The editor of the Boston Globe’s investigative reporting unit discusses his team’s landmark story that raises questions about the practice of concurrent surgeries and patient safety.
The debate over the safety of concurrent surgeries was ongoing when The Boston Globe’s team of investigative reporters tapped into it, says the paper’s Spotlight Team editor Scott Allen.
The Globe’s October 2015 series looked at complex orthopedic surgeries at Massachusetts General Hospital and beyond, raising questions about safety, clinical oversight, and informed consent. MGH bristled at the suggestion that patients could be harmed as a result of the way overlapping surgery is practiced. “Nothing could be further from the truth,“ it declared on the website it set up in response to the Globe‘s reporting.
Allen: Concurrent surgery is something that is well known within the hospital community and among surgeons. It’s something that doesn’t come as a great surprise, but many members of the general public had no idea prior to us publishing this story.
We covered a court case that had nothing to do concurrent surgery. But, in the course of the oral arguments, there was a sidebar discussion about the way the plaintiff handled a case where the surgeon had three different cases going at once. The reporter who covered the case was [health writer] Liz Kowalczyk and it stuck in her mind.
The case involved a trauma surgery where the resident was mixing the cement to begin a hip replacement, and when it was time for the surgeon to do the surgery, the surgeon wasn’t there. [The resident’s] got the cement and she’s wondering where [the surgeon] is and she doesn’t dare to do the procedure on her own. So the anesthesiologist goes looking for the surgeon... The anesthesiologist testified that never in her career had she had to leave the OR to find the surgeon who was supposed to be the attending.
We started doing some research on it and found extremely good sources because there was a very lively debate inside MGH and we tapped into that debate. That’s how we were able to do the story. This is complex material and it can be extremely difficult for lay reporters to go toe-to-toe with surgeons if you haven’t also got extremely good sources who can explain every bend in the road. And we did.
HLM: Is it possible to do concurrent surgery safely?
Allen: People certainly said that. I don’t hold myself out—nor does the team —as experts in how surgery should or shouldn’t be done… In the name of efficiency, it makes a lot of sense for the surgeon to get to the closing, turn it over to one of the residents or fellows and go to the next room where the opening has already occurred for the next surgery.
It is easy to understand how that sort of staggering [of workflow] make sense from an efficiency standpoint and doesn’t jeopardize the patient’s well-being in any way. You have people working at their appropriate level of responsibility from start to finish.
What we were talking about were complex spinal surgeries that could be overlapping by four, five, seven hours. And the surgeon needed to be simultaneously mindful of both cases and go back and forth between rooms to check in on his other patient.
There was the risk that if something came up, he could not be at the second place when he was needed. [This] was a scenario that most alarmed surgeons around the country when we shopped around for the state of opinion on double surgery… Those are the ones that really scared people and they were the ones that would have required the most delicate calibration and planning for them to work. That’s where a lot of the debate was focused, and that’s where the critics at MGH focused—poorly planned, substantial overlap, simultaneous responsibility for two cases.
HLM: On its web page addressing your series, MGH says the practice is “in compliance with federal and state guidelines” andwas reviewed and deemed safe by ”several external organizations.”
Allen: That’s what they said, but there were several things that convinced us that it was not a satisfactory response. It had not quieted the internal critics at all… For a long time, the report was kept so closely, that even people involved in patient safety had not seen the report.
We asked, probably ten times, if we could see it or get a summary of it and it was all lawyer/client privilege. They would not release it at all. They eventually released to their top people. It was never given to JCHO (The Joint Commission). It was never given to us, and it wasn’t given to the internal parties to the debate over double booking. It was never in any way summarized or provided to anybody, which to us was a major hole in transparency and accountability.
HLM: Can you talk about the kind of policies other hospitals have regarding concurrent surgery?
Allen: In hospitals that have not had a big, internal dispute about this, there is a pretty good chance they don’t have a well-articulated policy on concurrent surgery. To the extent they have one, it is just the Medicare guidelines. That is their de facto policy.
Medicare has pretty much never enforced the double-booking policy, so whether you follow it or not, there has been very little enforcement. So, what you had was a situation that was ripe for abuse. I’m not accusing any individual—but the potential was there.
HLM:CMS requires that “the teaching surgeon must be present during the critical or key portions of both operations. Therefore, the critical or key portions may not take place at the same time.“
Allen: There is no set of standards on what constitutes the “critical part“ of any surgery. So the individual surgeon who is doing the double-booked procedures is telling you what is the critical part of each surgery. That’s pretty obviously an enormous loophole. It’s undefined and it is up to the person doing the double-booking to decide what’s important.
HLM: What has your team learned about patient consent for concurrent surgery?
Allen: [Concurrent surgery] is not common knowledge among the general public and it not common knowledge among patients. The informed consent form is an important document. But, the fact of the matter is, patients sign those documents without fully understanding them. They don’t read them closely; they trust their doctors.
The obligation is larger than what you put into the forms… The obligation is to affirmatively tell the patient: This is the way we practice here. If you are not comfortable with that, you shouldn’t do it.
If you are a surgeon and you are going to be out of the room while the case is still active, the patient ought to know that. The last thing the patient is thinking before going unconscious is: I’m entrusting my life to this surgeon. If he is not going to be there part of the time, I should at least know that and have assurance that in no way am I going to be harmed.
Good news: Mortality rates for many cancers are dropping. The challenge: Hospitals and health systems will be serving a new kind of patient—older, sicker, and harder to treat—says a report from the American Society of Clinical Oncology.
When it comes to the quality of cancer care, an oncologist is the person to consult. For anyone looking for advice about the high cost of cancer drugs, a doctor is probably not the first option.
But the American Society of Clinical Oncology's exhaustive 2016 "The State of Cancer Care in America" has a lot to offer on that front.
The report, presented at a Tuesday Capitol Hill congressional briefing, will disappoint those expecting another rant against $140,000, bankruptcy-inducing cancer drugs. Instead, while ASCO calls cancer costs "unsustainable," it makes the pharmaceutical industry's argument that notoriously expensive new meds are not the only element of care fueling the dramatic increases.
Despite the generic name, this is the state of cancer according to practicing oncologists—not patients, payers, or hospitals. So, if you are looking for an update on the state of cancer care and delivery, this is where you'll get the doctors' view.
The result: There's a lot of good news and a lot of bad news—sometimes in the same package. There's a lot going on with cancer.
