of money pouring into this industry and should start shining a very bright light on where that money is going and how it is being spent B E F O R E we dig into everybody’s pockets to keep it going. It is pathetic that Sorrel King has had to invest such a chunk of her life to improving the quality of HC after her daughter’s senseless and preventable hospital death. Believe it or not she’s one of the lucky one’s, Johns Hopkins embraced her and worked with her to try and prevent another senseless death. THE MAJORITY of those in the hc industry turn a blind eye and wait us out, just hoping we’ll shut up and go away, often they tell us to shut up and go away. You think Josie is the only preventable death? You think the Quaid babies are the only accidental overdose? See this: http://www.deadbymistake and this http://www.empoweredpatientcoalition.org, the only thing that makes Sorrel unique is she was involved with a hospital who has ethics and honorable intentions. Most DO NOT.
Lisa,
I get the patient out of the healthcare system as fast as possible. That is the only safe play. Hospitals are very dangerous places and getting worse every year.
Lisa;
I am not familiar with you or your posts, but you can choose to be angry and want everything to change yesterday, or you can choose to work with the system and help change it, as Sorrel King has. There are so many problems with health care delivery today, one could spend weeks sitting in a room writing them all down. I do not accept your view that everyone in health care has your worst interests in mind; but a chaotically inefficient delivery system makes errors inevitable. A punitive legal system encourages if not demands silence (I have been there, done that with hospital lawyers.) There is no leadership for change unless mandated by the very federal government you spurn, because the one with the gold makes the rules. Sorry to be a realist.
Bev, how would you work with a system to change it? How would you personally go about doing that when that system tells you to go away? I spurn a government working against me. MD as Hell you are correct, especially teaching hospitals and we’ve been offering that advice for years, stay away from teaching hospitals. Bev, is a decade your definition of “yesterday.” How long are you willing to wait? Lucian Leape asks the same question, you willing to wait 100 years? You’re wrong, there is leadership for change (ie: Don Berwick) but there’s just not enough like him. No customer of any other industry would tolerate lip service and excuses that bad quality is the customer and society’s fault. Why are our standards so low when it comes to health care?
Lisa;
There are many others smarter than me who can explain why the system has not changed faster; Don Berwick being one (see his book “Escape Fire.”) The causes, like errors in all organized systems, are multifactorial. However, here’s how I see it as a retired hospital-based physician. I confine my remarks to inpatient care as that is my area of experience, but what goes on in physicians’ offices (which I have experienced as a patient) is another novel in its own right.
1. The process of taking care of a sick inpatient is recognized as more complex than almost any other industrial delivery system existent (see “The Innovator’s Prescription” by Clay Christensen). Complexity breeds a high number of steps in each process and high number of different people involved, which multiplies opportunity for error.
2. There is NO country-wide unified organized system for improving processes which would reduce # steps and therefore opportunities for error. Make analogies to Toyota’s auto assembly production system or the aviation system for reference. Each hospital is trying, to a greater or lesser degree, but they are all trying their own thing, with much repetition, waste, and failure.
3. There is NO incentive for fixing #2 right now. Reasons:
a. costs lots of $$ and effort. Since improvement is difficult to measure (like measuring improvement in elementary/secondary education), CEO’s do not see any ROI.
b. CEO’s see their primary mission as ensuring the survival of their hospital(s) in a hostile world. Since ROI in (a) is not visible, they regard it as inimical.
Their primary focus is financial.
c. Physicians, although they practice in hospitals (like MD as Hell), do not regard themselves as aligned with the hospital and often see it as the enemy of themselves and their patients. Therefore THEY also have no incentive to improve #2. Since they affect a lot of what goes on in hospitals, such as having the worst record in handwashing, they are part of the problem yet see others as the problem. CEO’s can’t control physicians’ behavior, and the physicians’ peers won’t control it, thus exacerbating #2.
d. Insurance companies only care about minimizing their own risk since they make money by maximizing premiums and minimizing payouts, just as in any other insurance industry. They have no incentive to improve #2 either – just to pick healthy people to cover.
