Greg Scandlen commented on the Grace-Marie Turner article, and as he’s a big player in the HSA wars, I thought I’d reply back in the main blog rather than in the comments. Greg and his ex-AMA buddies have their nice little "consumer" organization — you did realize that a consumer organization should be founded by ex-insurers and doctors, don’t you? After all they are the people with consumers’ best interests at heart! (Stop singgering in the back there…)
Greg seems to think that I believe that "every dollar currently spent on health benefits was necessary and efficient." Not quite sure that he’s been following this blog closely, such as some of my "criticisms" of physicians, that caused a minor fuss over my use of the term “waste motion” to describe 30% of the healthcare system’s behavior. I of course fervently believe that there’s huge waste in our system, but only a small small fraction of it is in the admin back and forth that happens between insurers and physician offices. That is the part of the “waste” that he thinks HDHPs and HSAs are going to drive out of the system. He is of course wrong, and if he had ever used a HDHP from a major insurer, he’d know.
Unfortunately for the physicians living in their HSA dreamworld, the way that high deductible plans actually work is simply to change who is paying the first few thousand dollars from being the insurer to being the consumer. The fact is that the PPO network and the pricing set up by the insurer is going to continue to be the main vehicle by which assessments against the consumer’s deductible are counted. So the hopes and aspirations of doctors to charge consumers directly without having to submit a claim to the insurer are going to be dashed, unless the consumer is dumb enough to pay up front, and try to get it back from the insurer later. Greg says that “Using an insurance mechanism to pay for routine care is hugely inefficient. It involves massive administrative costs from both the insurer and the provider” and he’s right (Hint: capitation or salaried physician systems don’t have that problem!) But HDHPs are just going to mean that the providers have to come after the consumers instead of the insurers for their money. Unless he really believes that a) consumers are happy to forgo the PPO deals the insurer has cut and pay larger amounts out of pocket, or b) insurers are going to happily count whatever charges providers can get away with against the insured consumer’s deductible, and then be happy to pay any amount above that. No way that’s going to happen….insurers are not that dumb. And if you look in Sunday’s Miami Herald, you see a great example of how this works in practice. And the provider in that case, believe it or not, has it somewhat right:
During the conversation, the billing person mentioned that if Stamm was uninsured and paid in cash at the time of her visit, she would have been charged $125. ”So why can’t you just give me the walk-in rate?” Stamm asked. That wasn’t possible, she was told, since they had to go to the trouble of billing her and attempting to collect.
So what are the consumer’s choices? Go out of network, and have the full amount counted against some mythical huge deductible that they’ll never reach. Go out of network and pre-negotiate the cash rate, which won’t be counted against a deductible at all. Or go in-network and take the pre-negotiated PPO rate which they learn from their EOB. The provider will not know whether or not the deductible has been reached without filing a claim with the insurer, and they’ll go through the same bullshit they do now with the insurer deciding to allow the claim or not, and deciding what the patient should pay. Then eventually the provider will have to come after the consumer for their share. So essentially all this movement does for providers is give them the added role of collection agents. Come to think of that, collections is probably a good business to get into!
The alternative is that the insurer will sell a high deductible policy, pay every dollar after the deductible, and just take it on faith that providers and consumers/patients will only send them the post-deductible bill, and that they’ll be scrupulously honest about the bill they’ve run up below the deductible at usual, customary and of course totally reasonable rates. Get real, people. The insurer has to count up to the deductible somehow! And that means administrative waste!
Meanwhile the rest of Greg’s comments are, I’m afraid, as equally muddled.
And first dollar coverage encourages needless spending. This needless spending can be curbed by rationing, or by demand-side behaviors. We tried rationing with managed care, and it works pretty well to hold down costs, but it was pretty unpopular. So now we’re trying to affect the demand side — getting people to make their own trade-offs.
Even his fellow travelers at Cato admit that most of the “needless spending” happens well past the deductible, (not that they have a solution for it). But apparently we’re only going to get at that with by impacting the demand on the first few thousand dollars of an individual’s spending, even though the literature and common sense show that there’s no market mechanism for that, that the reduction in services received is equally for necessary as well as unnecessary services, and that of course this disproportionately impacts those with lower incomes. But hey let’s do that anyway. It won’t make much difference overall. And while Greg thinks that we may have tried rationing via managed care, we didn’t try it properly (perhaps he missed Enthoven’s rants on the subject), and the insurance industry has shown in the last 5 years that it’s much better at risk-selection and raising prices than doing care management. (I’m in favor of rational versus irrational rationing, but that’s a different discussion).
Meanwhile, I’m still fascinated to discover what the HSA promoters really do believe, beyond those in their number who like making money off heavily underwritten, high-margin HDHPs. In her interview with me Grace Marie was going on about all kinds of non-HDHP related activities. Greg says:
HSAs are not the be-all-and-end-all of health care reform. But they are an enormous step in the right direction, and they will help bring about other changes like a demand for reliable information from consumers, greater accountability on the part of providers, and new more efficient ways of delivering care.
And he wants to promote HSAs in Medicare too! The first part of his plan, which is to convert Part B premiums and the deductible for Part A to one larger deductible, may not be too bad an idea, so long as there is continued help for those for whom the increase in deductible would be a real hardship (those with lower incomes but not dual eligible). After all that concerns private spending on Medicare recipients.
