When the government announced last week that a patient safety partnership with hospitals had saved 87,000 lives and nearly $20 billion over four years, there was an oblique reference to the role played by “financial incentives.”
Left unsaid was that a quiet effort has been going on for years to persuade hospitals they can make more money preventing harm than by allowing it to occur. In recent years, that’s included articles in the medical literature looking at the profitability of preventing serious bloodstream infections in critically ill infants in the neonatal intensive care unit (NICU) and in kids with leukemia.
For adults, there have been analyses of the financial impact of serious infections and surgical complications. In a presentation I heard earlier this year, a vendor mentioned the return on investment (ROI) of a technology that more rapidly detects when a post-surgical patient unexpectedly stops breathing.
These appeals to the bottom line (coupled with mention of the moral imperative, of course) stand out even more when one considers the context. It was back in 1999 that the Institute of Medicine issued its landmark To Err Is Human report estimating that up to 98,000 Americans died each year from preventable errors in hospitals. The IOM set a ten-year goal of reducing that number by half.
Yet by 2010, a New England Journal of Medicine study that merited page one New York Times attention found no substantial progress. I attributed the decade’s dearth of death reduction to a combination of the invisibility of error (it’s often not egregious), clinical inertia and income. Since then, preventable death estimates have gone as high as 400,000 a year; about 100,000 deaths and more than 1 million injuries is a conservative figure. A study published just two months ago found medication errors in half of all surgical procedures.
To be clear: no one is accusing hospitals ever deliberately ignoring imminent hazards. But most patient harm isn’t precipitated by loose-hanging wires or loosely qualified doctors and nurses. It results from a series of small, “less-than-best-practice” problems that ineluctably add up to avoidable patient injuries and deaths. Fixing them requires time, money and consistent clinical and management commitment.
As recently as 2006 the Society for Healthcare Epidemiology of America (SHEA) felt that to obtain that kind of support it had to teach its members to make the business case for infection control. “While society would benefit from a reduced incidence of nosocomial [treatment-caused] infections,” the society noted, “there is currently no direct reimbursement to hospitals…funding infection control activities.”
“No direct reimbursement” was a euphemism. As another physician noted in a journal article that same year, “a tacit but potentially significant barrier” to hospital management support was “a widespread but unsubstantiated belief” that serious infections substantially raised reimbursement.
Medicare, which accounts for about 40% of the average hospital’s revenues, began changing its payment rules in 2008 under the Bush administration. Since then the program has put out a growing list of “never events” it won’t pay for, ranging from amputating the wrong limb to some common infections. Separately, the 2009 economic stimulus legislation that granted hospitals and doctors billions of dollars to buy electronic medical records gave rise to rules requiring they use those systems to reduce medication errors and other hazards.
The potential profitability of harm has also gotten a higher public profile. A 2013 study in JAMA gave a long list of surgical complications resulted in a “higher per-encounter hospital contribution margin.” These included life-altering conditions such as a heart attack or stroke. Harvard’s Atul Gawande, a surgeon, study co-author, patient safety activist and author, told the Wall Street Journal the study was triggered by frustration. He’d seen the impact of a “simple checklist in surgery that we’ve shown to reduce complications by more than one-third, but people weren’t adopting it,” Gawande said. “We wondered whether finances were playing a part.”
Speaking of finances, the Department of Health and Human Services (HHS) told me in early 2012, shortly after the partnership with hospitals was launched, that it planned to invest $500 million over the first three years of the “hospital engagement networks.” The money has gone to the American Hospital Association and other organizations to create “learning collaboratives” of hospitals to share best practices to prevent injuries and complications. This “Partnership for Patients” has been controversial, with some academic experts doubtful about how data is collected and reported.
Studies of the impact of Medicare’s non-payment policies have also been equivocal. (The dollars at stake are often small.) Employers and health plans, who ultimately get stuck with the bill, remain skeptical there’s really a new ROI reality. As a study in the journal Health Affairs noted, “The impact on hospitals of reducing surgical complications suggests many will need shared savings programs with payers.”
Translation: One man’s costs are still, often, another man’s profits.
Here’s my best guess on what’s happening: the price “signal” provided by Medicare is real and is being amplified by the larger health system changing reimbursement from “pay for volume” to “pay for value.” In other words, if the bottom line hasn't yet changed, it's about to. Add in that many hospitals were starting to focus on safer care for the right reasons, that the engagement networks are run by peers and that these networks provide social support. (Think of it as Weight Watchers for patient safety). The net result is a significant shift in behavior.
As I’ve written for a long time, the push for safer care has had much less urgency and been much less far-reaching than it can or should be. Perhaps the latest results of the HHS-hospital partnership herald a new patient safety culture finally taking hold. That’s a nice thought this holiday season. Meanwhile, it remains critically important to support better data collection, greater transparency of individual hospital results and more focused purchasing by health plans, employers and consumers alike in order to reward those whose first priority is, truly, “first do no harm.”