3. The feds, although they have the potential power for forcing quality improvement, have no comprehension of the true nature of the problem and therefore no idea how to use their “gold” (Medicare, or whatever form of $$ they pay out to the industry) to fix it.
4. The medical education system, at both the medical student and residency level, completely ignores systems thinking or formal quality improvement training which would enlighten docs as to how to improve processes and
advocate for improvement to reduce errors.
5. Ditto #4 for hospital CEO’s – if they are trained at all.
6. The current legal system is a blunt instrument which only engenders fear and avoidance behavior without the mechanism to force true quality improvement. It also further pits the docs against the hospitals by trying to find ONE cause for an error, therefore encouraging mutual finger-pointing instead of collaboration for improvement.
I’m sure I’ve forgotten many things, but I see nothing changing until there is universal incentive to change, and I can only see that universal incentive happening, by changing the payment system until only high quality is rewarded and low quality is drastically penalized. This can only happen when physicians, hospitals and insurance companies are forced to cooperate to achieve quality, rather than each pointing at each other. Unless patients start paying for their own care and are able to influence this, the feds are the only answer as, once again, they have the gold.
Bev, patients don’t actually have to pay in order to influence quality. Besides, hospital care is frequently in the catastrophic bracket for most people.
However, if the data was collected and made public (feds can do that), it is likely people would chose hospitals with better records, and if you want to encourage that behavior, reduce the copay for the “good” hospitals. I think Barry was suggesting tiered copays as a way to reduce costs.
And as long as we are talking about preventable errors, why do residents have to work insane hours?
http://blogs.wsj.com/health/2009/11/23/ama-dont-guarantee-naps-for-residents-on-overnight-shifts/
Before anybody says that there aren’t enough of them, why are we not graduating more doctors? Medical schools are turning away thousands of qualified candidates each year.
And why do we limit the ratio of teachers to nurses in nursing school, but no limit on nurse-to-patients? Bev MD, I read the beginning of your long post, I’m not asking why it’s taking so long, I already know why. Lack of leadership. Dr. Berwick has said pretty much the same thing, why are we pouring so much money into hc and not looking at the value we’re getting for our dollar? You’re just not angry enough, Bev MD. Margalit is correct if information were made public, that would be a good start. Patients don’t have a choice and don’t have enough information to make a good choice. Bev MD #1 you are correct, which is why we recommend every patient have an advocate 24/7. Why are advocates kicked out? Labeled as “visitors?” Kept away from physicians? #2 Correct again, so why do we continue to leave this dysfunctional industry to govern thyselves? They’ve done an abysmal job. We accept the status quo? “It’s complicated, some are trying” isn’t good enough for me and shouldn’t be good enough for anybody. 3 4 and 5 correct correct correct. 6. I strongly disagree with you on this one. I agree with your last paragraph, no matter who is paying. My husband was hospitalized for 108 days, it didn’t cost us a dime. I regularly had a laundry list for the insurance case manager of items they should NOT pay for, call it a conscience but I knew this was costing somebody a fortune and his “treatment” (I just can’t call it care) was egregious. Fat lot of good it did, insurance companies just keep passing costs along.
When will Dartmouth report on the cost of medical errors/poor quality? Of those they studied, how many were in their last 2 years of life because of their medical treatment?
Just like Ms. Gur-Arie states about graduating more doctors–as a new-nurse and sick and tired of hearing about the nursing shortage in the U.S…why aren’t there monies invested in more nursing programs? And if the so-called Magnet hospitals only want an RN with a BSN degree and moan and complain that they have a shortage–why don’t the hospitals work out an incentive program with the associate’s nurses to obtain a BSN? I am so confused and angry when I hear that the U.S. is going on a crazed nursing recruitment from the Phillipines and other countries to “fill the nursing shortage gap”. There are so many nurse graduates –recent graduates who cannot find employment. Even President Obama recognizes this. First employ the U.S. citizens then look past our borders for help. My co-grads and i included are ready willing & able to work hard in hospitals.