Archive for the ‘Healthcare’ Category
Blair Hickman discusses patient checklist for hospital safety
Very interesting ProPublica article by Blair Hickman:
Propping up a patient’s hospital bed at a 30-degree angle can help prevent hospital-acquired pneumonia. Using alcohol wipes kills staph bugs, but you need bleach wipes to kill C. diff germs. High-protein snacks can help prevent bed sores.
However, most patients don’t know these things. And doctors and nurses can easily overlook these basic care practices.
Karen Curtiss makes it her mission to remind them. After her father and husband both experienced adverse events in the hospital, Curtiss says, she founded Campaign Zero to arm patients with the information they need for a safe stay. Her book, “Safe & Sound in the Hospital: Must-Have Checklists and Tools for Your Loved One’s Care,” collects scores of these simple actions and details that can make a big difference in a patient’s recovery.
Checklists have become more common for surgeons in the operating room. But according to Curtiss, she’s the only one producing checklists on hospital care for patients and families.
To make the checklists, Curtiss read everything she could get her hands on: nursing textbooks, information from the CDC, academic publications. She took her work to specialists and focus groups. And then distilled all of the information into something so simple a sixth-grader could read it.
We sat down with Curtiss, who is a member of ProPublica’s Patient Harm Community, to find out more about patient-centered checklists.
Why checklists?
Conventional wisdom says that when you go to the hospital, you take someone with you. However, nobody is prepared. There’s nothing in college that teaches you how to be an advocate. There’s nothing in your life experience. We have an army of people sitting bedside, who are ripe for education.
We put a checklist out on Campaign Zero, but I could tell from the traffic that people were finding it only after a problem had occurred. They were Googling bed sores and how to treat them, staph infections. People do not prepare to be sick. So I wrote the book.
I learned during my research that there are repeated problems that put people back into the hospital that nobody ever tells you about. For example, if you have congestive heart failure, you need to weigh yourself every single day. If you gain two pounds in a day, you have to get to a doctor right away.
But I don’t know how many people are told that. Even if you are told that when you’re discharged, many people are still on drugs and not thinking clearly. And it’s a hurried process. They need someone there with faculties intact to ask the questions, sweat the details, know what to look for and be encouraged to ask questions. The simple affirmation that it’s OK to ask questions makes people more comfortable.
Furthermore, we know checklists work. Atul Gawande, the author and surgeon, wrote in “The Checklist Manifesto” that the ideal checklist is no more than ten items. And they are effective. It’s been proven with other checklist projects, some that are being rolled out throughout the country.
So I said OK, if checklists work for the medical community, then they can work for families. It’s a potential win-win.
A lot of people in ProPublica’s Patient Harm Community say that when they ask questions, providers push back. What would you say to them? . . .
How hospitals kill patients
Of course, hospitals don’t kill patients, hospital staff kill patients—and not intentionally. Marshall Allen recounts in ProPublica a new doctor’s account of how her mother died in a (good) hospital and the many errors that (she believes) hastened the death:
For Dr. Elaine Goodman, the strongest lessons in patient safety didn’t come from her training. They came from her mother’s death.
Goodman had just finished her first year of medical school when she found herself spending months at the bedside of her 63-year-old mom, who was battling breast cancer in the hospital.
One morning she arrived to find her mother’s face and hands bloodied. Hallucinating and disoriented, her mom had yanked the cranial staples inserted during a recent procedure from her head.
Another time, a stethoscope fell on her mom’s face and gave her a black eye. She suffered frequent falls and preventable side effects from drugs. And she narrowly missed having an unnecessary brain operation and getting an incorrect drug.
“It was really eye opening for me to see the reality of how difficult it was to keep her safe in the hospital,” Goodman said. “It’s not enough just to have caring, qualified people to keep the patient safe.”
Goodman believes the incidents hastened the decline of her mother, who died in 2008 after six months in the hospital. A Harvard Medical School grad, Goodman is now a second-year resident in internal medicine and primary care at Brigham and Women’s Hospital in Boston.
Goodman shared her story after completing our Provider Questionnaire, part of our ongoing reporting on patient safety. ProPublica confirmed details of her mother’s story with one of the physicians who treated her and by reviewing her records. This interview with Goodman has been edited for clarity and length.
What did your experience with your mom teach you about medicine?
The hospital she was in is a nationally ranked hospital near Seattle. It wasn’t that we felt the place was not up to snuff or not capable of providing good care. But I hadn’t realized how hard it is to keep a complicated patient safe in the hospital. The harm is rarely caused by actual negligence. The vast majority of cases involve a lot of people doing fairly reasonable things, and somehow something just falls through the cracks.
One day my mom fell out of bed in middle of the night. They had bed alarms to notify nurse if a patient starts to fall out of bed. But there’s also a chair alarm, and the nurses showed us that there were only enough electric outlets for one alarm at a time, and the alarms had identical cords – making it hard for the nurses to tell which alarm was plugged in. The day my mom fell, the wrong alarm was plugged in.
There are lots of easy solutions to this. They could make the cords different. Or they could have two outlets, so both could be plugged in. I certainly hadn’t thought about that as a medical student, but all of a sudden it became the most important thing in my day when my mom was in the hospital.
Medication errors were frequent. My mom was on a seizure medication that needed the dose adjusted according to her nutritional status. The physicians probably knew this, but with all the handoffs, a new doctor would come in, see the drug level was low in her blood – and without carefully observing her nutrition – and then up the dose. She was being accidentally overdosed on the medication which caused her to sleep for days. As somebody who has a life expectancy on the order of months, those days were very important to us.
The biggest error related to her chemotherapy, which was administered by a device straight into the fluid of her brain. They’d give her the chemo about once a week, and it was supposed to last an entire week. One weekend her normal oncologist wasn’t on so the covering physician administered the chemo. About a week later her normal oncologist came to us in tears. She’d discovered that her colleague had not administered the right chemotherapy drug, and the type she’d received had only lasted a day, not a week. My mom had effectively gone for a week without getting any treatment. For her this probably didn’t change her life expectancy drastically, but it probably changed it a little bit. But this event itself was really terrifying. It had the potential to make a huge difference in the life expectancy of other patients.
