Communication-and-resolution programs can be tools for preserving patient safety, not just for avoiding litigation.
Hospitals and doctors hardly ever do anything wrong.
At least that's what some risk managers and health care lawyers would have us believe.
Even when doctors or other members of the delivery team know they've messed up, they are usually instructed to keep their mouths shut. An apology, or even the suggestion of error, they are told, is an invitation to a malpractice suit.
That was the old way of thinking about potential medical errors and liability.
An alternative approach, known as CRP for communication-and-resolution programs, offers a different way of thinking about what lawyers see as potential liability and what providers see as potential medical errors.
The CRPs are designed to take the madness out of malpractice, which are commonly long, expensive legal odysseys, whose outcomes are often decided by juries who must weight conflicting and complex medial testimony.
But as the battle again medical errors escalates on the clinical side, some suggest that CRPs can make malpractice less about the law and more about quality of care.
William M. Sage, MD, JD, at the University of Texas at Austin (UT) has been studying these issues for a while. His is lead author of one of a group on papers on malpractice reform and patient safety posted online on November 4 by the journal "Health Services Research."
Ushering Out the Deny-and-Defend Era
Hospitals, he said, need to change the way they look at medical errors and liability.
"I think they need to shift the mindset from, 'this is about defending against lawsuits,' to 'this is about assisting injured patients and the health professional involved,'" he said.
"Going along with that means reevaluating habits that you might have from the deny-and-defend era."
Sage's research looks at the "litigation experience" in Texas following strict tort reform.
The number of closed malpractice claims dropped, but the research found that the patterns in the way claims were resolved reflected "efforts by the university to provide some compensation to injured patients in cases that were no longer economically viable for plaintiffs' lawyers to litigate."
In other words, while there were fewer malpractice claims, a larger percentage of them were being settled without a jury trial. Between 2001 and 2015, the percentage of cases resolved in the courts dropped from 82% to 29%.
Not that the malpractice lawyers went away.
"We did see lawyers involved in approving the settlements, which we think is good and so did UT," he said. "Lawyers make sure that everybody understands what is going on and ensure that the process is fair."
Patients represented by lawyers still did better than those without. So, the study suggests that hospitals that adopt these programs try to address that imbalance.
Another study in same journal looked at CRP in use at five hospitals in New York, a state that, unlike Texas, has approved few tort reforms. The researchers looked at 125 CRP cases involving general surgery. They found that three-quarters of them did not involve substandard care.
The University of Michigan Health System had been one of the champions of the CRP approach. The idea is to identify true error and harm and compensate for it," says system chief risk officer Rick Boothman.
An Obligation to Tell Patients 'What Might Happen'
"If being honest and open about how we assess the claim fails to come to a resolution and litigation is unavoidable, we literally walk it over to the legal office and say, 'Have at it.'"
Boothman has been working to bring the approach to other hospitals. And while some are adopting it, he's starting to hear about hospitals that claim to have adopted CRP, but are really just cherry-picking convenient or inescapable cases," he says.
Hospitals that want to set up successful CRP programs need to promote the idea that it is counterproductive to defend care that no one is proud of.
"It only becomes part and parcel of the organization's identity when it comes to the attention of clinical leadership who believe that the way they treat injured people… is integral to their patient safety culture and their ability to continually improve," Boothman says.
Sage says it comes down to the professional consensus and legal obligations of informed consent. "If you have an obligation to tell a patient what might happen to them, don't you have an obligation to tell them what did happen to them?"
In the midst of an unprecedented "change management experience," the AHA's top quality executive wants leaders to take a page from other industries that must successfully manage high-risk processes.
Hospitals nationwide are enduring an unprecedented "change management experience," says Jay Bhatt, DO, who took charge of several of the American Hospital Association's quality efforts this summer, including the AHA's Health Research and Educational Trust.
Bhatt recommends that healthcare leadership take lessons from other industries that must manage change to avoid major harm or catastrophes.