"Cancer care in the United States remained a mixed picture in 2015. Declining mortality rates, growing numbers of survivors, and exciting progress in treatment were set against the backdrop of increasingly unsustainable costs and a volatile practice environment," the report states.
One example:
"Precision medicine offers notable advantages to patients in need of expanded treatment options. However, physicians and patients are struggling to manage overwhelming amounts of
information about risks and benefits of genetic testing—and its role in selecting treatment.'
The report is an important document, says Randall Holcombe, MD, the chief medical officer for cancer at the Mount Sinai Health System. He was not involved in the report's preparation, but says he is impressed with its scope.
"It is a really fantastic report," Holcombe says. "It has a ton of information in it that is really timely and essential reading for hospital leadership, as well as practicing oncologists."
Here are some of the key quality messages in the report:
Care is getting more complex and some oncologist are not equipped to deliver the complicated new treatments.
Demands on oncologists will grow, as demographics leave more Baby Boomers on oncology's doorstep.
But, since oncologists are aging as well, there may be fewer of them to treat patients.
And, as patients get older, they have more comorbidities.
Oncologists are struggling with their HIT systems, as well as variations in "cancer pathway" treatment guidelines.
"These trends… raise concerns about how the US cancer care system will be able to respond to the projected surge in demand for cancer care in the coming years, driven by the aging of the US population," says Julie Vose, MD, the president of ASCO, and an oncologist at the University of Nebraska Medical Center in Omaha. She spoke at the briefing Tuesday.
More Survivors; Unique Care Needs
In a way, the cancer care delivery system needs to adjust to meet the needs of its own success. Good news: mortality rates for many cancers are dropping. The challenge: hospitals and health systems with be serving a new kind of patient, who has been treated for and survived cancer. The report cites research that estimates the number of cancer survivors will grow to 14.5 million from 9 million by 2024.
Hospitals should take note, Holcombe cautions: "Cancer survivors are people who are relatively healthy, but have unique health care needs and require surveillance for their primary malignancies as well as secondary malignancies."
And while ASCO notes that the FDA approved 12 new cancer drugs last year (good news) the costs are high. Many of them are intravenous drugs that have to be delivered in the hospital and that could boost inpatient costs. The effect of biosimilars and upcoming changes in Medicare payment for cancer drugs on hospitals may be hard to predict.
With growing complexity of care and the aging of the oncology physician workforce, hospitals need to be thinking about setting up multidisciplinary teams, Holcombe says. And that can be difficult for some systems to do efficiently. Other items in the report that touch on quality of care and stand out:
While mortality is dropping for some cancers, it is increasing for others, including liver and pancreatic cancer.
Racial disparities persist and may be getting worse: For example, in 2015, breast cancer incidence rates for African American women was higher than for any other racial group, described in the report as "a troubling development" because African American women have higher mortality rates than other women.
So what of costs? The report repeatedly notes that the cost of new drugs is a problem, but makes the point that drivers of high cost of cancer "are varied, including development of new technologies and treatments, consolidation of oncology practices into hospital-based practices where care costs more, and rising drug prices.
Costs associated with newly insured patients, expanded prevention and screening programs, and growing populations of new patients with cancer and survivors will also likely contribute to future cost increases."
So, while it may not address the drug cost issue with the same urgency at others in the cancer care community, the ASCO report does cover the topic "extensively," Vose says. She agrees that, while drugs are a factor, the cost of care is also driven by costs such as imaging, delivery of care, and infrastructure needs.
It is probably unfair to expect a rant from ASCO on drug prices. They hardly ignore the matter and this is a long, tempered view. Also, like most non-profits, specialist organizations and patient groups rely on corporate support for meetings and other projects and often that support comes from drug makers.
So, some groups are in an awkward position when the interest of the pharmaceutical industry conflict with the needs of other constituents, such as patients.
Here's an idea I've heard. Some of these new drugs don't work a whole lot better than existing therapies. For example, they may offer only a few months of added survival, not the so-called cure former President Jimmy Carter seems to have experienced.
Doctors would do well to counsel their patients about the true benefits of the drugs, their costs, and the quality of life they can expect in those extra few months. The term that's kicking around–financial toxicity–could be added to the list of side effect as doctors help patients make choices about care.
As hospitals absorb more oncology practices and more of the expensive new drugs need to be delivered via IV, they will own a bigger slice of extreme drug prices. So, that's something hospitals chiefs might should be discussing with their cancer teams.
The mandatory shift to bundled payments for hip and knee replacements is a huge and complicated job for hospitals. "There is really no good blueprint" for it, says one surgeon. But it has to has to happen, and it and will.
In a few weeks, CMS will launch its long-planned mandatory program of bundled payments for hip and knee replacements. The goal is to "encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery."
Sounds nice, unless it's you who has to actually implement all the pieces that must work together and the coordination of care. A new survey of more than 100 hospital orthopedic departments found that 56% reported feeling unprepared for the new program, and only 10% reported feeling fully prepared.
Ready or not, it's coming.
In reality, bundled payments have been a long time coming. After much discussion, the rule was proposed last summer. It was finalized in November, with a January start date that was later moved to April 1.
So, why aren't hospitals ready? Are they in denial or just overwhelmed? Or, are they chipping away at it while the plan is phased in?
The survey was conducted by Function and Outcomes Research for Comparative Effectiveness in Total Joint Replacement or FORCE-TJR, a clinical registry based at the University of Massachusetts Medical School. One of a group of registries collecting data in the US, it describes itself as an "independent, unbiased, expert data collection, analysis, and reporting system to guide best total joint replacement surgical practices."
It's no wonder that they've seen a surge of calls from hospitals interested in their services. That's what inspired the survey, said Patricia Franklin, MD, a UMass orthopedist and principal investigator for the FORCE-TJR registry project.
"It occurred to us that people are doing their homework now, so they are probably not prepared," she said. Hospitals need to know that "this is coming and it's coming fast."
Getting ready for such a change is a huge undertaking, Franklin says. UMass Medical School is not one of the nearly 800 hospitals that will be enrolled; it's already accepting bundled payments. But it signed on to participate voluntarily through the Bundled Payment for Care Improvement (BPCI) pilot initiative.
So, Franklin says she's seen all the work that goes into setting up one of these programs. Among other tasks, it requires hospitals to "amp up information systems to answer the cost and quality questions needed to manage well in this environment," she says.