How did the hospital doctors and officials respond? . . .
Making sure nonbelievers follow the rules of your own religion
And yet I wonder whether those involved are willing to follow the rules of religions in which they don’t believe. Katie McDonough reports in Salon:
Last year, a pair of researchers at North Dakota State University won a $1.2 million grant from the U.S. Department of Health and Human Services Administration for Children and Families to start a sexual health program aimed at preventing pregnancy and sexually transmitted diseases in at-risk teens.
But as Kate Sheppard at Mother Jones reports, the school had contracted Planned Parenthood to provide the services, and antiabortion activists in the state started complaining about NDSU doing business with the nationwide women’s health — and in states other than North Dakota, abortion services — provider.
“When I see something that says this is Planned Parenthood — they’re not even a part of the state of North Dakota. They don’t serve anyone in North Dakota, and they shouldn’t be a part of North Dakota. They’re not a part of how we do business in this state,” said Rep. Bette Grande on a local radio show denouncing Planned Parenthood and NDSU. “It is an overt abortion industry that we don’t want to be a part of,” she added.
The uproar over the partnership soon reached NDSU officials, who quickly soured on the contract.
According to Sheppard:
On Jan. 15, NDSU President Dean Bresciani said on a conservative talk radio showthat the school had decided to block the funds, citing a “legal hang-up” that prevents the school from working with Planned Parenthood.
As the local newspaper Forum of Fargo-Moorhead reports, NDSU now says that it is “freezing” the grant while it figures out if it violates a 1979 state law that bars state dollars, or federal dollars coming through the state, from being used “as family planning funds by any person or public or private agency which performs, refers, or encourages abortion.”North Dakota Catholic Conference praised NDSU for making “the right decision,” and it got glowing reviews in the anti-abortion outlet Life Site News.
Professors and local reproductive and sexual health advocates balked at what they considered a purely political interference with research — and health service delivery.
According to a statement from Thomas Stone Carlson, president of the Faculty Senate:
We are aware that you have received significant pressure from legislators (Betty Grande and Jim Kasper in particular) who have political agendas that oppose the work of Planned Parenthood. The announcement of your decision to freeze this funding on a conservative talk show and the quick response of several conservative groups thanking legislators for this important victory against Planned Parenthood, makes it difficult to see your decision as anything other than bowing to political pressure.
Critics of NDSU’s decision to return the grant say it is the North Dakota teens who were the target of the program — youth who are homeless, in foster care, or in the juvenile justice system — who stand to lose the most in the botched partnership. As Sarah Stoesz, president of Planned Parenthood Minnesota, North Dakota, South Dakota, told Mother Jones, the funding would have served as a “lifeline for kids that don’t have other options.” Adding, “To turn away the grant on an ideological basis really just defies logic, particularly in North Dakota, where there is so little available to at-risk youth.”
“Best healthcare in the world” — not
WEALTHY it may be, but healthy it is not. The US population experiences poorer health at all stages of life than the populations of 16 other rich countries.
Despite leading the world in pioneering anti-smoking laws, cancer screening and controlling high blood pressure, the US trails its richer “peer” countries in almost all other measures of health and longevity, says a US National Research Council report published last week.
At 75 years, men in the US have the lowest life expectancy in the group, while women have a life expectancy of 81 years – higher only than Denmark.
In nine categories of ill health ranging from infant mortality rates to the prevalence of sexually transmitted disease, US citizens consistently came at or near the bottom of the table.
“I was stunned by how pervasive the disadvantages were across so many factors,” says Steve Woolf of Virginia Commonwealth University in Richmond, who chaired the report panel.
Woolf and his colleagues say that the problem is less to do with faults in the US health system, and more to do with behaviours that put US citizens at greater risk. “They consume the most calories per person, have higher rates of drug abuse, are less likely to use seat belts, and are more likely to use firearms in acts of violence,” says Woolf.
Financial Markets Agree With President Obama and Disagree with Paul Ryan
Dean Baker notes the difficulty Paul Ryan has in dealing with facts:
It probably would have been useful to remind readers that Representative Paul Ryan’s claim that country is facing a fiscal crisis is sharply at odds with the views of market participants in a NYT article reporting on his latest interview. The article quotes Ryan:
“I don’t think that the president thinks that we actually have a fiscal crisis, … He’s been reportedly saying to our leaders that we don’t have a spending problem, we have a health care problem. That just leads me to conclude that he actually thinks we just need more government-run health care.”
Of course the fact that investors are willing to lend the U.S. government trillions of dollars for long periods of time for interest rates of less than 2.0 percent indicates that the markets do not believe the United States has a fiscal crisis. Also, it is a fact that if the United States had per person health care costs that were at all comparable to those in other wealthy countries that it would be looking at long-term budget surpluses, not deficits.
It would have been worth reminding readers that Mr. Ryan has no evidence to support his assertions that the United States somehow has a fiscal crisis or that fixing our health care system would not address its projected long-term deficit problem. Readers might be mistakenly led to believe that Ryan’s position has a basis in reality.
Some interesting comments at the link.
To what extent can the religious demand that non-believers obey the religion
This is a genuinely tricky issue because each religion has dictates that are indeed accepted by those who are not adherents of the religion. For example, almost all religions prohibit murder, and nonbelievers generally also reject murder, so there is considerable overlap among the various religions and also the nonreligious for this particular dictate. The same goes for theft and adultery.
But when the religious belief requires, say, eating only a vegetarian diet, do members of the religion have a right to demand that nonmembers discontinue the eating of meat? Or would Jews and Muslims be right in forbidding Christians to eat pork?
I think most would say no. And yet the Catholic church will do anything in its power to prevent non-Catholics from using birth control, up to and including letting HIV continue to spread and kill people (as in the case of Africa, where the Catholic church has fought to prevent the use of condoms). And those whose religious beliefs require them to not use abortion seem determined to force even those who do not share that belief to obey it, despite the legality of abortion in this country—a country in which many believe an abortion is a matter of individual choice.
