Archive for July, 2012

The Culture of Quality – Priceless

There is no question that health care costs money.   But like anything we purchase we would like to get a quality product.  All the States in America pay for health care and to some extent are responsible for the quality of care in each State.  Control over quality is exerted through licensing and through medical and pharmacy boards.  Management of the Medicaid program is very directly the responsibility of the State.  How well do the States provide quality health care?  The chart below shows quality and cost rankings of the States.  The casual observer would conclude: the more money spent on health care the worse the quality.  Does money corrupt health care or is there some other answer?

Quality and Cost Rankings of States

The New England Journal of Medicine reports a reduction in death rate in States where Medicaid has been expanded.  This seems contrary to the previous data.  The more money spent by expanding Medicaid improves quality.   So does money corrupt or cure quality?

The answer to the previous question is simple:  it depends on management.  An effort to follow evidence based quality guidelines is usually rewarded with lower cost (see the example of asthma).   It does no good to stay within budget but fail to deliver quality (money “down the drain”).  The expanded Medicaid programs were showing better management and higher quality than some other State medical programs.

Sometimes, even with the best of intentions, health care money is wasted and poor quality results.  Dr. Donald Berwick, previously the head of the US Department of Health and Human Services, commented on the 5 main causes of waste in health care:

  1.  overtreatment of patients
  2. the failure to coordinate care
  3. the administrative complexity of the health care system
  4. burdensome rules
  5. fraud

Connecting the dots:

If a State contracts for a highway project there are engineering based  specifications on the final product.  Failure to have specifications for a highway leads to a bumpy road.   Failure to adequately specify evidence based health care  leads to waste, high cost and low quality.

The culture of health care in some states is collaborative and quality driven, and in other states the culture  is competitive and profit driven.  The Midwest tends to be the former (see the chart at the top).  The outcome for patients is better in a collaborative and quality driven environment.  Not just anybody can lead a health care organization.  The ability to build a culture of quality is essential for a government administrator or  a health care CEO.

The cost of US health care is about $8000 per person per year.   Other advanced countries achieve higher quality at a cost less than $5000 per person per year.   Excessive health care waste (Chalice, Robert. Improving healthcare using Toyota lean production methods : 46 steps for improvement — 2nd ed. Page 21) accounts for at least 30% of the cost of US healthcare.  The US must attack the problem of waste to reduce overall cost and at the same time foster a national culture of health care quality so all the States have similar high quality levels.

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The US Insurance Gap

Graph from N Engl J Med 2012; 367:3-6July 5, 2012

The graph above comes from an article in the New England Journal of Medicine by David C. Radley, Ph.D. MPH and Cathy Schoen, M.S.  It shows the distribution of uninsured adults across the United States.   Large parts of Texas, New Mexico and Alaska have over 50% uninsured adults.  Wisconsin and Massachusetts have less than 15% uninsured adults.  The graph is the result of an analysis of US Census Bureau data from 2009-2010.

The areas with low rates of insurance are also the areas with other health problems.  The authors conclude the uninsured areas are associated with low quality care,  poor access to care, unsafe prescribing, increased visits to ER for avoidable conditions, and more avoidable deaths.

The bottom line is the US healthcare system is designed for high cost and low quality care especially for those who choose not to have insurance or those who can not afford insurance.  Unless a person is extremely wealthy it is very unwise to forgo insurance in this environment.  The maldistribution of insurance enhances the argument for those in states with high rates of insurance not to pay more in taxes to cover those in states with low rates of insurance.  It seems strange that the states with enhanced revenue from oil and gas can’t seem to correct the insurance gap.

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False Positive — what’s not there can kill you.

An x-ray, biopsy or other medical test can have a number of possible results.  The uninformed patient or the unwary doctor can be fooled by some of the possibilities.  How could a little test hurt you — it’s just a harmless x-ray or small biopsy or just a few drops of blood?  There is some underlying truth about a condition we want to know.  Do we have a problem or not, yes or no, cancer or no cancer, pregnant or not pregnant, AIDS or no AIDS and many other questions.

Most people understand if the weatherman predicts rain tomorrow, but no rain comes, we laugh because we know prediction of weather is not always accurate.  Yet we don’t apply the same common sense to medical tests.  If a test predicts a person has cancer we believe it — the sad fact is medical tests are not always accurate.  A test can predict a condition when none is present which is called a false positive.  A test can predict a condition is absent when it really is present which is called a false negative.  A test can predict a condition which turns out to be correct which is a true positive.

So how can a little test hurt?  If the test is a false positive which leads to surgery which has a complication then a person could die.  This is not just theoretical, it happens.  The problem is made worse by a tendency of health care professionals to over-diagnose disease.  For example, if a pathologist is not certain if a biopsy shows cancer the safe thing to say is “possibly cancer” rather than “I don’t know”.  The surgeon says if it is “possibly cancer” the best thing is to “take it out”.  Later, when the patient is missing some body part and no cancer is found the surgeon says “you were lucky”.  Really?  Perhaps the patient should not have had the test in the first place.

In certain circumstances the chance of getting a false positive is higher than the chance of a true positive.  A good example is finding a small spot on a chest x-ray.  Most spots on chest x-rays are not cancers.  Because of the unreliable nature of the chest  x-ray for cancer screening, routine chest x-rays are not advised.