'A Coalition of the Willing'
Many of the hospitals that participated in the BPCI already had much of the clinical and data infrastructure they needed to pull off the shift, said Kevin Bozic, MD, a surgeon at the University of Texas at Austin. He studies value-based care and orthopedics. Bozic, who is also chair of the school's surgery and perioperative care department, calls those hospitals "a coalition of the willing."
"We figured out we can do this in the places that were prepared," he said. "But what about the places that are not prepared? How are we going to bring them along, because they will just stay in the fee-for- service world forever unless they have some incentive to move."
"Move" might be an understatement. Everyone I talked to about bundled payments offered a long list of clinical and data programs that need to be in place to make this work. Bozic said it took two years to set up the program at UT.
It's not that hospitals don't have their acts together, Franklin said.
"It is a new paradigm," she said. "Your hospital could have a great financial system for monitoring your in-house costs and utilization, but when you are trying to understand the 30- 90-day period, you probably didn't collect the total cost of the nursing home or ER visits. It is very much a new information infrastructure."
That's something her group is willing to help out with. FORCE-TJR has tracked more than 25,000 patients and their surgeons who are already using an episode management system that includes data on patient reported outcomes (PRO)—one of three measures CMS will use to assess quality. The group offers to use its benchmarks to help hospitals assess their readiness for the new program.
They have lots of competition. The changes brought about by the ACA have birthed an army of consultants willing to help hospitals figure out how to collect and crunch data. Those who offer help on the CJR bundles staffed booths at the American Association of Orthopedic Surgeons meeting. They advertise in publications like this one and have taken to social media to tout their services, which come in the form of remote monitoring,podcasts,softwareandwebinars.
Hospitals will definitely need help on the analytics side, says Bozic. The shift, however, will require much more effort.
"Most of what it is going to take to be successful in bundled payments you are not going to get from a consultant," he said. "It's trust and alignment from the clinical community and you can't buy that from a consultant. You need strong physician leaders who can lead change."
Franklin agrees that hospitals need to ensure that the clinical pieces are in place. In the survey, 75% of respondents said they were hiring staff. That makes sense, she says, because they'll need clinical nurse managers, transition coaches, or navigators who will track the patient through the entire 90-day episode of care.
Data is Key
The other piece is the data analysis, she says. Some integrated health system will have the data infrastructure needed to track patients, collect data, and improve care.
Some may not, so they had better move on it. Data is key to this and any quality improvement effort.
Thomas Barber, MD, is an orthopedic surgeon at the Kaiser Oakland Medical Center and a spokesman for the AAOS on bundled care for joint replacement. He the agrees that clinical, data and infrastructure needs must be met before the hospitals can successfully handle the CJR program. He thinks a lot of hospitals have pieces, but haven't yet put them together yet. They will, but probably not by April 1. But since the program will be phased in, that won't be a problem for a while, he says.
"It is going to be a challenge to put all those pieces together and manage it well," he says. "If you think 50% of the hospitals are well prepared for CJR, I would be skeptical. "
Dare we say that bundled payments will allow, or force, hospitals to tackle a lot of their problems at once? What about the need for good data systems, lower costs, and better quality? Tackle may be the appropriate term. The consensus seems to be that this is a huge complicated job, but it has to has to happen, and it and will.
"It is a significant amount of work for a large amount of people," Bozic said. "They night not know where to start. There is really no good blueprint for this."
"There really needs to be an alliance among patients, families, and communities. At the end of the day, they get to decide what is the right care," says Vikas Saini, MD, president of the Lown Institute.
Vikas Saini, MD, has worn a lot of hats: philosopher, entrepreneur, cardiologist, and Harvard Medical School lecturer. Today he's president of the Lown Institute, a Boston-based non-profit that seeks to "catalyze a grassroots movement for transforming healthcare systems and improving the health of communities."
Saini recently talked with me about the group's concept of "right care" and how some current approaches to evidence-based medicine fall short. The group was recently awarded a second $2 million grant from the Robert Wood Johnson Foundation.
HLM: The Lown Institute calls for an end to "the epidemic of overuse and underuse in healthcare." Can you talk about the difficulty of getting providers to deliver evidence-based medicine?
Saini: We have a complex system in healthcare. When you have decision making that occurs as fast and as densely as it does in healthcare, using a rules-based approach, in many ways, can slow things down.
One of the issues is that evidence is scarce… The amount of what we do for which there is no evidence is so large, that if you stuck to only the stuff for which there is evidence, a whole bunch of stuff we do in healthcare would simple go away. I don't know if that is right or wrong. The problem is we don't know.
If you took the view that there are a few really central areas that are settled practice and you create algorithms to try to herd the outliers into a narrow corrals, that might make some sense sometimes. But, the reality is that you have to individualize [care] to patients.
HLM: Why won't rules work?
Saini: We have adopted administrative techniques, sort of coercive techniques, for trying to deal with what is a clear problem of practice variation. [The variation] is clearly not justified: the problem is we don't exactly know what the right thing is. In that context, to enforce [guidelines] with either economic disincentives or other penalties, I just think it's part of the malaise.
I think it is challenging for hospital administrators to tell their doctors what to do. They are not doctors and sometimes there are financial incentives in both directions…
They have margins, they have revenues, and to really adopt with a fine-tooth comb an understanding of all the clinical decision—first of all, it's sort of totalitarian; second, it's not going to work. It almost invites hospitals to lose revenue and lose momentum because they spend all this time checking.
In many ways, it's a no-win situation.
HLM: Do programs like the ABIM Foundation's Choosing Wisely campaign get at the problems of "over-use" and "under-use"?
Saini: Choosing Wisely is low-hanging fruit. I would be hard-pressed to say there is much ambiguity there. I've never seen an estimate of how much money would be savedif you got rid of all Choosing Wisely activity in the American healthcare system. I would be surprised if it saved a lot of money.
Part of the real contribution of the Choosing Wisely initiative is in flagging the idea that there is stuff that just shouldn't be done. Making that statement is a huge ice breaker. For those of us who have known this and said this for 30 or 40 years, it wasn't shocking, but it was great that official, organized medicine was willing to say it. In that sense is was really important.
A lot of what happens in healthcare is in a gray zone. Care needs to be individualized; it needs to be sensitive to patient preferences. My own view is that the default option should be the less invasive, potentially less harmful option, and the less expensive option if there is no clear proof of superiority. So, yes, Choosing Wisely is great as a start, but it gets hard after that.
HLM:Can you talk about the concept of "right care"?
