Monday, March 31, 2014

Patients Come Second

Today is the deadline for the 2014 open enrollment under the Affordable Care Act, and there’s lots I could write about on that topic: the deadline suddenly getting softer, the frantic push for younger enrollees, the estimated $10b in subsidies that will be paid, or the surprising possibility that – after all the fuss and controversy -- we may hit the goal of 7m sign-ups after all, despite yet another glitch.  Then there’s the Hobby Lobby case currently before the Supreme Court.

But I’m not.  Instead, I want to talk about a couple of stories that got less attention and deserve more.  Both relate to patient safety.

The CDC reported that 4% of hospital patients – that’s one in every 25 – will get an infection due to their stay.  One in nine will die of that infection.  CDC thinks there is a trend towards improvement, but cautioned that earlier data on the topic isn’t directly comparable. 

It’s interesting to me that we apparently weren’t counting these indicators very carefully before, which doesn’t give me a whole lot of confidence about how well we’re counting them now.

CDC suggested that antibiotic-resistant pathogens played a large role in the infections.  In another report released earlier this month, they highlighted this problem, noting that physicians and hospitals vary widely – as much as three times -- in their use of antibiotics even for patients with similar conditions.  The President’s 2015 budget proposal calls for $30m to help the CDC detect outbreaks faster and improve collaboration across hospitals, among other proposals.  CDC estimates these measures could save 20,000 lives, prevent 150,000 hospitalizations, and save $2b. 

Seems like a good return on $30m.  We’re not doing this already?

We should remember that, for all that we spend on health care and for all our high-tech monitoring, estimates are that health care workers use proper hand washing as little as 30% of the time.  Antibiotic controls are all well and good, but seem sort of like chasing the horse after it is out of the barn.

In a commentary in JAMA Internal Medicine, physicians Scott Flanders and Sanjay Saint cite what they call the “chagrin factor” as an explanation for the antibiotic overuse, suggesting physicians don’t want to discover after the fact that they didn’t use an antibiotic when it might have been helpful for one of their patients.  They also noted that we have a tendency to place the interests of individual patients over broader societal interests (like minimizing antibiotic resistance), and recommend various measures that try to balance both interests.

What we should be chagrined about is the 4%, or about the 1 in 9, and certainly about the whole hand-washing thing.

Consumer Reports just released their own hospital safety ratings, showing wide variations in how hospitals perform on various safety measures.  They conclude that hospitals are not making safety a priority, as I’d touched upon in a previous post.  They also found that neither reputation nor teaching status necessarily made a difference in patient outcomes, which is consistent with a study by White, et. al. released earlier this year in Health Affairs.  Their study found that higher priced hospitals did better in reputation-based rankings like US News & World Report and not as well on more objective quality measures. 

The various studies illustrate that patient safety varies widely across providers, or that their ability to measure it does – or both.  Either way, it’s pretty scary.

The other patient safety news I wanted to bring up is a ballot initiative in California.  It seeks to raise the malpractice award limit of $250,000, which has been in place since 1975.  The proposal is being accompanied by a requirement to require random drug and alcohol tests for physicians, as well as to require physicians to use a prescription drug database to help combat patient abusers. 

Not surprisingly, the initiative is being opposed by the California Medical Association, which labels it the “trial attorneys’ ballot.”  They argue that it would only raise costs (although one would think that raising a cap after 39 years doesn’t seem unreasonable), and assert that the drug testing provisions have been added simply because they poll well among voters. 

They might well be right about the trial attorneys being behind the ballot, but what both sides should be thinking about is why the drug testing provisions do poll so well.  People who are supposed to care about patient safety should be working for those kinds of protections.  In fact, I wonder why physicians and other health care professionals don’t already face such drug tests everywhere already. 

After all, data suggests that 10-15% of physicians will have a substance abuse problem at some point in their lives.  The HHS Inspector General and a colleague raised this issue in an op-ed in The New York Times, Why Aren’t Doctors Drug Tested?  They cite cases where medical professionals with addiction problems stole drugs and adversely impacted patient care, but the problem is broader.  Over a year ago researchers from Johns Hopkins called for random drug and alcohol tests of physicians, as well as mandatory testing when there are unexpected patient outcomes – similar to what happens to pilots, railroad engineers or bus drivers when there are fatal crashes.  There hasn’t been a rush to put this into place.