He champions "high reliability" to improve safety at hospitals. High reliability is the technique of standardizing high-risk processes, and is used in nuclear power, aviation, and other industries where errors can have disastrous consequences.
Some organizations—including Medstar Health in the Washington, DC area and Advocate Health Care in Chicago—are moving toward higher reliability, says Bhatt.
"There are hospitals in which there over 900,000 blood transfusions without a mismatch, or three years without a catheter-based infection, or a million prescriptions without an error," he says.
In high-reliability hospitals, staff members are "sensitive to operations," he says. "Leadership is aware of how different processes and systems effect the organization… Each member of the staff is really thinking about those operations."
That creates an internal learning system that produces real-time feedback on what is working and what isn't. That involves leveraging the best evidence and learning instead of assuming, he says.
"Problems are complicated, and sometimes we want to jump to easy answers," Bhatt says. "But I like to step back off the dance floor and onto the balcony to see what is happening on the dance floor."
Setting Quality Priorities
The goal is to look at an organization's systems, issues, and patterns, identify what needs to change, then "dance" in a different way to achieve a different outcome, he says.
In addition to high reliability, the AHA has several other quality priorities, says Bhatt, who sees health disparities as a quality issue. He wants to ensure hospitals that serve complex patients in low-income communities are not penalized when it comes to quality measurement.
He acknowledges, however, that it is a complicated problem that may take some time to resolve. "It's an issue that is so important, that we want to make sure that we are doing it in a way that is most appropriate," he says.
"We haven't been able to think in concrete ways about metrics of socio-economic conditions in the same way we have be able to in other quality measurement areas. I don't know that we have had the data to be able to help us measure it until recently."
As more organizations capture and analyze data, and as it accumulates, it will be easier to incorporate this information into quality measures, he says.
Much of this comes back to change management. "Change comes with pain and loss, so part of the work is to say, 'How do we help folks tolerate the loss they are going to feel as a result of change?' "
Hospitals can start by encouraging leadership teams to share differing perspectives on issues. Timing is also important. "Helping manage that loss at a pace they can tolerate helps manage the change," he says.
Leaders can promote change more effectively if they can show staff members how the changes will save lives, improve outcomes, and lower costs.
"We need to streamline, we need to align, we need to focus, we need to partner," says Bhatt. "If we do those things, that will make a difference."
Speakers at an NCQA event suggest that some services could be delivered differently, by non-physicians working outside of hospitals.
Up until a few decades ago, drivers needing service or repairs had to take their cars to the repair shop. Then came companies (Midas in 1956 and Jiffy Lube in 1971) that offered inexpensive, routine services such as oil changes and replacement mufflers.
Now drivers had options.
Speakers at an NCQA Quality Talks event Monday suggested that a similar service delivery model could apply to medicine and lead to better, more efficient, less-expensive care.
Others said we are already headed in that direction through telemedicine, urgent care clinics, and programs designed to keep patients out of that human repair shop known as the hospital.
"The health plan of the future" was one of three themes explored at the event.
Speaker Barbara McAneny, MD, the CEO of the New Mexico Cancer Center, said she does everything she can to keep her patients out of the hospital. Her group has succeeded in preventing unneeded admissions through the creation of an oncology medical home.
Every time she admits patients to the hospital, their quality of life declines a little bit, even if they don't suffer complications or infections, McAneny said.
1. A Medical Home for Cancer Patients
Her team created the "COME HOME" medical home model which aims to "improve health outcomes, enhance patient care experiences and significantly reduce costs of care by keeping patients out of the emergency department and hospital as much as possible."
The program credits a system that includes triage, extended hours, and evidence-based medicine for reducing the costs of caring for Medicare patients by about 6%.
She noted that the country cannot afford the rising cost of healthcare, which leave less for education and other services.
"We are looking for a solution," McAneny said. "If you give doctors the tools that they need and the ability to hire the personnel to create a team… you can come up with a system that not only gives better healthcare at a lower price, but makes doctors a lot happier and willing to work a lot harder."