Saini: What right care really means is care that is effective—scientifically based—and which is sensitive to the patient preferences; it is wanted. Those preferences need to genuinely be elicited; that requires a strong relationship.
You can do a checklist and it sort of works. You can have shared-decision aids. That definitely helps, at least in trials of shared decision-making. [The question is whether they will work in deployed outside the clinical trial setting.]
The other element includes a dimension of economic stewardship. It's not that the provider or healthcare system need to be the stewards. There really needs to be an alliance with patients, families, and communities. At the end of the day, they get to decide what is the right care.
That is, not when an individual gets sick. Any of us, when we get sick, we want everything. We want the best. The problem is defining what that means at a population level. It's never easy. Our conception of right care is that there will be a day when patients, families, and communities think about this as citizens, as opposed to in the moment of the illness. That is the only way we'll get to the answer to that question. It can't be answered by experts. It can't be answered by technocrats. And it can't really be answered by patients.
There is a level of of deliberation that is not about individual care. It is a public deliberation about the nature of healthcare and what we want. How much do we want to spend and what for? When there is decreasing return, would you want to spend it on this or that? It's not about rationing. it's about figuring out what everyone's values are.
I think if you ask 95-year-old patients would they like to spend $500,000 in the last two months of their lives or would they rather leave $500,000 to their grandkids, it would be an interesting conversation.
HLM: Do you think initiatives associated with the Patient Protection and Affordable Care Act will move us closer to "right care"?
Saini: There are some new, great initiatives. It's a lumbering first step, so I'm not going to denounce it. I think it is a step forward, but I think that there are a lot of landmines, certainly with regard to value and in the area of overuse or unnecessary care.
I'm a veteran of the late '90s when it wasn't just managed care by the insurance companies: 1-800-no-you-can't. It was also clinician networks taking financial risks, what we now call ACOs. Rethinking how they are doing things, referral pattern changes. That's not new; that was 20 years ago.
What happed was politics—pushback from other stakeholders in the system. We got another bout of medical inflation, and now, we're poised once more to step forward.
But I would say the jury is out. There are many ways it could be turned back. One of my concerns is that there is a Faustian bargain. We've offered a lot of affordable plans—high co-pay, high-deductible plans—that give people so-called 'skin-in-the-game. And yet the information asymmetry and the power asymmetry is so vast, that it is really not realistic to expect a consumer-type relationship that will drive utilization…
I think if you give people high-deductible, high co-pay plans, they continue to face financial pressure. Some of the costs are moderating, but it is still too damn expensive relative to [people of] median income in the country. I think that's a huge political landmine because at some point, people are going to start asking, 'What is going on here?' We're seeing it with the drug prices.
HLM:What needs to be done?
Saini: I get that it sound Pollyanna-ish, but we think it is time for a new reformation in healthcare, in the provider community and beyond to rethink what it is that healthcare does, and what it doesn't it do.
Tackling these issue requires a change in mindset, a change in attitude, a change in framing, and almost the creation of a new way of thinking about what we do. That's a big job. It's clearly very complex.
Doctors, nurses and other healthcare providers need to work with civic leaders and community leaders, and share both their experiences and what they know and together craft a program that represents a path to a reformed healthcare system. I don't think that is what happened here. I don't think the ACA represents any public input.
We're building this network which we are calling the Right Care Alliance. It is recruiting mostly peer-to peer around specialties and areas of interests. It's just getting started. Our idea is that, over time, as it grows, we reach a critical mass and we'll have local networks. In any individual area, We'll have community members who can support each other and can begin to craft a counter-narrative and take that to the public.
We intend to craft a new community that is really change-oriented, that has the technical understanding that doctors and nurses can bring, but also the real world concerns of community leaders and small business leaders about the interaction and intersection of costs and quality
In the quest for quality care, business as usual won't do. Progress is what change is all about. And there's an upside: When value-based payments really hit, evidence-based medicine may get some traction.
"As we contemplate its contentious present and problematic future, we remain prisoners of its past." —Charles E. Rosenberg.
Change rarely comes easily. Hospitals are currently coping with major shifts in payment models, patient care, technology, and more. These changes are designed to improve the quality of care, but not all them are going well.
Lately, we've see revolts against meaningful use and excessive quality measurement. In addition, data is piling up on the failure of doctors and hospitals to deliver evidence-based care.
So, here's some blunt advice for the hospital industry: Change is constant. Deal with it.
Lee Penrose is the CEO of St. Jude Medical Center, a 351-bed Fullerton, California hospital which is part of the St. Joseph Hoag Health system. "In order to embrace a new future, we have to be more comfortable with change," he says.
"We have to be ready to experience our work in a different way. In this consumer-driven industry, were either going to change or we are going to be eaten up."
Still, Penrose, a 20-year industry veteran, says that hospitals are currently dealing with an unprecedented level of change. On his plate: a merger between St. Joseph Hoag Health andProvidence Health & Services, a system with 34 hospitals in five states.
Old Days, Old Ways
One way to understand the need for change is to look at what some might call the good old days. In the pre-DRG era, doctors ordered whatever care they saw fit, no one questioned it and insurance covered it.
Patients paid little; they were either too poor or too insured. With no consumer pressure, costs ballooned. Patient experience? Patient stays were longer, the food was horrible, and there was no cable TV. All the doctors were men, all the nurses were women, and all the bosses were white.
Patient safety and infection control measures were not what they should be. And, orders were scrawled on note pads, recorded on paper, and transmitted via courier or fax.
No one wants to go back there. But, with change, it is good to keep in mind that sometimes things get worse before they get better. Take the implementation of electronic medical records.
Anyone who has ever had to learn a new software program knows it takes time and practice. Until you get that muscle memory, you fumble around with tutorials, lose your work, and make many mistakes before you get it right.
In Epic or Cerner, of course, the stakes are higher than in, say, Photoshop. But you still have to account for the learning curve.
The HITECH Act's Messaging Failure
It usually takes a good decade for any industry to see returns from a large investment in information technology, says Julia Adler-Milstein, assistant professor of information, School of Information and assistant professor of health management and policy at the University of Michigan's School of Public Health. She is studying the implementation of HIT and says there is no reason to think it will happen more quickly in healthcare.
Julia Adler-Milstein
"That was really a failure of the message behind the HITECH (Act)," she told me. "It was sold as, 'You put in these systems and care gets better tomorrow.' There is no reason we should have thought that. This is always going to be a 10-year journey—maybe eight years, more like 12 years. The expectations were never set at that time scale. So, partly, that has led to this great backlash."