In the case at hand a number of people are determined, based on their own religious beliefs, to prevent company insurance plans from providing perfectly legal contraception services to those who do not share the religious beliefs. Their beliefs (in their view) are that it is not enough simply for themselves to adhere to their religious dictates, others must obey as well.
The only saving grace is that these same people observe the principle of reciprocity and they themselves adhere to rules imposed by other religions—for example, the people demanding that others not use contraceptives or abortion are willing to eschew meat (and particularly pork), pray 5 times daily in the direction of Mecca, and so on. Since they demand that their religious beliefs be imposed on others, they themselves are willing to accept the imposition of beliefs from religions that they do not hold. Oh, wait…
Alternatives to abortion rights
As the Right Wing closes down legal abortion clinics through legislation designed to make their operation too costly, we should be looking at where we’re headed once safe and legal abortions are unavailable. Kate Manning has a good summary in her op-ed in the NY Times:
WHY would a woman put a leech inside her body, in the most private of female places? Why would she put cayenne pepper there?
Why might a woman swallow lye? Gunpowder? Why would a woman hit herself about the abdomen with a meat pulverizer? A brickbat? Throw herself down the stairs?
Why would she syringe herself, internally, with turpentine? Gin? Drink laundry bluing?
Why might she probe herself with a piece of whalebone? A turkey feather? A knitting needle?
Why would she consume medicine made of pulverized Spanish fly? How about powdered ergot, a poisonous fungus? Or strychnine, a poison?
Why would she take a bath in scalding water? Or spend the night in the snow?
Because she wanted to end a pregnancy. Historically, women have chosen all those methods to induce abortion. The first known descriptions appeared around 1500 B.C. in the Ebers Papyrus, an ancient Egyptian medical text that mentioned an abortion engineered by a plant-fiber tampon coated with honey and crushed dates.
For most of history, abortion has been a dangerous procedure a woman attempted to perform on herself. In private. Without painkillers.
What is most striking about this history of probes and poisons is that throughout all recorded time, there have been women so desperate to end a pregnancy that they were willing to endure excruciating pain and considerable risk, including infection, sterility, permanent injury, puncture and hemorrhage, to say nothing of shame and ostracism. Where abortion was illegal, they risked prosecution and imprisonment. And death, of course.
The newspapers of the mid-1800s were full of advertisements for potions, pills and powders that claimed to cause miscarriage. “French Periodical Pills: Warranted to Have the Desired Effect in All Cases” was one such knowing ad that appeared in The Boston Daily Times in 1845. Those ads spoke euphemistically of “curing female complaint,” or “renovating” or “unblocking” the womb. They treated a problem that women called “suppression of the courses,” the idea being that monthly “turns” were the norm and that any cessation of normal periods meant they were “suppressed,” or that the womb was “obstructed.”
Many of the cures for these “ailments” were nothing but sugar and dust. But some of them were nonetheless quite effective. Those were the dangerous ones, containing as they commonly did, turpentine, opium, pennyroyal, aloes, snakeroot, myrrh or oil of rue. One of the most common ingredients was ergot, or claviceps purpurea, a fungus found on the stalks of grain. Women as early as the 16th century had observed that cows that consumed ergot miscarried their calves. The fungus, however, had disastrous side effects, called ergotism, also known as St. Anthony’s fire. Symptoms included a burning sensation in the limbs because of blood constriction, which led to gangrene. The poison could also cause seizures, itching, psychosis, vomiting, contractions, diarrhea and death.
Oil of tansy was another common abortifacient. Here is John Irving’s unforgettable description, from his scrupulously researched novel “The Cider House Rules,” of a doctor trying to save a woman after too many tansy-oil miscarriages: . . .
Electronic medical records have yet to live up to their promise
Interesting article on how more is required than simply converting existing systems to electronic format: the whole enterprise needs to be rethought and redeveloped with specific goals in mind beyond increasing billings and profits. Reed Abelson and Julie Cresswell report in the NY Times:
The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation.
Optimistic predictions by RAND in 2005 helped drive explosive growth in the electronic records industry and encouraged the federal government to give billions of dollars in financial incentives to hospitals and doctors that put the systems in place.
“We’ve not achieved the productivity and quality benefits that are unquestionably there for the taking,” said Dr. Arthur L. Kellermann, one of the authors of a reassessment by RAND that was published in this month’s edition of Health Affairs, an academic journal.
RAND’s 2005 report was paid for by a group of companies, including General Electric and Cerner Corporation, that have profited by developing and selling electronic records systems to hospitals and physician practices. Cerner’s revenue has nearly tripled since the report was released, to a projected $3 billion in 2013, from $1 billion in 2005.
The report predicted that widespread use of electronic records could save the United States health care system at least $81 billion a year, a figure RAND now says was overstated. The study was widely praised within the technology industry and helped persuade Congress and the Obama administration to authorize billions of dollars in federal stimulus money in 2009 to help hospitals and doctors pay for the installation of electronic records systems.
“RAND got a lot of attention and a lot of buzz with the original analysis,” said Dr. Kellermann, who was not involved in the 2005 study. “The industry quickly embraced it.”
But evidence of significant savings is scant, and there is increasing concern that electronic records have actually added to costs by making it easier to bill more for some services.
Health care spending has risen $800 billion since the first report was issued, according to federal figures. The reasons are many, from the aging of the baby boomer population, to the cost of medical advances, to higher usage of medical services over all.
Officials at RAND said their new analysis did not try to put a dollar figure on how much electronic record-keeping had helped or hurt efforts to reduce costs. But the firm’s acknowledgment that its earlier analysis was overly optimistic adds to a chorus of concern about the cost of the new systems and the haste with which they have been adopted.
The recent analysis was sharply critical of . . .
Gov. Rick Scott (R-FL) seems despicable
I’m sure he has good qualities, but he keeps them pretty well hidden. Sahil Kapur reports at TPMDC on Scott’s overt and deliberate lies about healthcare costs:
Florida’s Republican Gov. Rick Scott has rejected the Medicaid expansion under the Affordable Care Act. And now he’s in hot water for apparently inflating the cost of the expansion to Floridians in order to justify his decision.
