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A Fantasy Brought to You by the New York Times: Medicine Without Risk

Sometimes I agree with New York Times’ editorials. Sometimes I don’t. But I rarely learn much from them. To my mind, the problem with the form is that it encourages opining without evidence. So, I admit, I rarely turn to the editorials.

But Buckeye Surgeon pricked my curiosity by referring to a recent New York Times editorial as a “masterpiece of naiveté and contempt.”

Such strong language suggested that the editorial might be entertaining. Thus, I went back and read what turned out to be a piece congratulating Medicare for having decided it “will no longer pay hospitals for the added cost of treating patients who acquire any of 10 ‘reasonably preventable’ conditions while hospitalized. Those include incompatible blood transfusions, severe bedsores, injuries from falls, poor blood sugar control, and infections after certain surgeries.”

This is what I mean about editorials: typically they are monologues that cry out for a good copy editor who asks sensible, logical questions.  The first query that springs to mind is this:  exactly what does “preventable” mean?  How is a “fall” preventable?

If Mr. Smith decides to get out of bed, begins shuffling toward the hallway, feels woozy, loses his balance and falls, how could the fall have been avoided?  Should a member of the staff be stationed not more than six feet from each patient, ready to race in and catch him if he teeters? Or should Mr. Smith have been tied to his bed?  (Thanks to HealthBeat reader Howard B. for his comment on hospital falls about a year ago.)

Personally, I would prefer the risk of falling to the trauma of finding myself strapped to a hospital bed.
Of course if there were a banana peel on the floor, or a clump of green Jell-o, I would agree:  someone was negligent. But that’s not how most hospital falls occur. A patient wants to get up and decides he can make it to the bathroom. Maybe he rings for a nurse, and becomes impatient when one does not materialize within five minutes.  Is the fact that the nurse was busy a preventable “error”?

Apparently the Times thinks so. Because it declares that “The most important benefit will come if the new rules persuade hospitals to work harder to prevent errors and protect their patients.”

Here, let me do a little line-editing. “Hospitals” don’t work hard. People in hospitals—doctors, nurses, administrators—do the work.  If the writer means “the hospital’s administration,” say so.  And, on that point, I would agree: hospital administrators and hospital boards should commit more time, thought and money to reducing problems that threaten patient safety including medication mix-ups, incompatible transfusions, and a high rate of hospital-acquired infections. They need to invest in the systems (including electronic medical records) that could significantly reduce the instances of iatrogenic illness (illness inadvertently caused by medical care.)

As I have suggested in the past, too often U.S. hospitals invest in hotel-like amenities—or monuments to a donor—rather than patient safety.

But the Times doesn’t seem to be talking about administrators so much as staff. For in the very next sentence, it grouses: “The policy focuses exclusively on hospitals, as directed by Congress, and lets doctors off scot-free.”  This seems to suggest that it is doctors (and perhaps the nurses as well?) who need to “work harder to prevent errors and protect patients.”

I wonder if the writer has spent much time in a hospital recently. Has he or she spotted many physicians just lounging about?  Or are the slackers the nurses who, from what I have seen, appear to be multi-tasking much of the time?

Let me suggest that telling staff to “work harder” is not the answer to hospital errors. Most often, patients are harmed because too many people are doing too many tasks under too much pressure—with too little time to communicate properly with each other.

Nor are most mistakes caused by one person. Normally, it takes two, three or four people to hurt a patient. The Times points a finger at the surgeon who leaves a sponge in the patient. What about the surgical nurses who are supposed to count the sponges at the end of the surgery to make sure such a mistake doesn’t occur?

The Times also singles out the “surgeon who operates on the wrong patient.” But how did that happen? Usually because someone else wheeled the wrong patient into the operating room.  And how did that happen? Because someone else misidentified the patient while or after he was being prepped for surgery.  Normally it takes a series of slip-ups to lead to a real humdinger like mistaken identity in the OR.

Except in cases of extreme negligence bordering on the criminal, many of the things that go wrong in hospitals are systems errors.  A patient develops bedsores because the ICU doesn’t have a beeper system reminding nurses that some patients need to be turned every two hours. Even if they have a beeper, nurses may have ignored it because another, sicker patient needed attention.