Even well-executed changes can be hard to take, but in the case of HIT, users are coping with clunky systems that are not user-friendly, she says. And, it's not always clear to users how all that input is improving care.
And then there is the question of interoperability. All of the players—vendors, policy makers, and providers—share the blame for the inability of many systems to exchange data, Adler-Milstein says. "I think they really underappreciated how hard interoperability would be to begin with, let alone, after you've allowed thousands of different system to be implemented in your country," she said.
Physician Alignment
Another big change for hospitals is the growing ranks of doctors as employees. Healthcare systems are struggling to bring more physicians into their operations in a way that helps improve quality, safety and efficiency, says Peter Angood, MD, the CEO of American Association for Physician Leadership [formerly the American College of Physician Executives.]
Both parties get too focused on the mechanics of the contract, he says.
"Those places that are failing on the engagement of doctors haven't stopped to take that moment and clarify in a transparent way the purpose of the relationship and how to make it work on the short-, intermediate- and long-term," he says.
Beyond financial arrangements, issues that need to be clarified include the scope of responsibility, the amount of clinical work, and administrative work and expectations regarding measurement and outcome results, Angood says.
One way to improve that transitions? Angood recommends that hospitals make sure they have doctors in top jobs. Evidence suggest that "physicians in leadership roles can make the place run better," he said.
In general, good leadership can be key to successfully managing change at hospitals, Penrose says. "As leaders, were called on to help frame the change and put it in proper context and understand and articulate the 'why' behind change," he says.
"If we can't help those around us understand why change is happening, and why perhaps it is good for all of us, all we are going to meet is resistance. It is human nature to resist change and we see it every day."
Finally, it is good to remember that even when a new initiative goes off the rails and creates chaos, it's possible to steer things right. Last week, CMS and the insurance industry agreed to harmonize their quality measures. When value-based payments really hit, evidence-based medicine may get some traction.
HIT? Stop groaning. One thing the HITECH push did do right was drive the adoption of HIT.
"Now we have to figure out how to use these systems well," Adler-Milstein says. That means providers will need a better sense of the day-to-day value of the systems.
She also says there seems to be a consensus that interoperability needs to be fixed: "This high tech investment will be wasted if we don't' get interoperability right. There is a consolidation of focus on that issue that I've never seen before. It means that there is an opportunity to make some progress."
And progress, it could be argued, is what change is all about.
Hospitals don't have much to gain from the moonshot, at least in the short run. There are lot of other pressing, fixable problems with cancer care that the Obama administration's effort won't address.
I'm not excited about recent developments in the world of cancer research.
For starters, the American Society of Clinical Oncology (ASCO) has declared immunotherapy "the top cancer advance of the year" and everyone seems to think it is a big deal. But, I've been here for the inflated promises of interleukin, gene therapy, immunotherapy, the human genome, personalized medicine and angiogenesis. Now we're back to immunotherapy. I'm sure it's better than before, but I'm not excited.
A lot of people are also excited about the so-called Cancer Moonshot. In his State of the Union speech, President Barak Obama promised to boost the search for cancer cures the way President John F. Kennedy boosted support for the space program.
It just doesn't feel like more NIH money will rocket us toward better cures any faster.
Let's assume billions for research are well spent. Everyone is happy when we fund cancer research. Why be a buzz kill? Because, in reality, there are a whole lot of other problems with the way we develop and deliver the treatments we already have.
Diana Zuckerman
Prevention and Care Delivery
The Cancer Moonshot might do a lot more to improve the prospects for cancer patients by looking beyond cures and paying attention to problems with cancer care delivery, costs, access and prevention. With hospitals' fortunes now tied to outcomes and population health, they should be looking for breakthroughs in those areas, not toward another marginally effective $100,000 drug.
Diana Zuckerman is a former Congressional aide and long-time DC-based women's health advocate. She is one of the founders of the Cancer Prevention and Treatment Fund, a non-profit group that promotes cancer risk reduction and helps patients "in choosing the safest and most effective" treatments.
Zuckerman supports additional research funding. She's just not sure the moonshot will change much.
"This administration has a year left," she said "What are they going to accomplish? It takes more than a year. We've had so many wars on cancer and we've had a lot of progress. But if you want to make meaningful progress, you don't [just] throw money at a problem for a year."
Her wish list: Zuckerman would like to see more FDA scrutiny, both before and after approval, of marginally effective cancer drugs. Costs are another issue and one way to keep them down would be to prevent drug makers from charging so much for treatments made possible by publically funded NIH research. Like the moonshot.
The Cost Problem
"Our current cancer care delivery system falls short in terms of consistency in the delivery of care that is patient-centered, evidence-based, and coordinated. We are at an inflection point in terms of repairing the cancer care delivery system. If we ignore the signs of crisis around us, we will be forced to deal with an increasingly chaotic and costly care system, with exacerbation of existing disparities in the quality of cancer care."
The signs of a crisis are indeed many, including costs. The rise of the $100,00-plus per year cancer drug had triggered a wave of outrage from Congress to medical journals and to healthcare leadership.
Even doctors are speaking out. In 2013 more than 100 doctors treating patients with chronic myeloid leukemia made the unusual move of signing on to a statement in the journal Blood protesting high drug prices. In July, another 100-plus oncologists singed on to a statement in Mayo Clinic Proceedings supporting a petition protesting the high drug prices. It starts out: "The high prices of cancer drugs are affecting the care of patients with cancer and our health care system."
At least one hospital refused to pay the high prices for new drugs unless they offer any new benefit.
On February 4, not far from the White House, breast cancer survivor Zahara Heckscher (who prefers to call herself a "cancer thriver") took action she thinks will help keep the cost of cancer drugs down.
She was arrested during a civil disobedience protest at the offices of PhRMA, the drug industry trade group. Backed by the consumer advocacy group Public Citizen and Doctors without Borders, she's part of an effort to block new pharmaceutical industry intellectual property rules in the pending Trans Pacific Partnership trade agreement.
Critics say the patent, marketing, and data provisions could boost the cost of biologics worldwide. PhARMA says weak intellectual property rules in the pact "could be highly detrimental to the future of innovation in the U.S."
Heckscher said that, on one hand, she was "really excited" to hear about the moonshot, because she supports efforts to put more money into cancer research.
