Why should costs of Never Events be shifted to private insurance premiums?

Let’s look at non- payment for “Never Events”. The IOM report, “To Err Is Human”, stated as many as 98,000 die annually as a result of medical errors. These errors not only result in unfortunate health consequences but also direct and indirect costs borne by society as a whole. A medical error is the failure of a planned action to be completed as intended or use of the wrong plan to achieve an aim. Not all adverse events are the result of medical error, but adverse events that are the result of error are classified as preventable. Authors of the IOM study estimated the national costs of adverse events to be $37.6 billion and of preventable adverse events to be $17 billion. For instance, 4% of national health expenditures were associated with adverse events.

Reporting adverse events can serve two important functions: providers can be held accountable to performance, but more importantly, adverse events can provide information that leads to improved safety. I have always thought there is little incentive for a hospital to tackle adverse events since there are no financial consequences other than litigation. In fact, medical errors actually can make a routine surgery (as my husbands laparoscopic gallbladder) into a series of surgeries and income to a hospital. My husband’s insurance company actually tried to recover more than they contractually had to pay out.

In the Union Leader Article “It Should Never Happen”, Steve Norton, Executive Director of the NH Center for Public Policy, said the consumer is likely to see hikes in health-insurance premiums. He said, “ There is no reason why the cost of these never event services wouldn’t be shifted onto private insurance premiums.” I do not understand this statement. Why should private insurance premiums go up? I can understand maybe the uninsured would suffer from this but why private insurers such as BCBS since the insurer would be saving money. Here lies the problem. Is it true that hospitals will shift these costs onto the consumer without consequence to themselves? This was not the intent of mandatory reporting. Mandatory reporting with analysis of where things went wrong was supposed to decrease these events with huge health care savings to the consumer. I fail to see how this makes hospitals accountable for change if there are no consequences. Maybe the events should be shifted from the outrageous salaries of hospital CEOs making upwards of 700,000. It seems to me this feeble attempt not to pay will not affect hospital receivables at all. Poor quality health care costs a lot of money and we are all paying for it.

Never Events vs. Preventable Adverse Events

For almost a decade, since my husband’s death, I have been studying patient safety issues and medical errors. I was disappointed that the Union Leader article “It Should Never Happen” (Oct., 12, 21008) did not give clear and concise information to the public. During both articles in a two part series it was referred to the 98,000 “Never Events”. The IOM study clearly defines adverse events as an injury or death due to medical intervention (not an underlying problem). Those events due to medical error are considered preventable. The 98,000 preventable adverse events referenced in the IOM study are not necessarily those 28 “never events”. Let me suggest the “28 Never Events” developed much later by the NQF does not come close to investigating all instances of “system failures” that are accountable for the death or serious injury of patients.

The IOM study recommended nationwide mandatory reporting of errors by hospitals to local governments when the error results in serious injury or death. Hospitals have resisted this. Many preventable adverse events (medical errors) are due to the medical staffs inability to identify a critical situation and act upon it. Many errors fall into the category of “Communication Errors”. Some are due to complacency, lack of knowledge, poor surgical training, lack of judgment or medical narcissism. There are many articles and books devoted to medical error and it’s association with medical narcissism.

The article also quoted Rep. Batula’ s interest. Rep. Batula was the head of a study committee of medical errors and patient safety back in 2003. This study committee went on for over two years. He did not do his homework and a watered down bill passed with the birth of NH Quality Assurance Commission. The people of NH deserve a good understanding of the issues involved. This issue takes hard work to implement a system that actually makes our hospitals safer.

Many people like my husband die from a serious known complication, in his case a bowel perforation inflicted on him during a laparoscopic gallbladder. For 55 hours, John sat on a ward with all the signs and symptoms of this fatal complication. It was clearly not diagnosed in a timely fashion. I was lied to about the severity of the surgical blunder. It was a “system’s inability to recognize a known complication” which resulted in my husband’s death. He sat on the ward, not ICU, and came so close to death that the surgeon involved operated a second time with no anesthesia because he was so critical. My husband always said, “People dying on the operating table is TV drama”. Although in the never event category for surgical error the patient would have do die on the table or in recovery. When I finally got my husband transferred to a tertiary center, he was operated on for a third time. And even though the surgeon gave him a zero chance for survival the staff kept him alive for a while. Let me suggest this never event reporting system does not come close to letting us know if patients are safe in our hospitals. What would it tell us about the rate of perforations? When perforations happen, it’s important to delineate when are they just considered complications or considered medical errors? Yes, I agree that no patient should get lost, assaulted or abducted from a hospital. Are those not criminal actions?
I believe in mandatory reporting of adverse events but not just the NQF never events which do not, I feel, do justice with the real problem of patient safety. On a positive note, I believe it is useful for the public to understand not only who uses the Rapid Response Team but if it is even effective. This is an issue of accountability and if our hospitals are doing a good job at making our hospitals safe for their patients. With no transparency and tracking of these adverse events, I believe trust will continue to dwindle.