The website Health News Florida reported Tuesday that Scott was warned in letters by the state legislature’s top economist and budget analyst that his administration’s figure — that the expansion would cost the state $26 billion over 10 years — was false.
Scott’s aide reportedly said, in emails obtained by HNF, that the figure was based on the assumption that the federal government — which is tasked with paying for the vast majority of each state’s Medicaid expansion for the first decade — would not fulfill its promise.
But after the report was published and caused a stir, including scathing criticism from Rep. Kathy Castor (D-FL), Scott said through a spokeswoman that his Agency for Health Care Administration would consider alternate cost estimates.
“AHCA’s report concluded that adding people to Medicaid under the new law would cost Florida $26 billion over 10 years,” said Scott’s aide Melissa Sellers. “Others have asked AHCA to use different assumptions to calculate different cost estimates. We look forward to reviewing those cost estimates as well.”
Castor accused Scott — a former hospital executive who rose to national prominence in 2009 while campaigning against the ACA — of deliberately deceiving Floridians.
“Not only did Gov. Scott manufacture flawed cost estimates, but it appears he had been advised that the numbers were flawed and used them anyway,” Castor said in a statement. “Florida Legislative Appropriations staff advised the governor’s office that the numbers were misleading, but it appears that the governor ignored it. … Clearly this was not a mistake. Knowing that the numbers are wrong and using them anyway is.”
The Scott administration’s Medicaid figures were disputed by multiple nonpartisan analyses. . .
The helplessness of the invisible hand of the market
For a while, there seemed to be a fad of believing that a free market could solve all problems—the invisible hand would unfailingly direct resources where needed, and the government should just stand back, butt out, and let the market work its magic.
I think with the bank scandals and depressed economy from the bursting of the financial bubble (a bubble created by the rolling back of regulations that had prevented such follies), the bloom is off that particular Libertarian rose. But just to drive the point home—that government intervention is often needed to make free markets responsive to human needs—take a look at this story by Joshua Green in the Washington Post:
The actor Jack Klugman died on Christmas Eve at age 90. Klugman was best known for his roles as the unkempt sportswriter in “The Odd Couple” and as the crusading medical examiner on “Quincy, M.E.” the wildly popular 1980s medical drama. Few people remember it today, but he also played an instrumental role in passing critical health-care legislation, the Orphan Drug Act, through Congress in the early 1980s, using “Quincy” and his own celebrity to roll Sen. Orrin Hatch (R), who was blocking the bill.
Klugman’s unlikely star turn in Washington stemmed from a 1980 hearing by the House Subcommittee on Health and the Environment on the problem of developing treatments for rare diseases. The problem was that many terrible diseases didn’t afflict enough people to entice pharmaceutical companies to develop treatments. Hence they were ”orphan” diseases. They included Tourette’s syndrome, muscular dystrophy, cystic fibrosis, spina bifida, ALS and many more. The situation was especially tragic because scientists who discovered promising treatments often couldn’t interest drug makers, who didn’t see potential for profit.
The issue of orphan diseases was so obscure that only a single newspaper, the Los Angeles Times, sent a reporter to the hearing (and the Times only did so because a local boy suffering from Tourette’s testified). But the article caught the eye of a Hollywood writer and producer named Maurice Klugman, who himself suffered from a rare cancer and also happened to be Jack Klugman’s brother. Maurice Klugman wrote an episode of “Quincy” about Tourette’s and the orphan drug problem.
To capitalize on the publicity and build momentum for a bill, Rep. Henry Waxman (D) of California, the subcommittee chairman, invited Jack Klugman to testify before Congress. Nowadays on Capitol Hill, you’re as likely to run into Bono or Ben Affleck as your own representative. But at the time, a bona fide celebrity speaking to Congress was a huge deal. . .
When public officials fail in their responsibilities
This story by Jennifer Preston, Sheri Fink, and Michael Powell, gives a detailed account of how New York City public officials, from Bloomberg on down, failed in their duties to see that the citizens of the city do not come to harm. This story is not about the failure to plan for Rikers Island. It’s about the nursing home patients who were effectively abandoned:
Hurricane Sandy was swirling northward, four days before landfall, and at the Sea Crest Health Care Center, a nursing home overlooking the Coney Island Boardwalk in Brooklyn, workers were gathering medicines and other supplies as they prepared to evacuate.
Then the call came from health officials: Mayor Michael R. Bloomberg, acting on the advice of his aides and those of Gov. Andrew M. Cuomo, recommended that nursing homes and adult homes stay put. The 305 residents would ride out the storm.
The same advisory also took administrators by surprise at the Ocean Promenade nursing home, which faces the Atlantic Ocean in Queens. They canceled plans to move 105 residents to safety.
“No one gets why we weren’t evacuated,” said a worker there, Yisroel Tabi. “We wouldn’t have exposed ourselves to dealing with that situation.”
The recommendation that thousands of elderly, disabled and mentally ill residents remain in more than 40 nursing homes and adult homes in flood-prone areas of New York City had calamitous consequences.
At least 29 facilities in Queens and Brooklyn were severely flooded. Generators failed or were absent. Buildings were plunged into a cold, wet darkness, with no access to power, water, heat and food.
While no immediate deaths were reported, it took at least three days for the Fire Department, the National Guard and ambulance crews from around the country to rescue over 4,000 nursing home and 1,500 adult home residents. Without working elevators, many had to be carried down slippery stairwells.
“I was shocked,” said Greg Levow, who works for an ambulance service and helped rescue residents at Queens. “I couldn’t understand why they were there in the first place.”
Many sat for hours in ambulances and buses before being transported to safety through sand drifts and debris-filled floodwaters. They went to crowded shelters and nursing homes as far away as Albany, where for days, they often lacked medical charts and medications. Families struggled to locate relatives.