On the other hand, states and some physician organizations, like the American Society of Interventional Pain Physicians, are in favor of allowing or even requiring physicians to have their patients take drug tests in order to get prescription painkillers.  Testing is OK for bus drivers and for patients, but not for physicians and other health care providers? 

Providers, heal thyselves.

Our health care system simply does not have a culture of patient safety, or of quality improvement, and the two are related.  Everyone is too focused on either increasing their own revenue or cutting someone else’s costs.  There’s precious little emphasis – well, financial emphasis anyway -- on team work, collecting and sharing data, or using the data to improve processes of care. 

Our malpractice system exacerbates the situation, as it focuses on placing blame rather than assuring quality.  As best I can tell, neither patients nor providers like the current system, nor benefit much from it.  The odds that a patient suffering harm from their care will actually get compensation, or that truly incompetent providers will be stopped from practicing, are better than playing the lottery, but not so much that you’d want to put a bet on it happening. 

If we’re truly committed to patient safety, it has to start with fuller, broader and better collection of data, then using that data to weed out the actually incompetent providers, to identify medical errors and substandard outcomes, and to create feedback mechanisms to improve patient care.   Studies have already shown that fuller disclosure of errors and even just apologies actually reduce both malpractice claims and possibly overall costs.  So why isn’t there more disclosure?

Recent studies have greatly increased estimates of deaths due to errors in hospitals and help expose the tip of the iceberg of errors in outpatient settings.  We know patient safety is a problem, and a big one at that.  It’s not sexy like ACOs or mobile apps, but if we don’t focus more of our attention – much more – on it then shame on us.

Sunday, March 23, 2014

Einstein Was Right

No, I’m not talking about the recent confirmation of the existence of gravitational waves, as predicted by Albert Einstein almost a hundred years ago in his General Theory of Relativity.  I’m talking about a quote of Einstein’s that I recently read: “If I had only one hour to save the world, I would spend fifty-five minutes defining the problem, and only five minutes finding the solution.”

Somehow, I suspect our many attempts to “reform” the health care system often may have those proportions backward.

What started me thinking about this was a provocative post in Forbes from Reenita Das, “Are the Days of Building Affluent Hospitals Dead?  In it, she talks about “frugal innovation” – usually an oxymoron in the U.S. healthcare system – particularly as practiced in emerging markets.  She gives the example of GE’s low cost electrocardiography machine sold in emerging markets, and spends more time discussing the Indian-based hospital chain Narayana Health -- a low cost, high quality hospital chain that is both succeeding and expanding. 

Narayana Health just opened a hospital in the Cayman Islands, particularly aiming at the U.S. medical tourism trade and not interested in being subject to U.S. regulations.  They expect to be able to start out 30% cheaper than U.S. competition and plan to discount even further in the future.

Narayana seems to be coming at solutions from a different angle, and perhaps they see the problem differently. 

Sometimes I view our health system as being like the U.S. auto industry in the early 1970’s: insular, inefficient, split into oligopolies, and turning out products that are often neither high quality nor what consumers really want.  I worry that our health care system is working on the equivalent of adding a couple miles to the MPG, increasing the number of cupholders, and figuring out how to allow hands-free texting -- while somewhere in the world someone is perfecting a portable teleporter that will make cars unnecessary altogether. 

The science fiction writer William Gibson once famously said, “the future is already here – it just isn’t evenly distributed.”  I think of this particularly in terms of technology diffusion, with the implication that technologies which will be omnipresent fifteen or twenty years from now almost certainly already exist.  The trick is figuring out which ones they are and how to best make use of them.

Again, clarity on the problem is required in order to develop the right solution.

Formulations of the problems with the U.S. health care system abound.  Of course, the problem that the Affordable Care Act tried to solve was the shockingly high number of Americans without health insurance.  After all, most experts seem to agree not having health insurance is bad. 

Still, the problem of lack of coverage may be poorly formed.  Evidence of this may be found in the so-called Oregon Medicaid experiment.  Oregon was forced to randomly choose which residents qualified for an expansion of their Medicaid program, allowing for a real-life controlled study.  The results found that those who got the new coverage did, in fact, end up using more health services, including preventive care, but they didn’t find any significant improvements in measurable health status.

