Patient Safety Focus

If Higher Quality Care Costs Less, Why Does Health Care Still Produce Potentially Avoidable Complications? -- by Francois de Brantes, MS, MBA

 

For years, healthcare services researchers have maintained that there is little, if any, link between the cost of care and its quality. They drew this erroneous conclusion by using both flawed data and flawed methods of analysis.  The researchers used claims data to measure quality (flawed data because quality can only be reliably measured using medical records), and looked at total costs of care (flawed method).

 

During the past several years we have focused on improving our understanding of variation in the total cost of care, using defined windows of time to bound medical episodes of care.  For example, we can reasonably bound a medical episode for acute myocardial infarction within a 30 day time window, including the hospitalization of the patient and any care post-discharge during the balance of the window.  As we’ve performed these analyses, we noticed that we could split the total costs consumed during these windows of time into two components — typical or evidence-informed care (costs that are to be expected in such cases) and costs associated with potentially avoidable complications (costs that should not occur if care were delivered optimally. What we found is that these potentially avoidable costs consume anywhere between 15% and 20% of all dollars spent in the US health care system.  More importantly, we also found that higher quality providers had far fewer costs associated with potentially avoidable complications and that, as a result, their episode costs were also lower.

So if better quality costs less, why aren’t we seeing providers rush to improve the quality of care they deliver and lower overall costs? Because the way they’re paid encourages them to do the opposite. If a patient develops an infection during a hospital stay, the hospital gets more money due to a longer stay and the attending physicians bill for more services. No wonder then that health care costs are rising faster than the general rate of inflation.  And until we get the payment incentives right, it’s hard to see how we will ever achieve a high-performing health care system. The bottom line today is that what we call potentially avoidable costs, someone else in the industry is calling revenue.  That has to change.

 

Francois de Brantes, MS, MBA is CEO of Bridges to Excellence and Prometheus Payment, Inc.

 

 

Aetna Tightens Programs Regarding Serious Reportable Adverse Events

Building on its past efforts and those of other public and private health insurance organizations, Aetna announced today that it is taking several steps to strengthen its patient safety programs.

For patient members, Aetna is providing information on its member Web site about how patients can protect themselves from medical mistakes.  Public information with this type of advice is available from the U.S. Agency for Healthcare Research and Quality, which came out with a tip sheet shortly after the publication of the Institute of Medicine's report To Err is Human in 1999. 

Aetna will also require that facilities, physicians and other health care professionals waive charges for care during which the wrong surgery is performed, surgery occurs on the wrong person or on the wrong body part or side of the patient's body, as well as for eight other serious reportable adverse events (also known as "never events").

To encourage hospitals to learn from such mistakes, Aetna also requires that when a serious reportable adverse event happens to an Aetna member, hospitals must:

• Alert Aetna and either The Joint Commission, a state reporting program, or patient safety organization;
• Analyze why the event occurred and how to improve processes in the future to keep such an event from happening again; and, 
• Communicate with the patient or patient's family about the event.

More Hospitals Agree to Take Key Steps When "Never Events" Occur

More hospitals than before have agreed to take key steps when a “never event” occurs during the course of care in their facilities.  Never events – serious reportable adverse events that should never happen during course of care – include surgery on the wrong body part, certain surgical site infections, and leaving a foreign object inside a patient’s body during surgery. 

 

These findings come from the 2008 Leapfrog Hospital Survey, which just announced that 63% of hospitals participating the Survey have agreed to:

• Apologize to the patient or family affected by the never event;

• Report the event to at least one of the following agencies: the Joint Commission, a state reporting program for medical errors, or a Patient Safety Organization;

• Perform a root cause analysis consistent with the instructions from the chosen reporting agency; and,

• Waive all costs directly related to the serious reportable adverse event.

This is an increase over last year, when 52% agreed to the policy.

 

For a recent interview we did with Leapfrog Group CEO Leah Binder, go here.

Medicare Encouraging Patient Safety through Financial Disincentives -- by Lisa Hayden Espenschade

On October 1, 2008, Medicare placed new financial responsibilities on hospitals for certain “reasonably preventable” hospital acquired conditions.  In addition to Medicare’s new policy, covered here in more detail previously, private insurers are following suit.

 

Catheter insertion is associated with two conditions on the list: vascular and urinary tract infections. Medicare is also targeting surgical site infections after coronary artery bypass and some other orthopedic and bariatric procedures.

