Two recent publications address the failures of our medical practitioners and health care institutions. After reading them, all I could think of was Pogo, the Walt Kelly comic strip character (more on that later). The first article is the September 2012 report from the Institute of Medicine analyzing the cost of waste today in health care (OT, 10/10/12, and see excellent graphic summary posted by Sarah Kliff, Washington Post, 7 Sept 2012). The numbers are astounding and almost too large to believe, but data in IOM reports are reliably solid. A summary follows:
America spent $2.6 trillion on health care last year; a full $750 billion—one-third—did nothing to make anyone healthier. Here is a list of the causes for waste and their projected bite out of the health care dollar spent.
- Fraud: $75 billion
- Excess administrative costs: $190 billion
- Unnecessary services: $210 billion
- Inefficiently delivered services: $130 billion
- Excess administrative costs: $190 billion
- Prices that are too high: $105 billion
- Another analysis focuses on the care of the elderly, who often have the most care and the more complex medical problems. Three of the findings are that:
- less than 50 percent of elderly patients are up to date on clinical preventive services (e.g., immunizations);
- elderly patients with co-morbidities require up to 19 medication doses daily (greatly expanding the chance for error and negative drug interactions); and
- one out of five elderly inpatients is readmitted within 30 days.
The IOM report, rather than fingering specific caregiver groups or health systems, blames this waste mainly on a faulty system of care: a lack of coordination of care, inefficient and wasteful administration, failure to share patient data with the next doctor, a lack of transparency, and so forth.
The system of care is faulty, to be sure, but let's be honest about this data. Doctors write the orders, doctors refer patients to multiple specialists, doctors do the surgery, and primary care doctors have the lowest income (along with pediatricians and psychiatrists) in the profession because they have no technical sources of income like surgery, chemotherapy resale and administration, or radiology or radiotherapy services.
It is abundantly clear that when technical services such as imaging are brought into a surgical or medical practice, usage of imaging, for example, goes up dramatically and all partners enjoy extra financial gain. The system of reimbursement encourages this behavior but who is ordering the tests?
One might defend the current system by saying that “we provide superior care.” But the IOM report goes on to describe specific wasteful practices along with what proven existing models from other industries could do to mitigate or remedy the problem. Here are a few:
- In health care, 20 percent of patients reported that test results or medical records were not transferred from one place to another in time for an appointment. Online banking allows customers to view their entire financial history and conduct transactions in seconds; patients should have real-time access to their medical records and use technology to streamline administrative tasks.
- In health care, one-third of hospitalized patients are harmed during their stay and one-fifth of Medicare patients are re-admitted within 30 days. Hospitals and providers should constantly assess performance and learn (and change) from experience to reduce errors and harm.
- In health care, 63 percent of patients don't know the cost of their care until they receive a bill, and 10 percent never find out the cost of their care. Patients and clinicians should have easy access to prices of tests and procedures and to reliable information about care outcomes and quality. Consumer Reports, a non-profit organization that accepts no ads in its publications, has been doing this for washing machines and autos for decades. How much more important for one's health care such a system would be.
This does not look like superior care to me, and the means and models for making these improvements are not mysterious trade secrets, but rather, common-sense solutions that work in other industries. But doctors and hospitals are paid irrespective of the level of quality or efficiency and whether the patient is harmed or not. Any normal service industry would quickly go out of business if that approach were used.
‘How to Stop Hospitals from Killing Us’
The second publication, by Dr. Marty Makary, a surgeon at Johns Hopkins and co-developer of the checklist in Atul Gawande's The Checklist Manifesto, is entitled, “How to Stop Hospitals From Killing Us” (Wall Street Journal, 21 Sept 2012). In that article and in his book Unaccountable: What Hospitals Won't Tell You and How Transparency Can Revolutionize Health Care (9/12, Bloomsbury Press, ISBN 1608198367), he points out that when an airplane crashes in the U.S., even a small one, it makes headlines. There is a thorough federal investigation, and the tragedy often leads to important information for the aviation industry so pilots and airlines learn to do their jobs more safely.
American medicine is far deadlier: Medical mistakes kill enough people each week to fill four jumbo jets. No headlines, no federal (or often any other) investigation; these incidents go largely unnoticed by the world at large. The same preventable mistakes are made over and over again and patients are left in the dark about which hospitals have significantly better or worse safety records than their peers.
As doctors, we swear to do no harm. But on the job we soon absorb another unspoken rule: to overlook the mistakes of our colleagues. The problem is vast. U.S. surgeons operate on the wrong body part as often as 40 times a week. Roughly a quarter of all hospitalized patients will be harmed by a medical error of some kind.
If medical errors were a disease, they would be the sixth leading cause of death in America—just behind accidents and ahead of Alzheimer's. The human toll aside, medical errors cost the U.S. health care system tens of billions a year. Some 20 to 30 percent of all medications, tests, and procedures are unnecessary, according to research done by medical specialists surveying their own fields.
Makary says, “It does not have to be this way. A new generation of doctors and patients is trying to achieve greater transparency in the health care system, and new technology makes it more achievable than ever before.”
He believes that five relatively simple, but crucial, reforms would be a good start toward keeping patients informed of the important issues that impact the quality and safety of their care with the added benefit of improving the quality of care.
The following recommendations can be found in greater detail in his book, but these are brief excerpts:
Every hospital should have an online informational “dashboard” that includes its rates of infection, “premature” readmissions, surgical complications, and “never event” errors (mistakes that should never occur, like leaving a surgical sponge inside a patient).
The dashboard should also list the hospital's annual volume for each type of surgery that it performs, including outpatient and minimally invasive surgery, and patient satisfaction scores. (I disagree with Dr. Makary on the latter measure; in my experience, patient satisfaction scores are often influenced by the same “off-point” issues he notes—parking availability, bedside manner, geographic convenience, family ties to the doctor, and so on—that are important to patients, but tell us nothing about the medical quality of care.) “Instantly, New York heart hospitals with high mortality rates scrambled to improve; death rates declined by 83 percent in six years.”
“Cameras are already being used in health care, but usually no video is made. Reviewing tapes of cardiac catheterizations, arthroscopic surgery, and other procedures could be used for peer-based quality improvement. Video would also serve as a more substantive record for future doctors. The notes in a patient's chart are often short, and they can't capture a procedure the way a video can. They are being taped and reviewed to learn whether steps were not taken or the standard of procedure was met, including hand washing. This can be very effective for correcting rushed or inadequate procedures.”
Cameras offer a unique learning experience, like a football coach reviewing the films of games to see in detail what was done well or poorly.
‘No More Gagging’
“Increasingly, patients checking in to see doctors are being asked to sign a gag order, promising never to say anything negative about their physician online or elsewhere. In addition, if you are the victim of a medical mistake, hospital lawyers will make never speaking publicly about your injury a condition of any settlement.
“We need more open dialogue about medical mistakes, not less. It wouldn't be going too far to suggest that these types of gag orders should be banned by law. They are utterly contrary to a patient's right to know and to the concept of learning from our errors.”
What Walk Kelly Said…
So what about Pogo? Walt Kelly drew a comic strip in 1971 in the early days of the environmental movement. Pogo and his friend decide to take a walk in the woods to enjoy the views and environment. Soon they find the trails and surroundings befouled by human trash and the walk becomes painful. In the last panel, Pogo says, “We have met the enemy and he is us.”
This is exactly how I feel about shoddy medical care. Unless physicians, their professional organizations, and health systems get serious and require a high standard of care, nothing will change. I believe that public disclosure of how doctors and hospitals fare in key quality measures and key transparency issues would be the best antidotes. That certainly worked for cardiac surgery in New York.