It’s the public spending on Medicare recipients that I’m concerned about. As far as I understand the plan, if a Medicare recipient who chooses to moves to a HDHP gets the difference between what they spend and the average, put as cash into their private account. “Any savings to the Medicare program would be converted into a cash deposit to the beneficiaries’ HSA account.” It’s bad enough HDHPs destroying what’s left of the community-rated risk pool in the individual market, and giving employers an excuse to get out of providing health benefits. But that process was well underway anyway, so honestly it’s not that big a deal — not that I’m going to stop calling its advocates on it.
But now Greg wants to remove money from the Medicare risk pool to give it to healthier than average Medicare beneficiaries.
The per capita premium and deposit would need to be risk-adjusted at least for age and geography, much as CMS currently does for Medicare Advantage plans.
Well here as a tax payer I must object. Every time Medicare has split its risk pool so far, it’s basically handed over more money than “sickness” to the private sector plans. And don’t take my word for it (although common sense and the retreat of private plans from the Medicare program when payments were cut in the late 1990s should be proof enough) because the GAO has said so twice. (Read down here for the details). And now Greg wants us to allow the healthy people to pull out actual cash, leaving proportionately more sick people, more demand, and less money in the traditional program for the taxpayer (or as the current Administration’s accounting would have it, the taxpayer’s children and grandchildren) to pay for. Thanks.
Funnily enough Greg’s being hanging out with Grover Norquist lately (Apr 4 entry here). That whole notion about drowning the Federal Government in a bath tub must be catching. This goes to the whole notion of deliberately destroying a risk pool, except that unlike in the case of the private insurance market where the poor uninsurable sucker gets stuck with the problem of having to deal with the extra costs, this is one that the taxpayer will pick up. I thought these “conservatives” were in favor of lower taxpayer spending! (OK, I know in real life they just are in favor of lower taxes for the very, very wealthy…but that is their rhetoric).
I would still love Greg, Grace-Marie or anyone to take the challenge of explaining how I’ve got my math wrong (read down in this example) when I say that handing out cash into private accounts from a common insurance pool means that someone else has to pay in to the pool to provide care. It’s an explanation we commies have been waiting for, and we’re still waiting. Just because the private market doesn’t really have large community rated pools any more doesn’t make the theory wrong, and when they want to do this to Medicare, they are talking about a large community rated pool.
And if they don’t really believe that HSAs/HDHPs are the “the be-all-and-end-all of health care reform” what the hell do they believe? They don’t seem to talk about much else. Don’t they have an overall policy solution for the market. Their rivals in the single payer and the managed competition crowd do. At least those two groups are having a rational disagreement about how to cure the same problem, and have been saying the same thing since the 1980s. Of course, in our bizzarro world they never get any attention, and the pro-HSA crowd is ruling our political rhetoric.
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The monsters inc line is “your silence is very reasurring”
The monsters inc line is “your silence is very reasurring”
“Anyway, this link to a discussion of HSAs lists seven problems presented by critics. I’d be interested in your response to each. Thanks.”
Steve
Steve,
It’s been a busy couple of months. I’ll gladly respond to your 7 HSA “problems” that you have linked in your post.
1) “Healthcare costs aren’t raising because people go to the doctor too often; it’s because of more expensive procedures still being driven by consumer driven health plans.”
This is partly true. The fact is, everything goes up in price at some point. It’s called inflation and technology. However, the network’s negotiated rates for procedures, office visits, ER visits, UC visits, etc. are considerably lower for a person IN the network ( someone with health insurance and a supporting network of providers ) versus someone with NO health insurance who won’t GET that negotiated rate. The fact that you use HSA funds to pay for these things with PRE TAX dollars can only be a GOOD thing. You get more bang for you buck, and any money you don’t use in the HSA rolls over for next year.
2) “It is doubtful that shifting to higher deductible plans will reduce healthcare inflation, and whether the government should encourage this trend with tax cuts.”
Doubtful? If you go to a higher deductible plan, the insurance company is paying less for you up front. FACT: Most people don’t hit a 500 deductible in a years time. The less money the insurance company pays out, the better for them. They get less premium, but they also have less payout to the client. It’s a win/win, except for the broker above the agent who gets a lower bonus. The government should and IS backing HSA’s because it’s a great benefit, for ANYone, not just the middle class and higher. Why pay more than you have to for health care and health insurance?
3) “It is unrealistic for the typical consumer to make complex decisions about what forms of care are worth the expense, which would result in people not receiving the care they need, including essential preventive medical care. Poorer workers and people with chronic illnesses will suffer the most.”
What? So we’re all stupid? I hardly think so. The problem is that the vast majority of consumers and business owners have been duped into thinking that their current method of providing insurance for their employees is the best way, and it really isn’t. And poorer workers and people with chronic illnesses will suffer the most? The poor have other options. Those with chronic illnesses have other options. Why don’t most people hear about them? There’s no COMMISSION for these plans. What motive does a commission based agent have to tell someone about a plan that he gets no compensation for showing them? It’s all about the distribution model, and it is severly flawed, from top to bottom.
4) “Current healthcare quality indicators used today do not strongly motivate consumer choice of providers{2} The type of information available to for selecting providers is sparse and suspect.{3} And transparency of cost and effectiveness is problematic.”