The decision not to empty the nursing homes and adult homes in the mandatory evacuation area was one of the most questionable by the authorities during Hurricane Sandy. And an investigation by The New York Times found that the impact was worsened by missteps that officials made in not ensuring that these facilities could protect residents.
They did not require that nursing homes maintain backup generators that could withstand flooding. They did not ensure that health care administrators could adequately communicate with government agencies during and after a storm. And they discounted the more severe of the early predictions about Hurricane Sandy’s surge.
The Times’s investigation was based on interviews with officials, health care administrators, doctors, nurses, ambulance medics, residents, family members and disaster experts. It included a review of internal State Health Department status reports. The findings revealed the striking vulnerability of the city’s nursing and adult homes.
On Sunday, Oct. 28, the day before Hurricane Sandy arrived, Mr. Bloomberg ordered a mandatory evacuation in Zone A, the low-lying neighborhoods of the city. But by that point, Mr. Bloomberg, relying on the advice of the city and state health commissioners, had already determined that people in nursing homes and adult homes should not leave, officials said.
The mayor’s recommendations that health care facilities not evacuate startled residents of Surf Manor adult home in Coney Island, said one of them, Norman Bloomfield. He recalled that another resident exclaimed, “What about us! Why’s he telling us to stay?”
The commissioners made the recommendation to Mr. Bloomberg and Mr. Cuomo because they said they believed that the inherent risks of transporting the residents outweighed the potential dangers from the storm.
In interviews, senior Bloomberg and Cuomo aides did not express regret for keeping the residents in place. . . [In other words, they learned nothing. - LG]
Why hospitals should be non-profit
Because profit-oriented hospitals must constantly increase profits, cutting costs and services, increasing fees, and pushing doctors to bill more. Judy Creswell and Reed Abelson report in the NY Times:
or decades, doctors in picturesque Boise, Idaho, were part of a tight-knit community, freely referring patients to the specialists or hospitals of their choice and exchanging information about the latest medical treatments.
But that began to change a few years ago, when the city’s largest hospital, St. Luke’s Health System, began rapidly buying physician practices all over town, from general practitioners to cardiologists to orthopedic surgeons.
Today, Boise is a medical battleground.
A little over half of the 1,400 doctors in southwestern Idaho are employed by St. Luke’s or its smaller competitor, St. Alphonsus Regional Medical Center.
Many of the independent doctors complain that both hospitals, but especially St. Luke’s, have too much power over every aspect of the medical pipeline, dictating which tests and procedures to perform, how much to charge and which patients to admit.
In interviews, they said their referrals from doctors now employed by St. Luke’s had dropped sharply, while patients, in many cases, were paying more there for the same level of treatment.
Boise’s experience reflects a growing national trend toward consolidation. Across the country, doctors who sold their practices and signed on as employees have similar criticisms. In lawsuits and interviews, they describe growing pressure to meet the financial goals of their new employers — often by performing unnecessary tests and procedures or by admitting patients who do not need a hospital stay.
In Boise, just a few weeks ago, even the hospitals were at war. St. Alphonsus went to court seeking an injunction to stop St. Luke’s from buying another physician practice group, arguing that the hospital’s dominance in the market was enabling it to drive up prices and to demand exclusive or preferential agreements with insurers. The price of a colonoscopy has quadrupled in some instances, and in other cases St. Luke’s charges nearly three times as much for laboratory work as nearby facilities, according to the St. Alphonsus complaint.
Federal and state officials have also joined the fray. In one of a handful of similar cases, the Federal Trade Commission and the Idaho attorney general are investigating whether St. Luke’s has become too powerful in Boise, using its newfound leverage to stifle competition.
Dr. David C. Pate, chief executive of St. Luke’s, denied the assertions by St. Alphonsus that the hospital’s acquisitions had limited patient choice or always resulted in higher prices. In some cases, Dr. Pate said, services that had been underpriced were raised to reflect market value. St. Luke’s, he argued, is simply embracing the new model of health care, which he predicted would lead over the long term to lower overall costs as fewer unnecessary tests and procedures were performed.
Regulators expressed some skepticism about the results, for patients, of rapid consolidation, although the trend is still too new to know for sure. “We’re seeing a lot more consolidation than we did 10 years ago,” said Jeffrey Perry, an assistant director in the F.T.C.’s Bureau of Competition. “Historically, what we’ve seen with the consolidation in the health care industry is that prices go up, but quality does not improve.” . . .
Continue reading. A capitalistic, free-market, profit-making approach does not always produce the best result, as you see.
Romney averts his gaze and washes his hands
Paul Krugman today in the NY Times:
Mitt Romney doesn’t see dead people. But that’s only because he doesn’t want to see them; if he did, he’d have to acknowledge the ugly reality of what will happen if he and Paul Ryan get their way on health care.
Last week, speaking to The Columbus Dispatch, Mr. Romney declared that nobody in America dies because he or she is uninsured: “We don’t have people that become ill, who die in their apartment because they don’t have insurance.” This followed on an earlier remark by Mr. Romney — echoing an infamous statement by none other than George W. Bush — in which he insisted that emergency rooms provide essential health care to the uninsured.
These are remarkable statements. They clearly demonstrate that Mr. Romney has no idea what life (and death) are like for those less fortunate than himself.
Even the idea that everyone gets urgent care when needed from emergency rooms is false. Yes, hospitals are required by law to treat people in dire need, whether or not they can pay. But that care isn’t free — on the contrary, if you go to an emergency room you will be billed, and the size of that bill can be shockingly high. Some people can’t or won’t pay, but fear of huge bills can deter the uninsured from visiting the emergency room even when they should. And sometimes they die as a result.
More important, going to the emergency room when you’re very sick is no substitute for regular care, especially if you have chronic health problems. When such problems are left untreated — as they often are among uninsured Americans — a trip to the emergency room can all too easily come too late to save a life.
So the reality, to which Mr. Romney is somehow blind, is that many people in America really do die every year because they don’t have health insurance.