 

These three types of infections accounted for 42,096 cases in fiscal year 2007, according to the Centers for Medicare and Medicaid Services. Vascular catheter-associated infections are the worst offender on Medicare’s list--affecting 29,536 patients in 2007. Bladder catheterization is linked to another 12,185 infections.

 

Economic incentives, such as no longer elevating payments to cover the costs of preventable complications are likely to motivate improvement, but to improve, hospitals need effective systems designed to prevent the medical errors in the first place.

 

Many prevention principles – particularly hand hygiene – apply to both these types of catheter-related bloodstream infection (CR-BSI).  This is where Hospital Video Auditing (HVA) can help:  it gives 24/7/365 monitoring for adherence to safety practices and protocols and encourages health care workers to both improve and sustain their performance. 

 

Previous posts on CR-BSIs include:

Hygiene. A study at Huguley Memorial Medical Center in Fort Worth, TX, looked at simple measures for limiting infection: practicing hand hygiene, avoiding femoral lines because of proximity to the groin, using gloves and other physical barriers, and monitoring the appearance of lines.

Checklists. Atul Gawande’s December 10, 2007, article in The New Yorker detailed infection prevention research from Peter Pronovost, a critical-care specialist at Johns Hopkins Hospital. Pronovost found providers often skipped crucial steps during line insertion. Our post excerpting Gawande’s article includes information on hospital culture and successes using checklists.

Studies, Statistics & Safety. Robin Walters, RN, BSN, notes studies about costs of CR-BSIs plus strategies and guidelines for prevention. Among them: the Central Line Bundle from the Institute for Healthcare Improvement and participation in infection prevention collaboratives like the 5 Million Lives Campaign and the National Healthcare Safety Network.

Lisa Hayden Espenschade is a freelance writer based in Scarborough Maine who has written on genomics, gene therapy, stem cells, and other drug discovery topics, as well as other biotechnology issues.

 

Interested in submitting content to PatientSafetyFocus.com? Please go here to learn more.

Medicare and Medicaid increasing incentives to reduce "never events"

The Centers for Medicare & Medicaid Services (CMS) announced on July 31, 2008 that it is taking several additional actions to improve the quality of care in hospitals and reduce the number of "never events" -- preventable medical errors that result in serious consequences for the patient.

For the Medicare program, CMS has provided additional incentives for hospitals to improve the quality of care provided to people with Medicare, including payment provisions to reduce never events that occur in hospitals.  In addition, CMS sent a letter to state Medicaid directors providing information about how states can adopt the same never events practices. Almost 20 states either have already eliminated or are considering eliminating payment for some never events.

Last year, CMS listed eight preventable conditions for which it would not make additional payments.  This year it is adding three:

• Surgical site infections following certain elective procedures, including certain orthopedic surgeries and bariatric surgery for obesity
• Certain manifestations of poor control of blood sugar levels
• Deep vein thrombosis or pulmonary embolism following total knee replacement and hip replacement procedures

Many private insurance companies have now implemented similar policies as covered by Patient Safety Focus earlier.

New York proposes landmark legislation for patient safety

New York Governor David Paterson (pictured left) has announced legislation that works to dramatically improve patient safety and better facilitate the prevention and response of infectious disease transmissions (as well as prevent future infection control violations).

All told, the Governor's Program Bill increases the authority of the Department of Health (DOH) in epidemiological investigations while providing consumers with access to more information about physicians--particularly those charged with misconduct.

According to Governor Paterson, “It is critical that our system of disciplining physicians be as strong as possible to ensure that cases of misconduct are uncovered, reported and acted upon – even as we remain mindful that persons charged with misconduct have a due process right to challenge such charges. The improved access to information will also lead to better health care for the entire State of New York.”

The legislation is focused on illuminating misconduct by physicians, malpractice claims and legal actions, so as to better inform the public of potential threats. And among its myriad points, the bill also includes that course work or training in infection control practices, already required for physicians, physician assistants and specialist assistants, must also be completed by every medical student, medical resident and physician assistant student--along with documentation of such training.

In his comment, New York State Health Commissioner Richard F. Daines, M.D. said: “This bill strengthens patient safety by updating current law to the way medicine is practiced today. Thanks to Governor Paterson's support, the State Health Department will have clearer authority and access to more information to assist in medical conduct investigations. Patients also benefit from access to more information about the physicians who provide their care.”