What does this have to do with HSA’s? Choosing a provider has nothing to do with an HSA. Transparency of costs and effectiveness? Clearly, a politician somewhere who is against HSA’s for whatever reason, wrote this one.
5) “The uninsured people will not be helped because they do not face high-enough marginal tax rates to gain much benefit from the tax deductions. And if many healthy workers to give up their employer-based coverage, it could undermine the entire structure of employer-based coverage in small firms.{4}”
Again, what is the problem? If a person doesn’t make enough money to SAVE enough money… another politician line pandering to the poor. Any pre-tax savings is still pretax savings. IT also makes it easier at year end to do your taxes. Instead of itemizing your healthcare costs, just toss in the amount you put into your HSA on the appropriate line on your return. And undermining the employer based small firms? What in the workd do you think is happening RIGHT NOW? Group insurance plans are KILLING employers. It’s the worst buy in America, with fully funded DENTAL plans coming in a close second.
6) “Families already struggling with high out-of-pocket healthcare expenses will likely have to devote an increasingly larger share of their budgets to healthcare. Even Medicaid beneficiaries, who have generally been protected against high costs, are at risk, and the most vulnerable families may face high debt, bankruptcy, or loss of insurance as consumer co-pays increase.{5} People are significantly greater chance of spending a large share of one’s income on out-of-pocket health care expenses than with comprehensive health plans. {6}”
Ok, so someone high up on the ladder at one of the major carriers must have written this one. If you are an employer, I guarantee you that the majority of your people aren’t using their benefits completely. Why? They don’t need to; they aren’t sick. And I can show you how to keep the same copays for your employees, actually provide the same benefits all the way around, for less out of pocket expense TOTAL for the year, than you are paying now. It’s not rocket science; it’s knowing the rules, and knowing how to play the game. For those that are self employed and NOT part of a group, I’ve got good news. I can save you even MorE money. If you are using an HSA and are married, and are a business owner, I can show you how to REALLY save at tax time and on your bottom line for your healthcare costs.
7) “* While they may benefit young and healthy workers without dependents, the wealthy, and employers who can shift costs to their employees, HSAs hurts others since they run counter to “the premise that the community has a responsibility to care for all members … HSAs are a sham substitute for comprehensive reform.”{6a}”
What?! An HSA can ONLY be a good thing. It’s using pretax money to pay for things. And employers who are shifting more of the cost to their employees don’t have to do that… again, you just need to know all the rules. Obviously, if you think that setting up HSA’s and raising deductibles is putting more risk on your employees, you do NOt know the rules and how to play the game. Anyone here who wants to know how this is possible, needs to email me. I have some information that many CPA’s I meet with… the majority of them… even those who have been in the business for 30+ years…. are not aware exists. Most are shocked to learn what I can show them in terms of what is possible.
In summary, HSA’s are a GREAT method for people to save money. They are best for a young single person. For others who are married, these is another option that is even better for them, especially if they own a business.
Keep in mind, we are looking at two different points of view here. For an employer, HSA plans are good as long as he does not FUND them. Let the employees do that, tax free through their 125 plan. It’s portable, and it’s limited as to how much you can fund.
For a person looking for their own best option, if they are single, an HSA is the best option. If married and own a business or self-employed, there is a much better option that is UNLIMITED and UNCAPPED and provides even more write-offs than an HSA.
There IS no health insurance crisis; it’s all a bunch of hot air being bellowed out by big insurance companies to keep the vast majority of America from asking questions.
“Why are my rates going up for now reason?” Must be the crisis.
Tim Hare
President, TH & Associates
Mason, OH
Please note that I have taken sections of this thread and put them on our virtual forum at Wellness-Plus Forum You are welcomed to join us there.
Great string. Will be adjusting some of my practice based on the points discussed. Take care.
I’ve really enjoyed the discussion with everyone here. I’ve learned a lot and I have thought a lot. I’d be interested in your opinions on my post about P4P on my own blog Treat Me With Respect: P4P is Unethical.
> California is the only state with a staffing law
No, it isn’t. Of course, this won’t solve the problem of the absolute number of nurses.
I wonder if this is the natural experiment to show whether increased staffing actually leads to reduced errors as has been asserted to justify these laws…
t
Tom:
The California Nurses Association pushed through this legislation in 1999. They threatened to strike if it were not enacted.
The California Nurses Association is hardly a group of policy makers, and they were opposed every step of the way by virtually everyone else including the governor. Indeed, in 2005 the California Supreme Court declared the the governor did not have the power to block implementation of the law as he had been doing.
So, California is the only state with a staffing law and it was opposed by virtually every other player in the healthcare system. I don’t think that this demonstrates a concern on the part of policy makers for the well being of hospitalized patients.
> The paper work IS her job, not the care of the
> patient.
> I don’t disagree that paperwork is a problem, but it
> is administrative paper work, not paperwork that
> contributes to the well-being of the patient.
Who says paperwork, even administrative paperwork, does not contribute to the care of the patient? And who says non-administrative paperwork necessarily does?
It is apparently true that nursing tore a page from the software engineering playbook in order to enhance its professional standing. Back around 1980, software engineering got very “documentation oriented” and the mark of the True Profssional became not how much solid, working code he produced, but rather how many reams of documentation concerning the code not (yet) written he’d produced. Only a True Professional would bother with being so very thorough, not like those cowboy code-slingers over there, no sir! I understand the same thing happened in nursing at about the same time, for approximately the same reason. We started getting nursing notes like “I entered Mrs. Smith’s room this morning at 7:23 a.m. to check her dressings and help her toilet. She sneezed once, and seemed sleepy. I said ‘God bless you’…”
But the strategy bit both groups in approximately the same anatomical area. In software engineering, we got Extreme Programming, and in nursing we got Charting by Exception.