Care 'Doesn't Seem Coordinated'
"All that is fantastic," she said from her home in Washington D.C. "However, I am highly aware that the proposed actions in the moonshot leave out many of the existing problems with access to cancer medicine and treatment. I would like it if it could be expanded to take these other issues into consideration. "
Heckscher, who said her early stage breast cancer came back as late stage breast cancer, has spent a lot of time in different hospitals, for both first and second opinions. She has been happy with the care she's received. She feels, however, that providers could all do a lot better job coordinating the non-clinical services she finds important, such as financial counseling, support groups, and art therapy.
"The effort felt really piecemeal and I had to scramble around to find the schedules, "she said. "It doesn't seem coordinated."
And it doesn't seem that complicated or costly to fix.
The list could go on. Let's look at disparities. African American women have a higher incidence of the aggressive triple-negative subtype breast cancer than other groups. African American men have higher rates of prostate cancer incidence and death. Prevention: Lung cancer kills 150,000 people in the US, more than breast, prostate and colon cancer combined. Environmental causes: It's barely a blip on anyone's research agenda.
So, hospitals, like the rest of us, may not have much to gain from the moonshot, at least in the short run. In terms of all these other problems in the way we deliver care—we'll just have to keep looking for solutions here on planet earth.
Studies suggest both physicians and patients are reluctant to give up low-value healthcare services that waste money and can do more harm than good.
Turns out, it's not so easy to make wise choices about healthcare. Several new studies find that, even with urging, doctors and patients are having a hard time passing on low-value services, including many identified in the Choosing Wisely campaign.
Not that it should be a surprise. You don't need an MD to know that change is difficult.
The specialty societies of the Choosing Wisely campaign have offered up a menu of low-value services they suggest patients can live (well) without. The trick is to convince providers and patients to abandon superfluous old-reliables and "might-as-well" tests. They waste money and can do more harm than good.
Somehow, the message isn't getting through.
Stacey L. Sheridan, MD
A study out of University of California-Davis found that doctors who were coached on how to avoid low-value care were just as likely to order the tests as uncoached doctors. In a January Mayo Clinic study, nearly half of the doctors surveyed at Choosing Wisely CME sessions said they get daily requests for low-value services. They reported that a shrinking percentage of patients "always or almost always" followed their advice to skip the tests.
What About Decision Aids?
Researchers at the University of North Carolina, Chapel Hill set out to compare the efficacy of four different "evidence-based decision supports sheets" for prostate cancer screening in men 50 to 69 years old, osteoporosis screening in low-risk women ages 50 to 64 years old, and colorectal cancer screening in men and women between the ages 76 and 85 years. None of the support sheets had any impact.
Stacey L. Sheridan, MD, is a researcher at UNC's Sheps Center for Health Services Research and lead author of the study. Changing what patients and providers know about low-value services may not be enough to result in change the use those services.
Much more is required, she told me. "What the larger literature suggests is that it takes widespread change in culture and change in organizational structure and leadership to support… deimplementing low-value services," she says.
In the age of more-is-less in healthcare, we now need to deimplement, roll back, and undo. When a service is underused or not used, it is changed through implementation. When something is over-used, it needs to be deimplimented.
Good Luck With That
It's one thing to flip-flip on dietary advice about the health benefits of coffee, carbs, and fat. Try telling a woman that she didn't need the mammogram that found a breast tumor when she was 45. She'll tell you it saved her life and will hear nothing about overdiagnosis or indolent tumors.
The downside of mammography is somewhat difficult for people to grasp. The message on prostate cancer screening is not.
PSA tests can lead to procedures that leave men incontinent and impotent. Patients might say 'Go for it; better safe than sorry.' But increasingly, they are holding off. Both screening for the condition and prostate cancer detection dropped significantly after 2008, when the US Preventative Services Task Force (USPSTF) recommended men over age 75 skip the PSA test.
Joshua Fenton, MD
The rate of screening dropped 20% between 2010 and 2013. So did the mortality rate. The National Cancer Institute reports that death rates dropped an average 3.5% each year between 2003 and 2012.
Still, PSA testing is seen as the low-hanging fruit of useless tests. Several critics charge that the Choosing Wisely advice doesn't go deep enough and ignores high-priced, but questionable procedures.
You have to start somewhere. Joshua Fenton, MD, is a member of the Department of Family and Community Medicine at the University of California Davis Health System. He led a study that measured the impact of "patient-centered techniques" designed to help doctors address patient concerns about low-value tests.
His group sent faux patients to 61 doctors and had them request inappropriate spinal MRI or DEXA—dual-energy X-ray absorptiometry—for low back pain. Fenton and his team discovered that the doctors who had been trained to use the patient-centered techniques were just as likely to order the tests as the doctors in the control group.
Fenton says the message may have been too complicated for a brief intervention. He also thinks it may not have addressed some of the other factors driving that testing, including a doctor's fear of malpractice.
"They don't perceive a clear downside to doing the test, and the patient is asking for it," Fenton says. "There are potential upsides. If I miss something, I could get into a lot of trouble. So, I better just do this test. The patient wants it anyway, and they are going to be happy with me if I get them this test."
Engaging the Patient
So, will patient engagement have any impact? Can patients embrace the idea that more care is not necessarily better care and stop asking for tests?
It depends, says patient advocate Dave deBronkart, co-chair of the Society for Participatory Medicine. The engaged patient is not always the informed patient, he says.
"When you let people have opinions, you can get people who want stupid things," he says.
Some of this is driven by conflicting messages aimed at patients.
DeBronkart points to direct-to-consumer medical marketing and to me—the media. I can't own all of it, but he's right. There is a lot of awful consumer healthcare reporting out there, and much of it perpetuates the demand for so-called breakthroughs and other forms or marginally effective and low-value care.
Stories overselling health screening are constantly getting slammed on the Health News Review, a website run by a group of journalists and clinician who fact check health news stories and press releases. The site aims to "improve the public dialogue about health care by helping consumers critically analyze claims about health care interventions."
So, deBronkart notes that many patients are still learning.
"It's a mistake to judge someone's potential by problems they have when they are rookies," he said. "We have to change the culture so the people who we are newly enfranchised as a part of this process learn to get a clue about the basics of science."
Seeking Consistency
Or, make the science clearer. The American College of Obstetrics and Gynecology held a private meeting at the end of January with several other unnamed groups to try to bring some consistency to the conflicting advice about mammography.