Hospitals cannot be prepared for every contingency. On the question of bedsores, Buckeye Surgeon observes: “All it takes is 30 minutes of unrelieved pressure from a mattress against your buttocks to compromise capillary blood flow to skin and subcutaneous tissues. Now imagine a 500 pound post op gastric bypass patient flat on her back on an air mattress. It takes 6 people to rotate her every two hours. She gets a pressure sore anyway. At what point was her care compromised? Please demonstrate the error. Ought we to have zero gravity chambers available for such scenarios?”

Finally, Buckeye points out that the notion of a “Never” event is deeply flawed when the list includes “urinary tract infections, surgical wound infections… c. difficile colitis, delirium, deep venous thromboses and other  such events that often arise in the setting of critical illness. Interestingly,” he writes, “you will not find a publishable work of science that describes how to reduce the risk of these events to zero.  Why? Because it’s impossible. If you put a rubber catheter into your bladder, I don’t care how sterilely it’s done, eventually a certain percentage of them will cause a urinary tract infection. It’s a foreign body, for godsakes.”

He has a point. Too often, patients want to pretend that medical care is risk-free. It isn’t. Whenever you choose to enter a hospital, or undergo an elective test or treatment, you are, in the words of Dartmouth’s Dr. Jack Wennberg “making a wager.”  You are gambling that nothing will go wrong, that you will not fall victim to a serious side effect, that you will not be touched by human error.

But in a situation where very ill patients are being treated by groups of sometimes tired, often harried human beings, patients are vulnerable.  Certainly, you have a right to expect that the hospital is doing its level best to reduce the odds that you will suffer harm. But pretending that “never events” won’t happen—or that they can’t happen to you –is just that, pretending.  This is why you and your doctor should always talk about risks as well as benefits before embarking on any medical treatment.

Finally, while I’m an advocate of containing Medicare spending, this doesn’t seem the best way to do it. If a hospital has a very high rate of hospital-acquired infections, I’m not interested in “punishing” the institution by refusing to pay for the extra treatment needed. I want the hospital fixed—or closed down.  Medicare should give the hospital a set amount of time to reduce the rate of infections. If it fails, Medicare should then refuse to send that hospital any more business. (This would, in effect, close its doors.)

As for the serious mistakes that should truly “never” happen (wrong site surgery, for example, or an incompatible blood transfusion), in these cases Medicare should require a thorough investigation, and a report, that is made available to the patient, the patients’ family, and the public, detailing exactly what happened. If someone in the chain has made an egregious mistake, that person should be fired. In any case, the hospital’s system for ensuring that the right patient is getting the right transfusion or the right surgery should be changed. And Medicare should require a second report explaining what changes have been made.

But the idea that refusing to pay individual physicians for “never” events will somehow make our hospitals safer by making doctors “try harder” to avoid harming patients is absurd. Trust me: a doctor’s worst nightmare is that something she or he does will injure a patient. Whoever thought that financial penalties are needed to “motivate” doctors in this area does not understand the profession.

What doctors need are systems that work, and nurses who haven’t been forced to work a double shift to help them do their job. Improving working conditions for nurses and doing whatever it takes to fully staff our hospitals would go a long way toward improving patient safety.

As for hospital administrations and hospital boards: yes, they might pay more attention to adverse events if they know that Medicare will not reimburse if an error leads to additional treatment. But the Times acknowledges that the new policy will not cost hospitals much money at first — “only about $21 million a year.”

Withholding relatively petty amounts of money, over what are often relatively minor mishaps, doesn’t begin to approach the type of structural reforms that our hospitals need.  Instead, such financial penalties are likely to lower hospital morale, dividing staff by encouraging individuals to blame each other for adverse events.

Instead of simply focusing what should “never” happen , Medicare should use positive reinforcement to encourage collaboration and esprit de corps,  by paying lump-sum bonuses for better outcomes—for example,  bonuses that everyone who treated those patients share.

Finally, Medicare should insist that, insofar has hospitals have surpluses or profits, they plow that money into patient safety. Hospitals that want to do business with Medicare should be asked to disclose how they are  investing their surpluses,  demonstrating that, when making financial decision, they are putting  electronic medical records and systems designed to reduce hospital-acquired infections ahead of parking lots, new lobbies,  bridges and new wings. In other words, a hospital’s investment decisions should not be made by its marketing department—nor by the “rain-makers” who want expensive new equipment for their specialty.

First, do no harm.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of  “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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ShannonMaggie MaharBrian Kleppertwabotetourt Recent comment authors
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Shannon
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Shannon

This is a very interesting issue that will have severe long term effects. Im wondering what the political and legal factors will be?