How many deaths are we talking about? That’s not an easy question to answer, and conservatives love to cite the handful of studies that fail to find clear evidence that insurance saves lives. The overwhelming evidence, however, is that insurance is indeed a lifesaver, and lack of insurance a killer. For example, states that expand their Medicaid coverage, and hence provide health insurance to more people, consistently show a significant drop in mortality compared with neighboring states that don’t expand coverage.
And surely the fact that the United States is the only major advanced nation without some form of universal health care is at least part of the reason life expectancy is much lower in America than in Canada or Western Europe.
So there’s no real question that lack of insurance is responsible for thousands, and probably tens of thousands, of excess deaths of Americans each year. But that’s not a fact Mr. Romney wants to admit, because he and his running mate want to repeal Obamacare and slash funding for Medicaid — actions that would take insurance away from some 45 million nonelderly Americans, causing thousands of people to suffer premature death. And their longer-term plans to convert Medicare into Vouchercare would deprive many seniors of adequate coverage, too, leading to still more unnecessary mortality. . .
A good illustation of why I don’t read David Brooks’s NY Times columns
Dean Baker, an economist of note, writes:
While we may not know whether David Brooks’ try out as a Romney speechwriter was successful, he clearly is doing his best for the campaign. Today he pushes the idea that a voucher system is the only way to contain Medicare costs. This requires ignoring an awful lot of evidence, but that is an exercise at which David Brooks excels.
To start, in dismissing the idea that governments can be successful in designing policies that contain costs, Brooks ignores all the evidence from every other wealthy country. All of them have much greater involvement of the government in their health care system (in some countries like the United Kingdom and Denmark they actually run the system) yet their average cost per person is less than half as much as in the United States. And they have comparable health care outcomes, with all enjoying longer life expectancies. If health care costs in the United States were comparable to those in any other wealthy country we would be looking at long-term budget surpluses, not deficits. (We could look to trade to reduce costs, but policy debates in the United States are dominated by ardent protectionists in the area of health care.)
Of course relying on the private sector to contain costs in Medicare is not a new idea, contrary to what Brooks seems to believe. The Gingrich Congress’ Medicare Plus Choice plan opened Medicare to private insurers as did President Bush’s Medicare Advantage plan. Both raised costs. We also have the massive under 65 market which is overwhelmingly served by private insurers. Yet per person costs have consistently risen more rapidly for the non-Medicare population (Table 16) than for the Medicare population. This is in addition to the fact that the administrative costs as a share of expenses for Medicare are less than half of the costs for private insurers (this is even after adjusting for the higher denominator with the expenses of Medicare patients).
Brooks seems to think it would be a great idea for providers to be paid by the patient rather than for the specific services provided. That may prove to be a very good idea and the Affordable Care Act actually puts in place a number of incentives to push providers into going this path. Most private insurers do not now follow this route in spite of Brooks’ positive assessment of this approach. But Brooks still links this method of payment with private insurers.
In effect Brooks is arguing that . . .
Continue reading. It’s astonishing how newspaper columnists routinely ignore (or are ignorant of) evidence, and how their editors never seem to call them on it. Another example that Baker points out: Robert Samuelson of the Washington Post (though Samuelson seems deliberately to write in bad faith):
Robert Samuelson is excited by the fact that Europe’s economy faces stagnation. Unfortunately he gets almost everything inthe piece wrong.
First, his central point, that the stagnation is due to overly generous welfare state, is 100 percent at odds with reality. The countries with the most generous welfare states are the Nordic countries and Germany, all of which are doing fine. The problem countries are Greece, Italy, Spain, and Ireland, all countries that rate near the bottom in the generosity of their welfare states.
The proximate cause of stagnation is quite evidently the decision by the European Central Bank to require austerity across the continent. In case anyone disputed this fact, the Conservative government in the U.K. agreed to prove the point by implementing an austerity plan in that country, which quickly threw it back into recession. In short, the immediate problem facing Europe is hardly overly generous welfare states; it is contractionary fiscal policies being pursued by European governments, in many cases against their will.
Other items that Samuelson gets wrong . . .
Why conservatives seem stupid to onlookers: They oppose their own ideas
This is clearly explained in a NY Times column on the Affordable Care Act written by J.D. Kleinke of the American Enterprise Institute (a conservative think tank):
IF Mitt Romney’s pivots on President’s Obama’s health care reform act have accelerated to a blur — from repealing on Day 1, to preserving this or that piece, to punting the decision to the states — it is for an odd reason buried beneath two and a half years of Republican political condemnations: the architecture of the Affordable Care Act is based on conservative, not liberal, ideas about individual responsibility and the power of market forces.
This fundamental ideological paradox, drowned out by partisan shouting since before the plan’s passage in 2010, explains why Obamacare has only lukewarm support from many liberals, who wanted a real, not imagined, “government takeover of health care.” It explains why Republicans have been unable since its passage to come up with anything better. And it explains why the law is nearly identical in design to the legislation Mr. Romney passed in Massachusetts while governor.
The core drivers of the health care act are market principles formulated by conservative economists, designed to correct structural flaws in our health insurance system — principles originally embraced by Republicans as a market alternative to the Clinton plan in the early 1990s. The president’s program extends the current health care system — mostly employer-based coverage, administered by commercial health insurers, with care delivered by fee-for-service doctors and hospitals — by removing the biggest obstacles to that system’s functioning like a competitive marketplace.
Chief among these obstacles are market limitations imposed by the problematic nature of health insurance, which requires that younger, healthier people subsidize older, sicker ones. Because such participation is often expensive and always voluntary, millions have simply opted out, a risky bet emboldened by the 24/7 presence of the heavily subsidized emergency room down the street. The health care law forcibly repatriates these gamblers, along with those who cannot afford to participate in a market that ultimately cross-subsidizes their medical misfortunes anyway, when they get sick and show up in that E.R. And it outlaws discrimination against those who want to participate but cannot because of their medical histories. Put aside the considerable legislative detritus of the act, and its aim is clear: to rationalize a dysfunctional health insurance marketplace.
This explains why the health insurance industry has been quietly supporting the plan all along. It levels the playing field and expands the potential market by tens of millions of new customers.