Deimplementation of mammography for women under 50? Not likely. But hopefully the groups can reach some consensus that will offer a path for patients toward a better understanding of the test's value.
The shift away from low-value treatment will also take widespread culture change at the provider level. And nothing drives culture change like money. Under the fee-for-service payment model, testing, scans, X-rays, and biopsies all bring in revenues.
Will the shift to value-based payments get us away from low-value testing?
A lot of pieces need to fall in place for that to happen, Sheridan of UNC says, but she thinks it's "a positive step in aligning the incentives and reward structure in a way that that reinforces the right thing."
Now that Medicare is paying for end-of-life care discussions with patients and families, we are finally beginning to acknowledge that a high quality death should be part of high quality care.
Let's talk about dying.
The much-needed conversation about end-of-life care was interrupted six years ago during the debate over the Patient Protection and Affordable Care Act when conservatives targeted a proposal that would have allowed providers to bill Medicare for hospice and palliative care planning.
Critics of the bill made it sound like there would be committees of doctors deciding which patients should continue to receive life-extending care and which should not.
This year, Medicare will cover "advance care planning" and so far, the term "death panel" hasn't resurfaced with any force. The conversation about end-of-life care is today more lively than ever, thanks to the growing ranks of baby boomers for whom it is a topic of increasingly inevitable interest.
One important facet of the conversation centers around quality of life versus length of life. It's an uncomfortable fact that even though most people say they would prefer to die at home, many take their last breaths in a hospital.
In 1980, 70% of US cancer patient died in the hospitals. In 1998 the number had dropped to 37%. One of the JAMA studies traces the downward trendof inpatient cancer deaths and found that the number dropped further—22% of cancer patients died in the hospital.
Dying at home in your own bed, surrounded by family sounds much better than dying in an ICU. But the numbers mask evidence of excessive end-of-life care that fails to benefit patients, families, hospitals, or the health system.
Cancer patients in US hospitals were much more likely to spend time in the ICU in the last three months of life than those in six other countries the JAMA study investigated. US patients were also more likely to receive chemotherapy at the end of life.
Carol Spence is vice president for research and quality at the National Hospice and Palliative Care Organization. She says that patients are coming into hospice after long-shot treatments have failed. Some don't survive more than three days, which is not enough time to set up needed network of hospice services.
"This [study] says that we are getting peoples straight from ICUs who are very, very sick, who don't have well-controlled symptoms, who are trying very, very aggressive care." Spence told me.
"That care, in some cases, exacerbated or created new symptoms." When the approach seems to be failing, they end up in hospice, but don't last long, she says.
He agrees that using hospice services for fewer than three to seven days is a sign of suboptimal care.
He says the shift to at-home deaths has been accompanied by more end-of-life inpatient care, "followed by abrupt discharge to home and then death." So, for health professionals, patients, and families it is as important to talk about dying as it is unpleasant.
Thomas Smith, MD
Death is often unpredictable, but sometimes it isn't. Doctors knows the progressions of terminal lung, pancreatic, or breast cancer. And, in those cases, a hospice planning visit with providers trained in end-of-life care is in order, Smith says.
He usually hears a gasp when he mentions the word "hospice" to a patient, who will then ask 'Does that mean I'm going to die?' Rather than saying, 'Oh no, that's not what I meant,' Smith says it is better to tell a patient he or she is not dying immediately, but that it's important to talk about a prognosis.
"We should also talk about having a system in place to help you live as long and as well as possible," Smith says he tells patients. "That's why I'm having this hospice information visit. So when it comes time for hospice, you know what it is and you know who is taking care of you so it can be an orderly transition."
Enough with the Heroics
In the age of engaged patients and evidence-based medicine, we should be able to resist the reflex to think that more care is better care, even in our most desperate moments.
It might also help to stop casting cancer as some heroic battle patients (and doctors) can win if they fight hard enough.
The former head of CMS says "we will never solve the problem of cost and finance by focusing on cost and finance." Instead, it will be resolved "by focusing on the design and redesign of healthcare and the improvement of its quality."
Donald Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement, believes health leaders need to focus on system redesign and quality, rather than on the bottom line to contain costs he describes as "out of control."
Some hospital chiefs have a hard time seeing that, he says. And while he believes in transparency, Berwick maintains that hospitals need a break from "measure mania," which he sees as more burdensome than helpful.
The former head of the Centers for Medicare & Medicaid Services, and the newest member of the Massachusetts Health Policy Commission talked with HealthLeaders Media this week. This is the first of a two-part interview. The transcript below has been lightly edited.
HLM: What are the most pressing quality issues facing hospitals today?
Berwick: The cost of healthcare in America remains out of control and continues to erode other important agendas in public and private policy and action. I see, by far, the biggest opportunity for proper cost reduction to be through the continued improvement of care.
I deeply believe that better care is lower-cost care. I see that hospital leaders continue to have difficulty in making that link and centering improvement in the strategic agenda of the hospitals. They are still driven by revenue maximization, market share, and more traditional approaches to management of the top line instead of the actual quality of care.
Berwick: The quality of hospital care is important in its own right. But there is also this immense opportunity to use the improvement of care to get costs to a reasonable level.
It's important to recognize that we have not yet sufficiently changed the payment system to align with what needs to be done. So, hospitals remain in a difficult position with a payment system that encourages revenue maximization as a strategy.
If you look at what is happens in hospitals, we have tremendous areas of overuse of procedures, technology, and tests that cannot help people. They are being done for historic reasons.
We have a tremendous amount of paperwork and non-value added activity that staff are forced to engage in and that the patient pays the price for. We have continuing problems with coordination and continuing problems with safety.
If we were able to address each of those, focusing on overuse of ineffective care, focusing on administrative burdens, focusing on safety and reliability of care and really getting authentically focused on the needs of patients, costs would fall and not rise.
HLM: Can you talk about your call for a reduction in the number of quality measures now required of hospitals and health systems?
Berwick: Over the past 20 years, as evidence grew about defects in care, there was sense of alarm. The reaction was to try to turn the lights on, to increase knowledge about the performance of healthcare in many, many dimensions for many people.
As a result, we began a festival of measurement, an almost measurement mania, where we began to believe that the solution to performance was transparency and measurement. I'm a complete fan of transparency, but we've overshot.
Now, the number of metrics exceeds the ability of any reasonable human being to consume usefully. And, there has been insufficient diligence about the alignment and harmonization of measures.
HLM: In the age of big data, why aren't there measurements offering insights needed to improve care and contain costs?