NH Board of Medicine Takes On System Failures

After attending the committee meeting of the audit of the NH Board of Medicine, I was stunned that this board issues confidential letters to facilities about system failures. Dr. Cervenka enlightened the committee that the board felt it was their duty to advise and alert facilities when ,in fact, it was not the error of an individual doctor but a system failure. Although I agree that systems do fail in most instances, I was stunned that this board, which rarely acts on substandard care given by physicians, felt they should send confidential letters to these facilities and had the right to do this. In fact, the Department of Health and Human Services (DHHS) administers this chapter (RSA 151) through their Bureau of Health Facilities Administration. The Board is supposed to submit their system failure concerns to the Bureau. Whether this bureau does it’s attended job will be addressed in a later blog. I sat in disbelief since this board seems stretched too far to thoroughly act on their mandated responsibilities but feels the need to advise health care facilities on their failures. All concerns by law should be submitted to the bureau. I will suggest to you that this practice does not make the people of NH safer. In a confidential letter they are alerting these facilities about complaints going forward. The people do not know anything about the “system failures” and the board is not sure of the steps these facilities take to change these failures. At the audit meetings a common theme of “transparency” has been echoed by all and I am amazed that this committee seemed to be weighing towards giving this board the authority to alert facilities with out knowledge to the public, no follow-up necessary. Superficially this may be explained as positive step toward better quality but I think it could also be looked at as a way to alert facilities that may or may not use this information in a positive way.

An example given by the board certainly missed the mark in my book. A healthcare facility was found to not give their patients a release to sign before a vaccine was given. The patient had some kind of devastating consequence after this vaccine and probably through findings from the litigation process it was uncovered. (The board receives all copies of writs submitted to the courts.) It might help the facility to avoid litigation in the future. I do not think this example makes patients any safer.

Much discussion focused on a situation where an anesthesiologist felt targeted by the board for living 30 minutes away from a hospital that does c-sections even though the hospital was fine about this arrangement. The board felt this physician, although he claimed that there was not one instance where he was negligent, was not living up to the “best practice” standard. The complaint was anonymous. Was this political? After a year the board dropped action without any explanation. I understand why obstetricians would want such a standard in place. It is not sufficient to say that this anesthesiologist had not done any thing wrong. Should we wait until something happens to a mother or baby? I clearly understand the obstetricians’ concern but what is puzzling to me is why this is not a system problem? The hospital in question has decided to not follow best practice standards. This is where the board should not have pursued the complaint against the doctor but should have questioned the facility. Why does this hospital accept this practice? These are issues that should not only go to the Bureau of Health facilities but should also be made public. For some reason the NH Board of Medicine seems to make up their own rules and in many instances does not see the need to follow the rules that are all ready in place and for me that is the biggest problem of all.

Lack of Transparency Fuels Anger Towards the NH Board of Medicine

Each time I leave the House Committee Research meeting I wonder why so much time is wasted going over each observation of the Board of Medicine Performance Audit? Each observation and recommendation (there are 34 observations and recommendations) is read aloud by the auditor and the board then explains their response and objections to the recommendations. Is this really a productive way to understand the process of the board?

By the questions asked by some of the legislators, I do not think they understand the process any more than at the beginning of this marathon. I can relate since it took me years to try to understand the workings of this board. Finally, the committee members have a flow chart to try to understand the process of what actually happens when a complaint is submitted. I fail to see why the auditors are grilled so heavily. They are auditors for the state of NH and work out of the Office of Legislative Budget Assistant. The purpose of the audit was to determine how efficiently and effectively the Board of Medicine has administrated its operations and regulatory responsibility according to state law. They did not comment on the merit of a complaint with respect to medical care, a big problem with the NH Board. When the audit was released there was public concern and outrage. I often wonder if Rep. Irwin did not accept public testimony last May so the media would lose interest and it would be business per usual in Concord.