> What states have laws about staffing ratios
> and what are the laws? Are the staffing ratios
> realistic?
California, for one. My understanding is the nursing profession lobbied for the law, and I presume the staffing levels are realistic, but I don’t have the expertise to comment. California takes into account both census and acuity at least at a gross level. I know Missouri mandates staffing levels for nursing homes, but I think this was driven by the legislature following the nursing home horror stories of the 1970s rather than by professional groups. The legislation is probably modeled on what other states were doing, and on what the professional groups said ought to be done in their journals. Again, I presume its realistic, but haven’t the expertise to comment.
In any case, your point was that “no one” in policymaking positions has been concerned for making sure there is adequate staff to take care of patients and my point is that this simply isn’t true.
t
Amy: “Are the staffing ratios realistic? Are nurses being floated to departments where they have no experience to meet the staffing requirements? If so, that’s virtually the same as understaffing. Are per diem nurses floating through the hospital from department to department to meet the staffing requirements? That’s also a recipe for disaster.”
If the group is willing to mention additional kinds of troublesome practices and policies typically existing in facilities and doc’s offices, I will compile a list of clinical/patient-related things a transformed healthcare system should change.
Here’s a few I’ve noticed in the mental healthcare field when I was practicing psychology:
• A diagnostic system (DSM) that was largely useless in making treatment determinations
• Insufficient integrated care (i.e., medical and non-medical collaboration; failure to focus on mind-body interaction in the medical field)
• Difficulty determining when an emotional problem had an underlying physiological cause, and visa-versa
• Wide variation in treatment methods/techniques/procedures and lack of a valid, clearcut way to determine the most cost-effective approach for any particular patient
• Lack of an effective system for managing continuity of care
• Lack of precision in prescribing psychotropic meds
• Insufficient services for helping the chronically, severely mentally ill outpatient in the community
• No widespread use computers for diagnostic and treatment decision support
• Lack of clinician-practitioner collaboration and failure to do wide-spread outcome studies in the field
• Use of assessment tools (questionnaires) that gave little insight into the nuances of a patient’s particular problems
• Discharge from hospital often apparently tied to insurance coverage, not patient need.
pgb:
“My presumption that the Harvard data is biased will be hard to prove.”
So, then, we will have to assume that it is true unless someone shows us a good reason why it isn’t.
“I find it interesting that when I am in the OR the OR nurse dedicates nearly 50% of her time to record keeping rather than the care of the patient.”
That’s quite disingenuous. You know as well as I do that it is not the job of the circulating nurse to take care of the patient. That is the job of the anesthesiologist. The job of the circulating nurse to throw out instruments and sponges, to count them and to make sure they are all present at the end of the case. She is supposed to be recording this at all times. The paper work IS her job, not the care of the patient.
I don’t disagree that paperwork is a problem, but it is administrative paper work, not paperwork that contributes to the well-being of the patient.
“But as a PRACTICING surgeon I do have a finger on the pulse of the US healthcare system and have seen the absurdities that have been forced down the throats of the doctors over the past few years.”
That’s not what we’re talking about though. We are talking about whether are healthcare system is in great shape and it’s not. In fact, it is so broken, it boggles the mind. It may be that until you are a patient with a serious illness, you may not realize it.
No one has argued louder than me against some of the administative regulations that are counterproductive and don’t save any money anyway. This hardly leads to the conclusion that doctors aren’t causing quite a few problems on their own. The level of arrogance among doctors can be absolutely horrifying. The bottom line for doctors is that the LAST thing any doctor worries about is the experience of the patient. We’re taught to make patients better and if they have to wait hours to see us, it’s their tough luck.
Do you round at dawn? I’m sure that’s very convenient for you, but it is obnoxious to the patients who deserve to sleep and deserve to be wide awake when visited by those who are making decisions about their care. Do you routinely keep patients waiting hours at a time in your office or the ER? These delays are almost always avoidable if some thought is given to scheduling for patient convenience as opposed to scheduling for income. Do you make patients wait at home for hours before returning their phone calls?
Why am I so sure you do those things? I’m sure because almost every doctor does these things, and I did them, too. There are a million things on the mind of a practicing doctor, but patient experience isn’t one of them.
Tom:
“False — in some places the concern is even enshrined in the civil law in the form of staffing ratios. Hospitals sometimes close floors for a lack of staff, and not necessarily a lack of demand.”
Civil law? What states have laws about staffing ratios and what are the laws? Are the staffing ratios realistic? Are nurses being floated to departments where they have no experience to meet the staffing requirements? If so, that’s virtually the same as understaffing. Are per diem nurses floating through the hospital from department to department to meet the staffing requirements? That’s also a recipe for disaster.
Tom: “we’re trying to do 21st century medicine with 19th century organizational designs and processes.”
PGB: “Causes of the errors are multifacotorial…We now have a separate sheet for IV abx orders that probably is a significant improvement for patient safety.”
So, changing organizations designs and processes — like having a separate sheet for IV abx orders — can reduce errors significantly.