People who study the statistics of medical testing can figure out which tests have the best chances of true results.  This is important information for patients and doctors.  Recently, the PSA test has come under criticism.  It seems the test has a high rate of false positive results and to make it worse, positive results may lead to unnecessary surgery.  In view of the statistics, experts now do not recommend PSA tests for routine screening for prostate cancer.  Hopefully, this will lead to better tests while the old PSA test heads to the history books.

Another important question is whether the result of a test will change treatment.  If not, then don’t do the test.  For example, surgery in the very elderly is dangerous.  So if no surgery would be recommended for a 100 year old person then don’t do a CT scan of the brain.  Is that mean and uncaring?  No, it is taking care not to do tests that lead to harmful procedures.

So, more information is not always better.  It is smart to avoid tests with a high false positive rate.  National guidelines do exist for many tests so search for them on the Internet and as they say “ask your doctor”.

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Malpractice — same problems over and over

What causes medical malpractice suits for health care providers and hospitals?  The simple answer is ERROR.  The most serious errors happen in hospitals but the most frequent errors happen in outpatient clinics.

James Reason (“Human error: models and management.” Bmj 320.7237 (2000): 768-770) is well known for his study of the causes of human error.   He breaks error into 3 main categories:

  1. Skill based error (not paying attention to the right things)
  2. Rule based error (not following the right rule or following an incorrect rule)
  3. Knowledge based error (not knowing or incorrectly concluding)

Health care providers make human errors all the time.   When the error actually causes injury the injured party will sometimes seek compensation through the legal system.

If humans “do the best they can” performing a task the error rate is about 10%.  For example, if a nurse is to administer a medication to a given patient there will be an error 1 out of 10 times.  Wrong patient, wrong medication, wrong dose, or wrong time just to name a few possibilities.  The goal in error reduction is an error rate in the 1 out of a million range.  Humans alone can not do that!  Prevention of errors absolutely requires systems — sometimes as simple as a checklist or sometimes as complex as a robot that packages medications with a barcode and later scanning of the code before drug administration to a patient.

Medical malpractice suits (excluding the presence of legal malpractice) arise out of a failure to have adequate systems to control error.  But, malpractice suits are only the tip of the error iceberg.  All interventions in health care must have active quality monitoring and error prevention systems.  Health care providers, to their patient’s detriment, yearn for simpler times — just the good old doctor-patient relationship in a small office with low overhead costs and no malpractice lawyers.  Without a focus on quality and standards the good old days were really the bad old days of medical care.

The cost of medical malpractice to the US healthcare system is estimated at $55 billion or 2.4% of the overall system cost.  However, the statistic misses the point.  How much is spent on preventing errors?  A wonderful trade-off would be to spend that much money to prevent errors in the first place rather than paying compensation for errors after they happen.  Lawyers say they see the same errors over and over.  One patient, one error, one trial then repeat with no intent to stop the cycle.  This is a major flaw in the US justice system.  Each settlement and each trial should result in some change to the system where the error happened.  The usual outcome is “it’s your fault”, “try harder” and “do the best you can” — which are clearly failed quality strategies.

Prevention of errors is a costly endeavor (although well worth the cost).  The following are examples of systems to reduce errors:

  • Electronic medical records
  • Electronic prescribing (computer checks for mistakes)
  • Checklists for surgeons
  • A strong quality management program both inpatient and outpatient
  • Standardized orders in the hospital
  • Standardized protocols for outpatient treatment
  • Mandatory involvement of health care providers in quality improvement
  • Development of a culture of safety for health care providers
  • Formalized hand-off when changing shifts or going off call
  • Barcoded medication administration
  • Robotic packaging of medications
  • Hourly nurse rounding to prevent falls
  • Include the patient in the effort to improve safety


The above list is seriously incomplete.  Health care is complex and changing.  The systems to prevent error need to be adapted to the circumstances and to our changing understanding of treatment.

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Cost Shifting – the underground payment system

COST SHIFTING DIAGRAM

Hosptials are licensed by the state and certified to provide Medicare and Medicaid services.   They agree to provide care sufficient to stabilize a patient.  If the hospital is a non-profit institution they must provide community service (indigent care) in an amount equivalent to what they might otherwise have to pay in taxes.  For- profit hospitals will try to transfer indigent patients to community or state hospitals but room is limited so they often provide uncompensated care.  County, State and Federal (VA and Indian service) hospitals are financed from taxes.   Much indigent care is paid for by the government.

Uncompensated care in hospitals is funded in a circuitous (underground) manner.   Uncompensated care just means the patient can not pay — the patient may end up going bankrupt.  However, the hospitals have another way.  There is a constant stream of money that comes from insured persons flowing to insurance companies and then to hospitals.  To balance the books for uncompensated care hospitals raise the price of care to insurance companies that in turn raise the price to insured people.  Hospitals often have to negotiate the pay increases with many insurance companies.  The “system” comes into a balance as long as the numbers of uninsured patients are not too great.

The net effect of the underground system is uninsured  patients do get care and hospitals stay solvent.   However, look at the system from a distance and try to follow the money.   Complex negotiations, patient transfers, government payments, and patients shifting into Medicaid (Title 19).  The cost of doing the paperwork is astounding and combined with the cost of a social-work army it almost matches the cost of delivered care.  In the end, insured people pay twice, once in the cost of insurance premiums and second in taxes.

This is our system.  We designed it this way.  Is this graft and corruption?  No.  However, it is wasteful,  inefficient, unmanageable and unsustainable.   The most simple solution is to provide insurance for those who can not afford it.  The cost is the same and possibly less than the sum total of private and governmental costs now.  Such a system would be understandable and subject to being managed.

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