In the year 2007, the board had 14 actions with 5 actions on physicians that were reprimanded in other states and 1 termination of an action. There were only 8 actions by the state of NH. Of those actions not one was related to standard of care with the majority drug related or record related. Why are these numbers so small and why not one related to medical care? In the Union Leader article dated May 4, Dr. Sydney Wolfe, director of Public Citizen’s Health Research Group said nationally NH ranked about in the middle and seriously disciplined 10 physicians. Where did he get those numbers? Since as many as 98,000 people die each year do to medical errors, it is hard to believe not 1 physician in this state delivered substandard care. Colorado in contrast, had 106 board actions with 44 (41%) related to substandard care. (2006)

As I left the NH House Committee meeting on the audit of the NH Board of Medicine, I realized a common theme was the “lack of information” given to both the complainant and the licensee. If no information is given regarding the process of an investigation and how the board determined it’s outcome then both the public and the licensee feels betrayed by the system. Why is it so secretive? Why can’t the board easily explain the process by which they make a ruling? Is the board fair and honest in the process that they go through to come to some kind of action or no action? Why can ‘t they accurately inform the licensee or complainant of the process? Is it because the board and its administration do not view the process in a standard way and stick to the rules? Do they understand the rules and regulations? Those are questions I still cannot answer.

In a Union Leader article dated Nov. 1, 2005 a Portsmouth internist stated, “My big question is why the big secrecy if this could help doctors to learn and maybe prevent mistakes from being repeated? What are secret documents that the public should not see? Does the Attorney Generals Office dictate the board? Why do most doctors in NH choose to settle with the board? Is it to keep the true issue from the public? Some of the laws on hearings seem nonsensical. Since all hearings are public, even those exonerated, many physicians choose to settle so the public does not know the details of the investigation. Does this protect physicians from public disclosure? As you can see, I have more questions than substance. I have this sinking feeling that after this committee makes its determinations the people of the New Hampshire will still be in the dark when it comes to the NH Board of Medicine.

Accountability in the year 2008

I must apologize for my absence. Late June my computer started to malfunction, no one could fix it locally. It was under warranty so I decided to send it to IBM for repairs. Costumer service assured me it would be back in 7days. Almost a month later I still have no computer. I did exactly what IBM instructed to do; Put it in the delivered FED-EX box, paperwork was completed and FEDEX came to pick it up. That was the last my computer was seen. One laptop lost was the message I got from IBM after numerous phone calls and promises to call me back. In IBM language a call back means never or three or four days later after you have called to complain once again. There were no real apologies. Each department blamed the next department and finally blamed me for losing my computer. And so it goes, blame everyone else instead of just admitting mistakes and proceeding from there. Each phone call with rude and arrogant remarks began to fuel my anger. Each day I had to remind myself “chill” it is the lazy days of summer and no one is going to die from this. I received little assurance from management that any of these clerks would get spoken to about not following protocol.

Accountability is what makes people diligent at whatever job they do. When I worked at a large Boston hospital every laboratory test performed had to be initialed many times. When processing hundreds of specimens per shift an occasional initial might be missed even though the test was done correctly. The supervisor would question you to make sure you did the test and reminded you in no uncertain terms this was lax behavior and not tolerated. That was in the seventies…Today, I feel many people drop the ball on many levels. Sometimes a slip up on any of these levels can have devastating consequences. It is the system as a whole that many times fails the patient. My husband use to say the only accountability for the medical community is litigation. Administrators are not stopping bad things from happening. Nurses are not losing their jobs and for the most part the public can not get any information about their care and the care of their loved one. In many cases like my husbands the patient is blamed for the situation. Administrators are at the helm to develop a system that is accountable to their community. Unfortunately, that does not happen very often and those hospitals that are demanding accountability are few and far between. The loss of my computer is a miner glitch in my life but it is this attitude of non-accountability that forever changed my life eight years ago. We as patients must unite and demand a climate of accountability which has to be a part of the patient safety agenda.

Thanks to my daughter who graciously let me borrow her computer.

Leaders in Public Health-Are they getting it right?