Berwick: A lot of the measurement is managed by organizations and people who are not deeply enough involved in the delivery of care. So there is a gap between the measurement enterprise and the care enterprise.
That's costly because the measurements then lack meaning in the care process. I think the time has come for a whole new era of disciplined skepticism about measurement… preserving and increasing the measurements that tell us how things are going and allowing the workforce and the system to do their work. These are costs that take resources from actual patient care and even from improvement.
HLM: How can hospitals respond to your call for a 50% reduction in quality measures?
Berwick: The methods for doing that need to be worked out. You don't want to throw the baby out with the bathwater, but harmonization is key.
When we are trying to measure something thing four or five different ways—stop and measure it one way. With each of the metrics we're using, subject them to a test. Are the results of the measurement used by anyone? If we are doing measurement and recording data that no one uses, stop it, because there's no action being taken. It can't be useful.
HLM: What kind of measurements do you think work?
Berwick: I personally think the measures that end up having most value are not at the atomic or system levels. They are about achievements for patients—length of life, quality of life, satisfaction. Patient-centered measures are the ones that will survive the scrutiny best. I'm a fan of PROMs and PREMs (patient-reported outcome measures and patient-reported experiences measures).
These are becoming better and better and could provide a more consolidated basis for what we are doing and [how we improve].
HLM: How do you see hospitals responding to the push for patient-centered care?
Berwick: I think there is a new, more modern level of authenticity about that focus on [patient] needs that hospitals have found difficult to adopt, in which you really do regard the patient and family not as your guests, but as your hosts.
I've often said we need to act not like we are hosts in our organizations, but like we are guests in people's lives. That's a shift of power. We are asking the people we serve more and more about how we are really doing, what they really need, what they want and what they don't want and tuning in more to their real needs and desires instead of our habits.
HLM: You talked about costs being the biggest problem facing hospitals, but you have suggested that those looking to improve quality take some time to consider changes without considering the price. How can hospitals address costs while making changes that don't account for costs?
Berwick: My plea is to take the spotlight off finance and profit as the primary responsibility or activity of senior leaders because I believe we will never solve the problem of cost and finance by focusing cost and finance. We're going to have to solve that problem by focusing on the design and redesign of healthcare and the improvement of its quality.
As long as executives are leaning in on revenues and profits, they will not have the energy; they are not evincing the confidence to work on care as the route to success.
I promise healthcare leaders that if they will focus on quality as their central agenda, on the needs and desires of the people they serve, if they focus on waste and its continual reduction, if they focus on the experience of the workforce, they will be financially successful.
Maybe that sounds paradoxical. But the route to financial success in healthcare in the future is not in the study and management of finance. That's the wrong agenda. It won't succeed.
Nearly half of the hospitals queried about caesarean section rates by researchers from the Leapfrog Group declined to provide the information.
Why can't we get cesarean sections right? We've had the feminist women's health movement followed by evidence-based medicine and now the push for patient engagement. Still, more than half of all hospitals are doing too many C-sections, according to this week's report from the Leapfrog Group, a national advocate for patient safety.
Known for its consumer-friendly "Hospital Safety Scores," Leapfrog has taken on cesarean sections. "Never before have purchasers or patients had a single, standardized C-section rate to compare by hospital at the national level," the group notes.
The Leapfrog Group tried to take if further by adding a C-section query to its annual survey of 2,500 hospitals. But, click on the "Find your Hospital's Rate" link and you get a long list of institutions that "declined to respond."
Granted, the list is alphabetical and Alabama hospitals seem especially reluctant to report. Only six of roughly 90 hospitals in the state voluntarily shared their C-section data with Leapfrog. And while some of the 2,500 hospitals surveyed don't offer obstetrics, the net result is that only 1,122 hospitals disclosed their rates.
Is there also something about the C-section rates that they don't want us to know? Let's not assume any variation of this scenario, such as that hospitals are looking the other way because doctors make these choices. And those doctors must know what they are doing and, by the way, they are keeping beds filled and revenue up. Also, Medicare isn't watching because not many women over 65 are having babies. (With assisted reproductive technology, that's not unheard of.)
Let's speculate that some hospitals are watching their numbers internally and acting on them, even if they don't want to share them. Or that they might not be tracking C-section data at all.
Still, in talking to a reporter from New Jersey, Leapfrog CEO Leah Binder said she was concerned about the ten Garden State hospitals that declined to respond to the Leapfrog survey. "You do have to worry as to why they're not reporting," she said in the article.
This data, incomplete as it is, comes at a time when the national C-section rates are dropping after more than a decade of increases. The Centers for Disease Control and Prevention reports that the low-risk cesarean delivery rates peaked at 28.1% in 2009. The rate decreased from 2009 through 2013, reaching 26.9%. "Declines were widespread during this time. Low-risk cesarean delivery rates were down for more than one-half of states."
Hospitals are dealing with a lot of demands, right now, including meeting health information technology standards, ICD-10 implementation, Medicare performance measures, and other patient safety initiatives. And on top of the hospital ranking efforts of Leapfrog, Consumer reports, and U.S. News & World Report, hospitals now have to cope with the sometimes snarky rankings from patients/consumers on Yelp and Facebook.
C-section Reporting Guidelines Issued
Leapfrog set its target rate at 23.9%, not a huge difference from the actual national rate. Still, that the rates vary so much suggests that there's a problem.
For example, a pregnant woman in Colorado has a 22% chance of getting a C-section; in Florida, the rate is 33%. With no Medicare stick out there, we'll have to count on hospitals and the doctors who work in them—or increasingly for them—to assess and address their rates, and by doing so, improve outcomes.
Last year, the American College of Obstetrics and Gynecology offered some help by issuing new guidelines that call on doctors to allow women to spend more time in labor before considering a C-section.
"Although cesarean birth can be life-saving for the baby and/or the mother, the rapid increase in cesarean birth rates raises significant concern that cesarean delivery is overused without clear evidence of improved maternal or newborn outcomes," the ACOG statement read.
A recent review published in the British Medical Journal offered another reason to avoid the operation if possible—higher rates of asthma, diabetes, and obesity in those delivered via C-section.
The hundreds of hospitals that didn't report their rates to the Leapfrog Group should be aware that they may not be able to keep them private for long. Consumer Reports notes that fewer than half the states currently collect C-section numbers. With the push for transparency in health quality and health pricing, that number is likely to grow.