The rationalization and extension of the current market is financed by the other linchpin of the law: the mandate that we all carry health insurance, an ideaforged not by liberal social engineers at the Brookings Institution but by conservative economists at the Heritage Foundation. The individual mandate recognizes that millions of Americans who could buy health insurance choose not to, because it requires trading away today’s wants for tomorrow’s needs. The mandate is about personal responsibility — a hallmark of conservative thought.
IN the partisan war sparked by the 2008 election, Republicans conveniently forgot that this was something many of them had supported for years. The only thing wrong with the mandate? Mr. Obama also thought it was a good idea.
The same goes for health insurance exchanges, another idea formulated by conservatives and supported by Republican governors and legislators across the country for years. An exchange is as pro-market a mechanism as they come: free up buyers and sellers, standardize the products, add pricing transparency, and watch what happens. Market Economics 101.
In the shouting match over the health care law, most have somehow missed another of its obvious virtues: it enshrines accountability — yes, another conservative idea. Under today’s system, . . .
Continue reading. It’s an interesting piece, for sure. I don’t know that I agree with all of it: for example, I don’t see “accountability” as particularly Republican (or Democratic, for that matter), but rather a logical, moral, and ethical idea vigorously fought by those who would be impacted by accountability: people eager to escape responsibility for the consequences of their decisions and actions. It’s not party-specific. Still, the column is good food for thought, should Republicans read it. Too bad no comments are appended to the piece.
The sorry state of American healthcare
Interesting interview in ProPublica that suggests that, perhaps, the US does not offer the best healthcare in the world. Marshall Allen interviews Dr. Marty Makary of Johns Hopkins.
Medical care has its own code and culture, which often does not put patients first, according to Dr. Marty Makary, a cancer surgeon and researcher at Johns Hopkins School of Medicine and the School of Public Health. And providers who speak against that code can pay a heavy price.
Makary’s new book, “Unaccountable,” explores why patient harm persists in the medical system and what can be done about it.
PP: What led you to write “Unaccountable”?
Dr. Makary: The debates about health care reform frustrated me because our complex system of health care and culture of medicine were reduced to simple sound bites. People pushed the idea that changing the payment system would solve the problems. But I observed every day what I see to be the main driver of health care costs: the massive variation in the quality of care – across the country, within cities, and even within good hospitals.
I saw this variation in quality and the alarmingly high error rates, and it hit me that unless we can be open and honest that up to 30 percent of health care is unnecessary, and that 1 in 4 hospital patients are harmed by a mistake, then we’re just going to be continuing to beat our heads against a wall trying to pay for a broken health care system, instead of fixing it.
PP: What type of problems did you observe?
Dr. Makary: I saw cases where a patient was not told about a minimally invasive way of doing a particular surgery because of physician preference or training, and the doctor would just hope that he wouldn’t find out. If that patient were empowered by talking to the right people, or by doing his own research, he would be able to get superior care. It’s no wonder that about a third of all second opinions about surgery yield different opinions.
Medical mistakes are the fifth- or sixth-most common cause of death in the United States, depending on the measure. But few people look at it that way. That’s because we haven’t been honest about it in the past. And we have hospitals that fire doctors and nurses when they speak up.There was a nurse recently fired in Florida for complaining about a doctor doing unnecessary procedures, a report substantiated by an internal report gotten by The New York Times. A cardiologist in Wisconsin was fired for pointing out that EKGs were misread more than 25 percent of the time. We need to change the culture of medicine.
There is New England Journal of Medicine-level data that suggests that almost half of care is not compliant with the evidence. In my own field of cancer surgery, I have seen patients treated in ways that are not supported with evidence.In the case of radiation treatment for pancreatic cancer, there is evidence from large cooperatives overseas that there is a harm to radiation. Many studies show no evidence of benefit to radiation, and yet patients are routinely offered radiation treatment and have the expectation that it’s going to help them do better. I see PET scans offered routinely – an expensive test – that has never been shown to benefit diagnosing pancreatic cancer.
PP: Why do these problems persist? . . .
$750 billion (or, 3/4 of $1 trillion) wasted in healthcare annually
Seems like an enormous opportunity for improvement. Take a look:
The image is from a Washington Post article by Sarah Kliff, who got it from this Institute of Medicine report. The article ends with this large graphic, again from the Institute of Medicine:
Krugman on the GOP’s death to Medicare initiative
Paul Krugman in today’s NY Times:
Paul Ryan’s speech Wednesday night may have accomplished one good thing: It finally may have dispelled the myth that he is a Serious, Honest Conservative. Indeed, Mr. Ryan’s brazen dishonesty left even his critics breathless.
Some of his fibs were trivial but telling, like his suggestion that President Obama is responsible for a closed auto plant in his hometown, even though the plant closed before Mr. Obama took office. Others were infuriating, like his sanctimonious declaration that “the truest measure of any society is how it treats those who cannot defend or care for themselves.” This from a man proposing savage cuts in Medicaid, which would cause tens of millions of vulnerable Americans to lose health coverage.
And Mr. Ryan — who has proposed $4.3 trillion in tax cuts over the next decade, versus only about $1.7 trillion in specific spending cuts — is still posing as a deficit hawk.
But Mr. Ryan’s big lie — and, yes, it deserves that designation — was his claim that “a Romney-Ryan administration will protect and strengthen Medicare.” Actually, it would kill the program.
Before I get there, let me just mention that Mr. Ryan has now gone all-in on the party line that the president’s plan to trim Medicare expenses by around $700 billion over the next decade — savings achieved by paying less to insurance companies and hospitals, not by reducing benefits — is a terrible, terrible thing. Yet, just a few days ago, Mr. Ryan was still touting his own budget plan, which included those very same savings.
But back to the big lie. The Republican Party is now firmly committed to replacing Medicare with what we might call Vouchercare. The government would no longer pay your major medical bills; instead, it would give you a voucher that could be applied to the purchase of private insurance. And, if the voucher proved insufficient to buy decent coverage, hey, that would be your problem.
Moreover, the vouchers almost certainly would be inadequate; their value would be set by a formula taking no account of likely increases in health care costs.