The bill appears to advance much of medical reporting to where it should already be; so it is a positive step forward. But what we encourage and implore--in addition to these measures--are systems that prevent human error in the first place (not just reporting them after the fact so as to prevent additional ones). After all, systems, like HVA, that continuously monitor on a 24-7 basis for many of the issues leading to hospital-acquired infections, and immediately alert hospital staff to potential issues, have already shown to improve compliance rates from 38% to 98+% and kept them there.

Full article on Governor Paterson's legislation is located here.

"No Pay" Policies Now Mainstream

Along with Aetna and Wellpoint, Anthem Blue Cross and Blue Shield and Medicare and Medicaid, now CIGNA insurance will no longer reimburse hospitals for preventable medical errors (PMEs). These reimbursements currently pertain to "never events"--which are errors in patient care that can and should be prevented, like operating on the wrong area and administering the wrong blood type (learn more about "never events" here).

The policy will become effective as of October 1, 2008 and, according to CIGNA, “CIGNA is committed to improving quality for our members throughout the health care system,”  said Jeff Kang, MD, chief medical officer for CIGNA HealthCare. “Our policy on never events and avoidable hospital conditions is designed to put patient safety first and to encourage hospitals to improve quality  every day, one patient at a time.”    

Helen Darling, president of the National Business Group on Health, remarked “Hospitals, health care professionals and health plans must all work together to ensure that ‘never events’ never happen, avoidable conditions are always avoided, and every patient receives quality treatment in a safe and caring environment.”    

There's now little doubt that "No Pay" policies have hit mainstream...the question now is how long it will take to progress from never events to cover more PMEs.

Full news release located here.

More Insurers Say "No Pay" to PMEs

A few months back we asked if the tides were turning. Now it appears those waves are gaining momentum.  No longer isolated to Insurance Companies' Aetna and Wellpoint, Anthem Blue Cross and Blue Shield in New Hampshire announced Thursday that it will no longer pay for Preventable Medical Errors (PMEs).

According to the article: "Anthem called the move an initiative aimed at working toward eliminating preventable major adverse medical events in order to lower health care costs.

From the standpoint of Donna Fitts, the vice president of Quality and Risk Systems at Portsmouth Regional Hospital, this decision by a major insurance carrier will have a positive impact on hospitals across the state, including her own. 'It will force us, in a very busy medical environment, to stop and take stock of the things we do,' Fitts said. 'It is crystal clear that many of these things are errors that should never occur in a hospital."

According to Anthem: "The primary focus of these efforts will be to ensure that physicians and hospitals are using appropriate processes, technologies and strategies to address 'never events' and, ultimately, to enhance the quality of care delivered to hospitalized patients," said Richard Lafleur, M.D., medical director, Anthem Blue Cross and Blue Shield in New Hampshire. 'We continue to work collaboratively with physicians and hospitals to analyze why and how these events occur, and to proactively find ways to improve patient safety and clinical care.'

In addition to improving patient safety and quality outcomes, Lafleur added that the initiative will help protect Anthem's members from additional costs resulting from medical errors. 'As a strong advocate for patient safety, we have a responsibility to our members to work with our hospital partners to put processes in place that focus on preventing these events,' said Lafleur."

Full article here.

Turning the Tide? Insurers say "No Pay" to Preventable Medical Errors.

In what could be the turning point for the hospitals getting dramatically more diligent on preventing medical errors, Aetna and WellPoint have taken a bold, and needed, stance: no more paying for preventable medical errors.

According to an article in The Wall Street Journal:

"The companies are following the lead of the federal Medicare program, which announced last summer that starting this October, it will no longer pay the extra cost of treating bed sores, falls and six other preventable injuries and infections that occur while a patient is in a hospital. The following year, it will add to the list hospital-acquired blood infections, blood clots in legs and lungs, and pneumonia contracted from a ventilator.

Private insurers are looking first at banning reimbursements for only the gravest mistakes. But health-insurance executives say it is only a matter of time before the industry also stops paying for some of the more common and less clear-cut problems that Medicare is tackling, such as hospital-acquired catheter infections or blood poisoning. "I'd rather have the cudgel in place first than push the list too far," says Aetna President Mark Bertolini.

Some hospitals and others are concerned that the new strategy could drive up medical costs in other ways as hospitals absorb or pass on the expense of introducing the safety and screening procedures needed to help avoid mistakes.

Ultimately, insurers say, the efforts will trigger safety improvements and savings for patients."

But the policy is not to save the insurers money, it's to save lives. According to, Thomas Granatir, director of policy and research at Humana, Inc.--which is working on a policy similar to Medicare's, "It's not a matter of not paying for them. It's about getting them not to happen in the first place."