Having healthcare organizations designed to focus on identifying, studying, and learning from mistakes; to put new processes into place based on what they learned; ceaselessly striving to gain new knowledge and implement it in new evidence-based guidelines/standards and innovative (HIT) tools aimed at eliminating errors (improving outcomes) and increasing efficiencies — Now THAT’S what ALL facilities and clinicians ought to be doing!
Learning organizations — continuously evolving, innovating, seeking to uncover problems and inefficiencies and changing the way they do things when improvements are possible — would go a long way in bringing the healthcare industry into the 21st century and solving the crisis we’re in. I just wish it wasn’t so tough for people to let go of the status quo, break inertia, and embrace new ideas and practices.
Who would be the winners and loosers with such a paradigm shift? I know patients would be winners.
Amy:
My presumption that the Harvard data is biased will be hard to prove. But as a PRACTICING surgeon I do have a finger on the pulse of the US healthcare system and have seen the absurdities that have been forced down the throats of the doctors over the past few years. I still use the abbreviations cc and d/c and I am proud of it. I will admit though, the rate of medical errors in my hospital have declined nearly 50% in the past couple of years. So the system is improving.
Steve:
The autopsy study is a great study and probably free of bias due to its design unlike many of the others quoted. Looking at the autopsy study it is quite impressive that 80% of the time the doctors got the dignosis correct. Often times these very sick ICU patients have multiple problems going on so that may account for some of the 20% that were “incorrectly” diagnosed.
Causes of the errors are multifacotorial. I know of one case in my department that occurred before I arrived that involved the misinterpretation of a gentamycin dose IV with the patient receiving 3000mg at once!! Patient survived but ended up with some hearing loss. Why did the pharmacist fill such an order?? Was the doctor’s handwriting that bad? Did the nurse know what a typical dose of gentamycin should be? Multifactorial like I said. We now have a separate sheet for IV abx orders that probably is a significant improvement for patient safety.
Tom:
I think it is already giving.
PGB
> What happened to my Dad is malpractice
And your son!
> There is a limit to the number of patients that
> can be cared for by one person.
True.
> No one seems to be concerned about this.
False — in some places the concern is even enshrined in the civil law in the form of staffing ratios. Hospitals sometimes close floors for a lack of staff, and not necessarily a lack of demand.
> Have you seen any studies comparing
> increased patient processing with safety data?
No — that’s what I was asking about. I bet there was no data collected at all before the 1980’s, so we can’t know whether errors are increasing, staying the same, or decreasing over long spans of time. All we can say is in 1999, there were 100K avoidable deaths per year, and now there are apparently fewer even in the face of increasing complexity(!). But there’s a way to go, and the goal should be zero.
I think we agree on this: we’re trying to do 21st century medicine with 19th century organizational designs and processes. Something’s got to give.
t
Barry: “The key question each group [of stakeholder] needs to ask itself before coming to the table is: what changes are we prepared to make that will cost our group money and/or power in the short run but will make the overall system better for most of us in the long term?”
An excellent question to focus on! Honest answers to this question will surface hidden agendas, perceived needs (both rational and irrational), and help direct sensible solutions.
Tom: “I am not sure incompetent doctors should be punished at all. Malicious doctors, sure. The merely incompetent? I am not so sure. I think a role should be found for them that takes advantage of their knowledge and training, and limits their ability to step beyond their capabilities…I think I am for Harm Reduction rather than punishment.”
Without a doubt! If our goal is to improve care we need encourage accurate outcomes reporting without fear a reprisal and a focus on CQI through learning and objective feedback.
PGB: “I have seen medical errors but not as many as the MSM or some librule think tank will lead you to believe. Bottom line the Harvard data is biased and any study coming from there has an agenda behind it.”
Here’s other research on errors:
• Study shows 44 errors in a 300-bed hospital per day, with 16% being an adverse event ending in death. (Medication Errors Observed in 36 Health Care Facilities, Barker et al. Arch Intern Med. 2002; 162: 1897-1903).
• The number of deaths caused by medical treatment, usually due to physician mistakes and negative drug effects, are between 80,000 (NCQA (2004). NCQA Report Finds Major Gains In Health Care Quality, But Only For 1/4th of The System. Available at http://www.ncqa.org/Communications/News/sohc2004.htm) and 250,000 (Starfield B. (2000). Journal American Medical Association; 284(4):483-5). These deaths were caused by unnecessary surgeries, medication errors, infections, and negative effects of drugs.
• One-third of patients with health problems reported experiencing medical mistakes, medication errors, or inaccurate or delayed lab results—the highest rate of any of the six nations surveyed. Consumer Affairs.Com (2005). U.S. Health Care Most Expensive & Most Error Prone. Available at http://www.consumeraffairs.com/news04/2005/medical_errors.html.
• Studies of autopsies reveal that 20 percent of the time doctors seriously misdiagnose fatal illnesses, so millions of patients are treated for the wrong disease (Leonhardt, D. (February 22, 2006). Why Doctors So Often Get It Wrong. New York Times. Available at http://www.nytimes.com/2006/02/22/business/22leonhardt.html?_r=1&oref=slogin)
PGB: “I find it interesting that when I am in the OR the OR nurse dedicates nearly 50% of her time to record keeping rather than the care of the patient. I believe this fixation with scribbling everything down onto paper in multiple forms with rampant repetition is one of the root causes for mistakes to happen. The eye is not on the ball (ie the patient) and instead is on a piece of paper!”