Why would anyone think that this was a good idea? The G.O.P. platform says that it “will empower millions of seniors to control their personal health care decisions.” Indeed. Because those of us too young for Medicare just feel so personally empowered, you know, when dealing with insurance companies.
Still, wouldn’t private insurers reduce costs through the magic of the marketplace? . . .
Bias in scientific findings
Two articles in The Scientist discuss bias in scientific findings, often the result of a conflict of interest—and, interestingly, disclosing the conflict of interest does not help but can worsen the bias. The first article, by Lisa Cosgrove, discusses the issue in general and provides good examples of bad results—for example:
Decades of research have demonstrated that cognitive biases are commonplace and very difficult to eradicate, and more recent studies suggest that disclosure of financial conflicts of interest may actuallyworsen bias. This is because bias is most often manifested in subtle ways unbeknownst to the researcher or clinician, and thus is usually implicit and unintentional. For example, although there was no research misconduct or fraud, re-evaluations of liver tissue of rats exposed to the drug dioxin resulted in different conclusions about the liver cancer in those rats: compared to the original investigation, an industry-sponsored re-evaluation identified fewer tissue slides as cancerous and this finding affected policy recommendations (water quality standards were weakened). (See also Brown, Cold Spring Harbor Laboratory Press, 13–28, 1991.) This example is just one of many that points to a generic risk that a financial conflict of interest may compromise research or undermine public trust.
Read the whole thing. The findings are disturbing and show the distorting effects of financial ties on ethical/legitimate behavior.
The second article, by Hayley Dunning, discusses off-label drug use and shows again the distorting effects of financial incentives. The article begins:
Directly promoting drugs for purposes outside those approved by the US Food and Drug Administration (FDA), so-called “off-label” use, is illegal for drug companies. However, it is not illegal for physicians and scientists to discuss off-label use with colleagues, deliver lectures, and author peer-reviewed studies. But according to a new study, published today (August 7) in PLoS Medicine, only 15 percent of physicians and scientists involved in such promotion adequately disclosed relevant relationships they maintained with pharmaceutical companies in published studies.
“The major finding is both unsurprising and disturbing,” said public health researcher Susan Chimonas of Columbia University, who was not involved in the study, by email. “The current disclosure system is woefully insufficient.”
The study, led by physician scientist Aaron Kesselheim of Harvard Medical School, looked at the publications of scientists and physicians named in prosecution cases against drug companies involved in illegal marketing of off-label drugs. Complaints, which were filed with the US Department of Justice by whistleblowers under the US False Claims Act, named scientists and physicians involved in off-label promotion, though they were not punished by the process.
Kesselheim and his colleagues scanned the literature for publications that covered the drug for which the complaint was filed, diagnoses or diseases treated by the drug, or mentioned other medications or alternatives in the same therapeutic class. Of 91 physicians and scientists named in complaints, 39 of them authored a total of 404 related publications. The majority of these authors acted as a paid speaker for the company that had developed and marketed the drug, while others wrote review articles, acted as advisory board members, or received support funds.
However, despite the close ties between the researchers and the drugmakers, only 62 of those 404 related articles (15 percent) had adequate disclosures, with the authors discussing fully the nature of their relationship with the company. The majority of other articles had no disclosure statement at all or had disclosures that did not mention the drug company. . .
It is evident that our healthcare system has been corrupted by financial conflicts. The unneeded heart surgeries in the (profit-making) HCA hospital chain, which I blogged two days ago, is just one aspect of that corruption. These articles show how pervasive the corruption has become. There is a clear pattern of misbehavior and it is not being addressed in any systematic way. Indeed, with those involved not being held accountable, the behavior will continue and worsen.
For-profit hospitals and unnecessary procedures
HCA, a large chain of for-profit hospitals, seems to have found an efficient way to increase profits: performing heart surgery on patients that did not need it but were insured. Reed Abelson and Julie Cresswell report in the NY Times:
In the summer of 2010, a troubling letter reached the chief ethics officer of the hospital giant HCA, written by a former nurse at one of the company’s hospitals in Florida.
In a follow-up interview, the nurse said a doctor at the Lawnwood Regional Medical Center, in the small coastal city of Fort Pierce, had been performing heart procedures on patients who did not need them, putting their lives at risk.
“It bothered me,” the nurse, C. T. Tomlinson, said in a telephone interview. “I’m a registered nurse. I care about my patients.”
In less than two months, an internal investigation by HCA concluded the nurse was right.
“The allegations related to unnecessary procedures being performed in the cath lab are substantiated,” according to a confidential memo written by a company ethics officer, Stephen Johnson, and reviewed by The New York Times.
Mr. Tomlinson’s contract was not renewed, a move that Mr. Johnson said in the memo was in retaliation for his complaints.
But the nurse’s complaint was far from the only evidence that unnecessary — even dangerous — procedures were taking place at some HCA hospitals, driving up costs and increasing profits.
HCA, the largest for-profit hospital chain in the United States with 163 facilities, had uncovered evidence as far back as 2002 and as recently as late 2010 showing that some cardiologists at several of its hospitals in Florida were unable to justify many of the procedures they were performing. Those hospitals included the Cedars Medical Center in Miami, which the company no longer owns, and the Regional Medical Center Bayonet Point. In some cases, the doctors made misleading statements in medical records that made it appear the procedures were necessary, according to internal reports.
Questions about the necessity of medical procedures — especially in the realm of cardiology — are not uncommon. None of the internal documents reviewed calculate just how many such procedures there were or how many patients might have died or been injured as a result. But the documents suggest that the problems at HCA went beyond a rogue doctor or two. . .
Continue reading. It’s a grim story, and the specifics are disturbing.
Profit-making institutions are compelled to show ever-increasing profits, no matter what. If profits don’t increase each year, top management jobs are at risk, so by golly, those profits do increase. That is why some things—hospitals, for example—are better left as non-profits.
UPDATE: The Eldest informs me that for-profit hospitals are illegal in Maryland—because of the obvious conflicts of interest that then occur.
