The Profitability (or Not) of Harming Patients

millenson-headshotWhen the government announced recently that a patient safety partnership with hospitals had saved 87,000 lives and nearly $20 billion over four years, there was an oblique reference to the role played by “financial incentives.”

Left unsaid was that a quiet effort has been going on for years to persuade hospitals they can make more money preventing harm than by allowing it to occur. In recent years, that’s included articles in the medical literature looking at the profitability of preventing serious bloodstream infections in critically ill infants in the neonatal intensive care unit(NICU) and in kids with leukemia.

For adults, there have been analyses of the financial impact of serious infections and surgical complications. In a presentation I heard earlier this year, a vendor mentioned the return on investment (ROI) of a technology that more rapidly detects when a post-surgical patient unexpectedly stops breathing.

These appeals to the bottom line (coupled with mention of the moral imperative, of course) stand out even more when one considers the context. It was back in 1999 that the Institute of Medicine issued its landmark To Err Is Human report estimating that up to 98,000 Americans died each year from preventable errors in hospitals. The IOM set a ten-year goal of reducing that number by half.

Yet by 2010, a New England Journal of Medicine study that merited page one New York Times attention found no substantial progress. I attributed the decade’s dearth of death reduction to a combination of the invisibility of error (it’s often not egregious), clinical inertia and income. Since then, preventable death estimates have gone as high as 400,000 a year; about 100,000 deaths and more than 1 million injuries is a conservative figure. A study published just two months ago found medication errors in half of all surgical procedures.

To be clear: no one is accusing hospitals ever deliberately ignoring imminent hazards. But most patient harm isn’t precipitated by loose-hanging wires or loosely qualified doctors and nurses. It results from a series of small, “less-than-best-practice” problems that ineluctably add up to avoidable patient injuries and deaths. Fixing them requires time, money and consistent clinical and management commitment.

As recently as 2006 the Society for Healthcare Epidemiology of America (SHEA) felt that to obtain that kind of support it had to teach its members to make the business case for infection control. “While society would benefit from a reduced incidence of nosocomial [treatment-caused] infections,” the society noted, “there is currently no direct reimbursement to hospitals…funding infection control activities.”

“No direct reimbursement” was a euphemism. As another physician noted in a journal article that same year, “a tacit but potentially significant barrier” to hospital management support was “a widespread but unsubstantiated belief” that serious infections substantially raised reimbursement.

Michael Millenson is a patient safety advocate and the president of Health Quality advisors

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