Maggie Mahar
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James, Brian, Mark, Thanks for your comments. James– First, thanks very much for the link to Bob Wachter’s piece. It is excellent. and yes, the term “Never Events” comes from the NQF, which is where I first ran into it. As Wachter indicates, the idea of spotlighting Never events is a good one —the question is, what do you then do about it? The devil is, as he says, in the details. And Wacther points out, many of these errors are not preventable: “Once we leave infection control, the evidence base becomes more tenuous. A number of suggested activities have… Read more »

Brian Klepper
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Actually, in this article Maggie commits the very crime she accuses the NYTs Editorial Page of: opining without supporting information. As several readers point out, there is an extensive literature on successful prevention of “never events,” typically achieved by restructuring systems, not making staff work harder. So Buckeye Surgeon’s righteous indignation notwithstanding, the NYTs is (generally) right, and its usually better to rely on science than anecdote to get to the truth. Also, this is not a small financial issue for health systems, but potentially the most disruptive change in reimbursement policy since DRGs were introduced in 1984. Many health… Read more »

twa
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twa

Why can’t we just trust these hospitals and doctors to do a good job? I mean, after all, these hospitals and doctors have worked very hard over the last 30 years to give us the best health system in the world. Right? Right? But seriously, maybe these measures are not exactly right, but if you have ever worked in a hospital you have to know that there is a tremendous need for external accountability. Of course no individual doctor or nurse or administrator wants to harm a patient. Yet we have systems that allow this to happen every day. Something… Read more »

Mark
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Mark

James, thanks for the reference for ‘never events’. After I posted, I read back through all of the cited articles and couldn’t figure out where the term came from… the NYT and the National Review didn’t use it. The ‘buckeye doctor’ clearly picked it up somewhere and Maggie picked it up from him (her). To ‘botetourt’, I do hope that these regulations prompt a more thorough exam of patients entering the hospital. To miss an existing bed sore or UTI, etc. is certainly malpractice. These exams should improve care. We can’t just treat the admitting Dx and ignore other problems.… Read more »

botetourt
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botetourt

Not to worry–hospitals are prevented from “balance billing” patients for amounts not covered by Medicare–except those charges which are a part of the Medicare “contract”–the inpatient deductible, and co-insurance. Most hospitals are providing a substantial discount to the inpatient Medicare program already–usually a lot more than is received by commercial plans–so any unreimbursed “never” events will only add to that overall discount. This is an example of policy overkill. No hospital wishes to be paid when it commits a gross error–but to lump patient falls, UTIs, pressure ulcers into these categories makes little sense. The toughest part is sometimes figuring… Read more »

James
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James

“The NY Times does not use the term ‘never events’. That comes from the (arch conservative) National Review which, being extremist, takes the concept of ‘reasonably preventable’ and runs it to the extreme to point out the dangers of socialized medicine. (And you seem to have followed it there.)” The term “never events” actually comes from a list published in 2002 by the National Quality Forum (NQF) of 27 items that should never happen in a hospital. The list was later expanded to cover 28 items. The CMS Medicaid policy takes items from that list as items they do not… Read more »

Mark
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Mark

The term is ‘reasonably preventable’. This is a concept that most people can understand. These conditions have been shown to be reasonably preventable through proper staff training and policies. Nobody believes that the incidence of these events can go to zero… but they can be reduced significantly. The NY Times does not use the term ‘never events’. That comes from the (arch conservative) National Review which, being extremist, takes the concept of ‘reasonably preventable’ and runs it to the extreme to point out the dangers of socialized medicine. (And you seem to have followed it there.) (BTW, having lived with… Read more »

Greg
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Greg

Well stated…my biggest worry with this is that if 1) certain “never events” are not truly “never,” in that there is a risk of them occuring even under the best circumstances, and if 2) hospitals won’t be getting paid for them even if they put in place state-of-the-art saftey protocols, then either: 1) the patients themselves will get billed, or 2) the hospitals will raise their fees on everybody to recoup these expenses, or 3) they’ll cut expenses and staff, making nurses and others even more overburdened and placing patients more at risk, or 4) they’ll close doors more often,… Read more »

BarbLibrarian
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BarbLibrarian

Will the doctor’s and hospitals simply bill the patient directly for these expenses if Medicare refuses to pay them? If I am not mistaken, I sign an agreement before medical treatment that makes me personally liable for all expenses not covered by insurance. So, who is being punished here?