Health care in the U.S. is the one area of the economy that both consumers (patients) and providers (doctors) have no idea what goods and services cost. The $2 trillion health care industry is a sector of our economy with little information about price and quality (http://www.aei.org/publications/pubID.24155,filter.all/pub_detail.asp.) It was reported ( Senz, New Hampshire Union Leader June 8, 2008 ) during her first New Hampshire visit, Dr. Julie Gerberding, director of the Center for Disease Control and Prevention, stated under the third party payer system, consumers who need a medical procedure seek out the most expensive provider because of a false belief that they will receive the best care. She later states “Consumers just don’t have the information they need to make value-based decisions.” She seems to contradict herself. I searched high and low for an evidence based study that pointed to this result. Do consumers base there decisions by how expensive a given treatment is? Let me suggest that they have no idea how expensive procedures are and if a patient tries to find out how much something is going to cost it takes an exhaustive amount of energy often without a definitive answer.

A good example is the recommendation of the CDC that all adults 60 years and older who have intact immune systems receive the shingles zoster vaccine (Zostavax). For years public policy officials have been saying just as Dr. Gerberding stated in her speech titled Health Care in the 21st Century, “the current system is a disease-care system, not a health-care system” Providers should focus on preventative care. My elderly neighbor visited her primary care physician who suggested she receive this vaccine. The doctor was practicing good preventative health care but there was one draw back-the vaccine is extremely expensive although the doctor was not sure of the cost. My neighbor tried to find out the cost. She called the local hospital. They could not tell her and suggested she contact her insurance company. She has Medicare plus a good supplemental plan. Finally, after an exhaustive search, numerous calls to the health insurance agency, she decided to have the vaccine since it seemed it was in the two hundred dollar range. A case that the doctor recommended a preventative measure that could possibly save money if my neighbor developed shingles but no easy answers to what my neighbor would actually owe if she received the vaccine. I credit her for her perseverance. Most people would have given up.

My guess the reporter did not actually understand what Dr. Gerberding was trying to say. Most Americans do not understand health care billing and I have encountered employees working for providers after many years do not really understand deductibles, co-pays etc, and can not easily give you a cost for a given procedure. Most conversations begin with it depends. Health care insurance policies since tied to third party payers (employers, government officials) is owned and controlled by the payers. Consumers do not drive the system. Decision making for the consumer is probably related more to reputation of a given provider (practitioner, hospital) than how much it costs. Many times it is a not even in the equation since the insurance company often dictates where a procedure will be done. For many years public policy have preached that our system is not health care but disease care. When are government officials going to support payment for preventative care? The U.S. health care system is costly, convoluted, inefficient, confusing and not equitable. Dr. Gerberding states the U.S. spends trillions of dollars on health care but is 37th in healthiest nations ranking. If the reporter misunderstood the director she gets a pass. It demonstrates how confusing it all is. I only hope that was the case. I hope you will give me a pass if a study does exist out there that supports this reported finding.

Let our legislatures know your experiences with the NH Board of Medicine-June 19, 2008

A two year long audit of the New Hampshire Board of Medicine uncovered many problems. The audit revealed the board did not investigate 21 percent of the complaints it received in 2005 and 2006 and found “weak if non-existent controls in many of the board’s regulatory and administrative operations (Union Leader, April 30, 2008). After an investigation by the Union Leader it was uncovered that “secret” documents instructing the staffers not to tell the truth to the public about the surrender of a doctor’s license mistakenly was filed with public documents. The Attorney General of New Hampshire is dictating to the board to lie to the public. This revelation in itself is enough for the citizens of New Hampshire to be outraged—never letting the public know the real impetus for the action of the board. What is the relationship with the board and the AG’s office? We need to get answers about the relationship of these two entities.

On May 13, I went to a hearing highlighting the observations of audit and the response of the medical board to these findings. The public was not allowed to speak. I had to sit back and hear the auditors challenged by the board members. Unfortunately, a lot of the time was taken up by the bios or should I say auto-bios of the board members that were present. After the meeting, I decided to try to reach out to some of the committee by explaining my blog and what I hoped to accomplish. I decided against it after the reaction of one of the committee members, Rep. Miller of Durham. I tried to explain my blog was about patient safety and medical error and tried to hand him my business card. He stated, I am a retired doctor and I am not interested in this and gave me back my card. Was he not interested in patient safety, medical error, or the concerns of the public? This response showed both arrogance and rudeness. He could have taken the card and later trashed it. How many legislatures on these committees are retired doctors?

The committee meets again on June 19, 2008 at 10:00 AM in Leg. Office Building (LOB) room 306-308. If you have concerns about the board and can attend the meeting please do. Speak if you would like to, just listen or email your concerns to anne-marieirwin@leg.state.nh.us. If you would like to email Sound Off, I will personally bring your concerns to the meeting (soundoffpatientsafety@gmail.com