Interesting point. What are the causes of the errors? Poor diagnostic decisions? Overworked clinicians & understaffed facilities? Assembly-line medicine? Too many distractions? Lack of HIT systems to speed and simplify record-keeping? Lack of clinician knowledge and/or skill? Limitations of the unaided human mind? Invalid practice guidelines? Failure to following valid guidelines? …
“Bottom line the Harvard data is biased and any study coming from there has an agenda behind it.”
Really? Prove it. That means offering actual data, not personal opinions.
Amy:
“The country is currently being bankrupted by the right wing of the Republican party which holds a death grip on the Executive, the Senate, the House, the Supreme Court, etc. blah,blah,blah.”
I did suspect, but now I know what side of the isle you fall on. I am sure you will be voting for Hillary in 2008 and hoping she revamps her failed bid to turn the entire US healthcare system into a big bloated beaurocracy.
“I’m just trying to correct your misaprehension that because you, personally, have not seen many medical errors, you feel free to dismiss the statistics provided by the group at Harvard and by Berwick et al. calculating approximately 100,000 avoidable fatalities per year.”
I have seen medical errors but not as many as the MSM or some librule think tank will lead you to believe. Bottom line the Harvard data is biased and any study coming from there has an agenda behind it.
If you want to talk about “reality”, then the NCHS data speaks for itself and no amount of double talk will hide the results. A success!
PGB
Tom:
“So your dad’s doc didn’t have time to read a damn report because of an evil manager? Two orthopods ignore two distinct episodes of clearly poor progress in your son because they “don’t have time”?”
I am saying that if you increase the number of patients that a doctor must see per day, and if you increase the number of patients a nurse must care for on a shift, and if you increase the complexity of their illnesses, and if you increase the amount of new research data you must master and incorporate, errors are hardly unexpected.
There is a limit to the number of patients that can be cared for by one person. No one seems to be concerned about this. Have you seen any studies comparing increased patient processing with safety data? I suspect that the insurance industry hasn’t even give it a thought.
What happened to my Dad is malpractice pure and simple, and I never suggested otherwise. What happened to my son involves arrogance and impatience and doctors who can’t give each patient the proper amount of time he or she deserves. The current set up of the healthcare industry rewards quick decisions, not accurate ones.
“I am sorry for what happened to your father and son and I do not mean to trivialize that, but you can not base conclusions for the US healthcare system on anecdotal experiences.”
I’m not. I am responding to your statement: “I really turn a jaundiced eye toward all the bad “news” coming out about our healthcare system from the Left about medical errors, etc.” I’m just trying to correct your misaprehension that because you, personally, have not seen many medical errors, you feel free to dismiss the statistics provided by the group at Harvard and by Berwick et al. calculating approximately 100,000 avoidable fatalities per year.
“It is interesting that CNN, ABCnews, and even the dreaded FOXnews do not have this story on their front pages of their websites. This is big news but will be swept under the rug b/c it does not support the MSM agenda that the US healthcare system is in shambles and harms patients!”
Awww, c’mon, this is just too easy. Go to Google News and type in US death rate declines and you will get 343 separate stories on the subject carried in the last 24 hours. Every major newspaper, network and website is covering the story. Blaming everything on some vast left wing conspiracy that doesn’t even exist is not going to fix anything.
The country is currently being bankrupted by the right wing of the Republican party which holds a death grip on the Executive, the Senate, the House, the Supreme Court, etc. Nonetheless, the right wing still has a faux persecution complex. There is simply not a shred of evidence that the fabulous news from the world of medicine is being supressed by the left wing media. I suppose it is part of the same faux conspiracy that is supressing all the “fabuous” new from the mega-disaster that is the Iraq war.
Let’s get back to the topic at hand: the American medical system, costs more, covers fewer people and makes more errors as the years go by. That’s reality. We can argue about who is at fault, but it is infinitely more likely to be various structural issues than some faux conspiracy on the part of the left wing.
On the apparent need for malpractice suit reform. Its short. It says half of malpractice suits are entirely baseless, and only about 4% of people who experience an adverse event or neglect actually sue. With increased transparency, we could eliminate junk lawsuits and have the total number increase ten or twenty-fold. Hmmmmm.
On an apparent success of a wellness program. It is a big population study/intervention aimed at preventing cardiovascular disease. Claims to have reduced MI by 75% in a big population in Finland.
Thanks to Health Wonk Review #5
> My personal suspicion is that many of the medical
> errors are the results of forcing medical
> professionals to be more “efficient” by increasing
> patient loads.
So your dad’s doc didn’t have time to read a damn report because of an evil manager? Two orthopods ignore two distinct episodes of clearly poor progress in your son because they “don’t have time”? With a knowledgable advocate in all three cases? I do not buy it. A PCP missing something, ketosis maybe, during a visit for another problem (maybe a burned hand) because office visits are seven minutes? Maybe I’d buy that.
I see the primary problem in hospitals as inefficient processes, extremely poor communication among completely isolated services, a ton of arrogant turf protection, and some ass-covering by means of obfuscation. There may be also some unprofessional behavior in the face of declining reimbursements: i.e. sacrifice quality experienced by patients in order to protect income levels experienced by docs.
