When hospitals make errors, patients end up injured, have longer hospital stays and some 100,000 or more die each year as a result. If patients are discharged too soon or without adequate care instructions, follow-up doctor appointments and few links to community or home-care services, those patients often end up bouncing right back into the hospital in fewer than 30 days.
From these blunders come significant costs—measured in terms of injury and death as well as dollars spent on “measurable medical errors” (those that cause harm to patients) and higher hospitalization charges. According to an April 7 report in Health Affairs, medical errors now cost our over-burdened health care system some $17.1 billion a year; the cost of avoidable hospital readmissions adds another $13 to 18 billion dollars a year.
Another study in the same issue of Health Affairs found that up to one-third of all hospital stays lead to hospital-related injuries ranging from serious acquired infections to deadly surgical mistakes. Don Berwick, the Administrator of the Centers for Medicare and Medicaid Services, said the study “raised the stakes by finding … that the number of adverse events could be ten times greater than we originally thought.”
As President Obama and Congress debate significant funding cuts to Medicare and Medicaid, the Department of Health and Human Services (HHS) is moving forward with initiatives already financed by the Affordable Care Act that do just the opposite. They are designed to exact savings in these programs by investing in initiatives and protocols that show promise in improving patient safety and in reducing hospital readmissions.
Evidence of this stepped-up approach was clear last week with the first-ever release of hospital-specific patient data that determines the number of “never-events”–eight serious, costly errors that CMS maintains should never happen–for example, foreign objects left in the body, patient falls and traumatic injuries, infected catheter sites, and serious pressure sores. The data are culled from a review of hospital bills submitted to Medicare for elderly and disabled patients between October 2008 and June 2010. Over strong objections from hospitals and their lobbying groups, (who question the accuracy of the data and managed to delay its release twice since the study was completed) CMS finally decided to publish the raw data on its “Hospital Compare” website.
Despite the fact that since 2008 Medicare has refused to reimburse hospitals for costs associated with these hospital-acquired conditions and stipulates that patients should not be billed for them either, “never events” still occurr far too frequently.
“More than 400,000 Medicare ‘never events’ occurred in the United States in 2008, with an estimated total cost of $3.7 billion,” write the authors of a new report in Health Affairs titled “The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors,” adding that the “cost of these events constitutes 22 percent of the total cost for medical errors.”
Unlike other hospital-specific information on Hospital Compare—for example, patient satisfaction scores; hospital readmission rates for certain heart conditions; 30-day death rates—the hospital acquired conditions data is presented as an unwieldy Excel file. In its current state (CMS plans to make it more accessible to the public later this month) the data set doesn’t allow easy comparison between hospitals unless you are very good at wading through and extracting information from a complicated spreadsheet.
Fortunately, Chicago Tribune reporter Judith Graham is more capable than I of doing just that. Graham found that, “All of Chicago's top medical centers appear on the list of hospitals with safety issues.” She notes that “the University of Illinois at Chicago Medical Center, the University of Chicago Medical Center and Rush University Medical Center all reported higher-than-average numbers of hospital-acquired bloodstream infections associated with catheters.”
But collecting—and eventually publishing—this data has spurred some Chicago hospitals (and presumably others around the country) to instate patient safety improvements. Graham reports; “Chicago's Resurrection Medical Center recorded 18 patient falls, the highest number in Illinois, during the period covered. Since then, the …facility has introduced hourly rounds where nurses check on vulnerable patients, asking if they need help going to the bathroom or reaching call buttons, to keep people from getting up unexpectedly and taking a tumble.”
She continues; “Chicago's Mount Sinai Hospital had the highest rate of older patients with serious bedsores, with seven such incidents. After becoming aware of the problem, the hospital…hired a second wound-care nurse in the fall of 2009. Now, its electronic medical records system automatically alerts a wound-care nurse when a patient is deemed likely to have serious skin problems.”
Despite continued complaints about the newly-public CMS data from doctors and administrators, the idea is not to punish providers for committing these errors, but to try and create a triage system for identifying the most urgent problems. Accountability and transparency are absolutely imperative if hospitals want to make major strides in improving patient safety. Quantifying the problem of medical errors is the first step in figuring out the best ways to reduce them.
For starters, the Health Affairs study notes that pressure ulcers were the most common measurable medical error found in all hospitals, “followed by postoperative infections and by postlaminectomy syndrome, a condition characterized by persistent pain following back surgery.” The authors found that just “ten types of errors account for more than two-thirds of the total cost of errors, and these errors should be the first targets of prevention efforts.”
As the Affordable Care Act’s provisions move forward, hospitals will find themselves rewarded for quality (for example, hospitals with better outcomes for stroke and heart attack patients and lower hospital-acquired infections rates, will receive higher payments). They will also be penalized for avoidable errors—starting in 2014, Medicare will cut payment by 1 percent to hospitals that have the highest rates of patient safety issues, for one. But the law also recognizes that using a “because I said so” approach to improving safety will be hard-pressed to bring about the desired results.
In recognition of this, yesterday HHS Secretary Kathleen Sebelius announced a new $1 billion funding initiative called Partnership for Patients that is designed to achieve two goals: reduce preventable injuries in hospitals by 40 percent; and cut preventable hospital readmissions by 20 percent. “Reaching those targets would save up to $35 billion over the next 10 years,” Sebelius said, adding that $10 billion of that would come from Medicare savings. “That's a return of up to $10 for each dollar we're investing.”
Funding for this initiative is already included in the ACA so it can’t be easily derailed by budget cuts. The Community-based Care Transitions Program has pledged to provide $500 million in grants toward community-based organizations that partner with hospitals to reduce 30-day hospital readmissions. (On April 6, the Commonwealth Fund published a relevant paper, “Reducing Hospital Readmissions: Lessons from Top-Performing Hospitals” that presents four case studies of hospitals with “exceptionally low readmission rates.” The case studies are provided in order to offer other groups insight into the best practices for ensuring smooth care transitions and keeping patients from bouncing right back into the hospital.)
In addition, CMS—working with hospitals and organizations that develop best practice and patient safety protocols—will pitch in up to $500 million more to achieve the Partnership's other goal of reducing preventable errors. The initiative has won the backing of health care stalwarts like hospital groups, insurers, the American Medical Association and Consumers Union.
The recent movement toward increasing patient safety and reducing the costs of preventable errors and readmissions comes at a vital time. After accusing Democrats of trying to gut Medicare during the mid-term elections, Congressional Republicans are now proposing to slash funding for the program by $450 billion. This indiscriminate budget cutting reeks of the bold but rash gesture. The Ryan budget plan would go even further, completely transforming Medicare by turning it into a voucher system that would force seniors to buy private insurance plans on an open market.
Although Obama continued to try and appease conservatives by committing to major cuts to social programs in his budget framework speech this afternoon, the recent actions taken by HHS clearly signify that the administration has not abandoned key provisions for reducing health care costs by improving hospital quality and accountability. Yes, there may have to be painful cuts in Medicare and Medicaid, but they should not be at the expense of efforts that require modest spending to reduce waste, errors, over-treatment and poorly integrated care. Spending $1 billion on efforts to prevent serious errors and frequent hospital admissions that drive health care costs up tens of billions of dollars makes infinitely more sense than slashing blindly at important social services. Why is it so difficult for so many conservatives to grasp this logic?