Perhaps lack of coverage isn’t the real problem we should be addressing.  

Well, then, there is the problem of cost.  Most would agree that our health care system costs too much, with spending that is far more than other countries, whether measured by per capita spending or share of GDP.  There’s no mystery why this is, as it has been fairly established (e.g. “It’s The Prices Stupid,” by Anderson, et. alia over a decade ago) that we simply pay health care providers more than comparable providers in other countries.  And we just keep doing it. 

Then again, we probably also spend more on, for example, automobiles or computers, than other countries (and we certainly devote more resources to defense and prisons), and we pay far more to, say, CEOs or professional athletes too, so perhaps neither the “excess” spending nor the high incomes are really unique problems of health care in the U.S. 

Many think that the problem is that, despite our inflated spending, we have very mediocre results compared to other developed countries, such as when looking at life expectancy.  Ipsos Research recently issued a report card for patient satisfaction with health care systems in 15 countries, and the U.S. scored only a gentleman’s B.  A Commonwealth Fund found that we lag on access to care and affordability of care as well.  Whatever we think we’re buying for all that spending, it’s clearly not better health. 

Still, even this is sometimes explained away with references to underlying cultural differences, like gun ownership, poverty, or traffic fatalities, that are not the fault of the health care system nor readily amendable to fixes to it. 

Politicians continue to claim we have the best health care in the world.  They might want to temper that based on the skewering The Daily Show recently gave that claim.  The truth is that, while it is certainly possible to get some of the best care in the world here in the U.S., that level of care is not uniformly available.  Whether you get the best care, average care, or poor care depends on lots of factors – where you live, insurance status, and race/ethnicity, to name a few.  

These variations are certainly a problem, but they’re not really unique to health care either.  For example, it’s often hard to find grocery stores in low-income areas, and if you have a particularly thorny legal problem you may want a lawyer from New York or Washington D.C.  Very few goods and services are uniformly distributed in terms of quality or availability.

One of the big problems with our health care system is that it often seems we don’t quite know what we’re doing. I’ve complained about this before (e.g., But Which Half?), and it doesn’t take much effort to find new illustrations of this: despite supposedly having one of the toughest regulatory processes in the world, FDA recalls of already approved medical devices doubled in the last decade; saturated fats don’t cause heart disease after all; new guidelines would put 13 million more people on statins; maybe routine mammograms shouldn’t be.

Honestly, it’s dizzying, and it’s harder and harder not just for consumers but also health care professionals to figure out what the “right” choices are.  Yet when ACA included the Independent Payment Review Board to try to rationalize (not ration, mind you) Medicare spending, it was greeted with accusations of it being a “death squad.”  Evidently not everyone agrees on this problem either.

One reason people get frustrated with our lack care system is because care is often so uncoordinated, even though we know both intuitively and empirically that coordination should be better for both the patient and for spending.  It’s hard to see how we ever even let this become a problem, since all parties supposedly have the patients’ best interests in mind, yet we did.  ACA did start the ball rolling on ACOs, which should improve coordination, but that ball still isn’t rolling very fast, with 60% of physician practices still reporting they don’t participate in an ACO, and don’t plan to anytime soon.  Care coordination may have to wait too.

Whatever the problem is, we’re just not very happy with our health care system.  A Rasmussen survey found that only 32% rated our health care system as excellent/good – and 32% rated it poor.  A year ago those figures were 40%/24%, so the needle is moving in the wrong direction.  The Commonwealth study referenced above found far more Americans thought our system needed to be completely rebuilt than citizens in other countries, with more than twice as many (27%) such respondents than the next highest country.

One way or another, we need changes, but hopefully ones that don’t seem like we’re just muddling along one tentative step at a time.

Maybe the future will be recognizable, like Narayana Health, or maybe it will be something already at least on the horizon, like gene therapy.  Perhaps it will be something even more unconventional, like nanotechnology, that will make the practice of medicine obsolete.  I don’t know what’s going to happen, but I’m fairly certain it will take someone radically redefining the problem, and coming up with a solution we aren’t expecting.  Moreover, I’m willing to bet someone is already working on it.

To use another, more well-known Albert Einstein quote: “we cannot solve our problems using the same thinking we used when we created them.”