There is plenty of blame to go around for medical errors, and in hospitals I think it falls mainly on managers’ tolerating inefficient processes, extremely poor communication among completely isolated services, a ton of arrogant turf protection, and ass-covering by means of obfuscation. Individual clinicians are in the main doing the best they can in a completely dysfunctional environment, and human frailty being what it is, one cannot be astonished at income-protecting behavior. Those that aren’t should be helped out the door.
I will admit to having a distorted view: nearly all of my experience with hospitals is from a big academic center, and only a little from a community hospital. I understand that smaller hospitals have fewer problems along these lines, but everything I have learned says it is a matter of degree only.
I have not seen evidence that errors are increasing in frequency lately: it may simply be that we know about them now. Have we got any insights on this?
t
We’re living longer, BUT there’s a great disparity in access, our costs are much higher, and we make lots of errors:
“For people with Medicaid or no coverage at all, access to basic care is worsening, as a result of stalled coverage expansions and service cutbacks. An improving economy could forestall further cuts and permit reversal of earlier ones, but progress in closing this rift does not appear imminent.” A Widening Rift In Access And Quality: Growing Evidence Of Economic Disparities. “Not only do Americans pay much more for medical treatment than anyone else in the world, they also bear the brunt of the most medical errors, according to a survey covering the USA, Australia, Canada, Germany, New Zealand and the United Kingdom. Almost 7,000 patients were consulted.” U.S. Health Care Most Expensive & Most Error Prone.
How can this apparent discrepancy be explained?
Well, let’s look at some of the data and conclusions of this mortality research:
• 27% of the deaths are caused by heart disease (the #1 killer), which declined by 6%, largely by use of medications to prevent it. OK, we have better medications and are using them more effectively. I bet this is a direct consequence of evidence-based practice guidelines being followed more closely in this area than before. A plus for better well care practices and science. It makes me wonder if the benefits of well care would have been greater if there is a corresponding decrease in mortality rate of patients who die due to errors and omissions when receiving catastrophic care.
• Life expectancy in the US is up a few months, yet people in many other countries are expected to live several years longer than Americans, despite paying substantially less on healthcare. And American blacks are expected to die several years before whites. Might it be that if we had universal coverage and access to top-notch care for everyone, that our mortality rates would actually exceed other countries?
• There is no indication of quality of life (morbidity) improvement of those living longer. Might it be that we’re living longer, but more miserably? I don’t know.
So, while this is certainly good news, I cannot say US healthcare system is a great success. What I can say is we have great potential to do great things, but many of our policies and practices are inhibiting/blocking realization of that potential.
FYI – I’ve summarized key insights emerging from this excellent conversation at Key Insights from Deep Healthcare Blog Conversation
Steve
Amy:
I am sorry for what happened to your father and son and I do not mean to trivialize that, but you can not base conclusions for the US healthcare system on anecdotal experiences. Just like the raging debate on whether or not to do routine PSA testing for prostate cancer screening, conclusions should be based on hard data. There is no harder data than the death rates for certain diseases. Prostate cancer death rates have fallen dramatically since the introduction of PSA screening so I conclude that PSA screening is good. The deathrates overall and broken down into various disease types have fallen dramatically according to the above data released by th NCHS thus I must conclude we are doing something right. Quite simple. The deathrate data does not lie.
As for medical errors, I agree whole heartedly that things need to be improved, but it is not the extreme emergency that the MSM would like you to believe. I find it interesting that when I am in the OR the OR nurse dedicates nearly 50% of her time to record keeping rather than the care of the patient. I believe this fixation with scribbling everything down onto paper in multiple forms with rampant repetition is one of the root causes for mistakes to happen. The eye is not on the ball (ie the patient) and instead is on a piece of paper!
“Whatever you do, don’t get sick. It’s a nightmare.”
You should have said, “Whatever you do, don’t get sick IN ANOTHER COUNTRY. It’s a nightmare.”
I have been in the hospitals in Europe, Japan and Canada and they ARE nightmares compared to the worst inner city hospital in this country.
“First of all, since when is Fox not part of the mainstream media?”
It is interesting that CNN, ABCnews, and even the dreaded FOXnews do not have this story on their front pages of their websites. This is big news but will be swept under the rug b/c it does not support the MSM agenda that the US healthcare system is in shambles and harms patients! Hopefully the truth will get out!
PGB
“The main stream media will down play this data b/c of their single payer/universal healthcare agenda… I think our healthcare system is in great shape and it appears from this data to be significantly extending patients lives. We really should be the model for all the broken socialized European and Canadian systems. I really turn a jaundiced eye toward all the bad “news” coming out about our healthcare system from the Left about medical errors, etc. From what I can surmise, the parts of our healthcare system that need fixing are those that are controlled by the government (Medicare/Medicade). The free market appears to be doing just fine.”
I’m sorry to say so, but I beg to differ. Have you been a patient lately? The healthcare system is quite broken and it is private insurers who have brought us to this sorry state.
The “main stream media” is running the debate? That’s absurd. The insurance companies, the drug companies, the device manufacturers, large employers who provide health insurance — these people are running the debate and it is a cop-out to blame this on something as completely ineffectual as the mainstream media.
First of all, since when is Fox not part of the mainstream media? Second, although much of the mainstream media is to the left of the American public, they have not had much success in influencing anything. Most of the mainstream media clearly thinks that George W. Bush is a moron and they weren’t able to prevent his election on two separate occasions.
Do not be so quick to blow off medical errors. My own father is dead because of one. In the very hospital where I trained and was an attending, he had a routine pre-op CXR that revealed early metastatic cancer. No one ever looked at the CXR report, and when he presented with symptoms 7 months later, he had massive amounts of adeno unknown primary throughout his chest. He died 8 weeks to the day from his presentation with symptoms, having failed to respond to any treatment.
One of my sons fractured his humerus severely last year. I could barely leave his side because practically every time I looked away, someone (doctor or nurse) made a mistake. The nursing mistakes were trivial, but the physician mistakes were egregious. One orthopod refused to readmit him several days after his surgery even though he was febrile, had shaking chills and pus coming from his external K-wire tracts. The orthopod insisted that he had the flu (!) and that as an obestetrician, I could not possibly understand what an ortho infection looks like. He was readmitted the next day when he was even more ill. (I know, I know, I should have stood my ground and insisted on admission; I learned though.)
After pulling the infected hardware, they fitted my son with a brace to immoblize his arm. He had a dramatic increase in pain after the brace was fitted and yet another orthopod and I argued about it over the course of a day. I insisted that a brace that was supposed to hold the arm in a neutral position should not be painful and ultimately demanded an X-ray. The film showed that the brace had knocked the healing ends of the bone apart and the distal humerus was displaced laterally and upward so that it rode a centimeter above the proximal portion. My son’s arm is now almost a centimeter shorter than it was originally.
I could go on and on and on, but I will spare you. My personal suspicion is that many of the medical errors are the results of forcing medical professionals to be more “efficient” by increasing patient loads.
I am a big partisan of the American physician, but the system as a whole is falling apart. Whatever you do, don’t get sick. It’s a nightmare.
I wouldn’t be so quick to criticize the British and Canadian systems, either. They are attempting to do something we would never dare, using less money then we have in our system. They are attempting to provide coverage for all. We conveniently ignore 40+ million people. We have no business chortling about our shorter wait times when a good portion of the population can’t even get through the front door.
Barry:
The main stream media will down play this data b/c of their single payer/universal healthcare agenda. Ends data is always the true data and cuts through all the politically driven BS. I think our healthcare system is in great shape and it appears from this data to be significantly extending patients lives. We really should be the model for all the broken socialized European and Canadian systems. I really turn a jaundiced eye toward all the bad “news” coming out about our healthcare system from the Left about medical errors, etc. From what I can surmise, the parts of our healthcare system that need fixing are those that are controlled by the government (Medicare/Medicade). The free market appears to be doing just fine. 🙂
PGB
I guess the US healthcare system is a great success!!!
I read this story earlier — very good news indeed.
The story also got me thinking about some of the negative publicity our healthcare system gets for spending a higher percentage of GDP but achieving lower overall life expectancies and higher infant mortality rates as compared to Japan, Canada, and most of the Western European countries. Is the analysis unfair and misleading? Since most of the other countries to which we are compared are far more homogeneous socieities as compared to our diverse society with large numbers of poor, recent immigrants, inner city and rural poor, many of whom may not take very good care of themselves even when adequate medical services are available to them.
I wonder what these statistics would look like if we compared, say, Canadians in the U.S. vs Canadians in Canada; Japanese here vs Japanese in Japan; Germans here vs Germans in Germany, etc. Perhaps Tom could speak to this, but I get the sense that the U.S. may be getting a bit of a bum rap on these metrics.
I guess the US healthcare system is a great success!!!
Officials: U.S. Deaths See Largest Drop in 60 Years
Wednesday, April 19, 2006
ATLANTA — In what appears to be an amazing success for American medicine, preliminary government figures released Wednesday showed that the annual number of deaths in the U.S. dropped by nearly 50,000 in 2004 — the biggest decline in nearly 70 years.
Link to the whole story:
http://www.foxnews.com/story/0,2933,192289,00.html
“Personally, I’d like to see no-fault compensation for all victims of adverse events. That would eliminate the very expensive legal wrangling, and preserve the bulk of each settlement for the actual patient. Furthermore, it would not reward victims for being victimized by doctors as opposed to being victimized by chance.”
Amy, just to clarify, I assume you are talking about medical events only here. If I, for example, were to seriously injure myself as a result of my own stupidity or negligence, I think I would have a hard time arguing that anyone should compensate me except to the extent that my health insurance will cover most of the medical bills, and disability insurance may cover some of the lost wages if I can’t work for an extended period.
Even within medical events, if I go in for a surgical procedure and am told up front that it only has a 40% chance of working and it doesn’t work, is that an adverse event? I know a couple of women who have tried invitro fertilization several times at high cost, and it didn’t work. Is that an adverse event?
Perhaps you could give a couple of examples of adverse events that you believe should be compensated beyond what we might all widely view as probable or at least potential malpractice. If the number of potential cases is dozens of times higher than what is in the current malpractice pipeline, is a no-fault approach affordable even with lawyers fees squeezed out of the system?
I agree most MedMal cases are caused by bad lawyers, but I suppose I am thinking about MedMal awards. Most cases are decided in favor of the docs. But haven’t I read someplace that 50% of MedMal awards are made against (an identifiable) 5% of docs? Something like this? Or maybe I am