The program is aimed at those newly diagnosed or suffering a relapse of cancer, but could be used for any patient with a chronic disease.
2. Consumer-Centric Care Delivery
Marcus Osborne is the vice president for "health and wellness transformation' at Walmart corporate headquarter. He asked: What if the healthcare system is not broken? What if it is working perfectly for all the different players, the providers and payers, and device makers and patients?
The hope is: "If we develop solutions that ensure all of their interest are aligned and ensure all their needs are addressed, the system will work better," he said. "If you believe that is the correct paradigm, you've got it all wrong. "
He suggested a system that is "100% about the consumer." That would require an "explosion" of digital services that would allow "consumers to engage with technology directly to get them the care they need, without having to engage with providers or professionals."
The doctor, he said, would no longer be at the center of care. He cited Lemonaid Healthas an example. The company offers $15 online consults and prescriptions for simple, but common problems such as urinary tract infections.
Osborne also noted that a recent glucose and cholesterol screening initiative conducted by Walmart served 300,000 people four hours, half of whom had never been screened before.
3. Closing the Disparity Gap
Other speakers talked about the quality issues related to disparities and cancer care.
"Upstreamist" Rishi Manchanda, MD, is the founder of Health Begins a group that helps providers and communities address the so called "upstream" living conditions such as diet and housing that make people sick.
He urged hospitals to screen for "food insecurity," and take steps to address the lack of access to healthy foods that can, for example, keep diabetics from eating properly.
Laura Esserman, MD, the director of the University of California San Francisco breast care center, doubled down on her criticism of routine cancer screening—often ineffective, and clinical trials—often inefficient.
She urged a reimagining of the healthcare system. "I am sick and tired of watching other industries outpace innovation in health care delivery," she said. "It is time for that to change."
A medical student is like a fly on the wall, said Lakshmana Swamy, MD, MBA, the lead author of the study and now chief medical resident at the Veterans Administration hospital in West Roxbury, MA. "We're not bearing the burden of care, but we spend many, many hours observing care," he said.
Unlike residents, medical students still have one foot outside the world of medicine, giving them a different perspective on the care they see. The study was designed to measure that perspective—it only asked whether the student's perceived problems, he said.
Swamy and fellow physician trainees at Wright State University's Boonshoft School of Medicine, in Dayton, OH, surveyed their colleagues.
They found that 62% of the respondents perceived problems in safety and 44% saw what they considered lack of evidence-based care. Most striking to Swamy was that 90% of the respondents said they had observed adverse events, and 29% perceived avoidable adverse events on a monthly basis.
Although the survey gauged perception, not actual medical errors, only 51% of students said they were comfortable reporting incidents to their superiors and only 20% noted a change in response to their concerns.
But whether the quality issues were real or not, they should be addressed, said Swamy.
"The problem is that they are seeing things and they are not talking about them. They are not learning about them. Either they are missing the opportunity to learn about quality and safety, or they are missing the opportunity to learn about clinical medicine."
What Hospitals Need to Know
However, the situation is changing, said Swamy, who is on the evaluation committee for the Accreditation Council for Graduate Medical Education (ACGME) program to improve resident training in several areas, including safety and quality.
Under the program, known as the Clinical Learning Environment Review (CLER), ACGME staff review programs at nearly 300 hospitals. The program issued its first report in May.
Many residents and fellows who were interviewed for the report indicated they participate in quality improvement projects, but appeared to have a limited knowledge of QI concepts and the methods and approaches to QI employed by the Clinical Learning Environment.
ACGME reviewers also found that when trainees did file reports questioning the care they observed, the trainees "received little or no feedback."
Hospitals often welcome that information, said Kevin Weiss, MD, who heads the ACGME's CLER program.
Review staff meet with both hospital and ACGME leadership teams after each review and discuss the results. Programs that receive ACGME accreditation must participate in the review, but results are not a factor in the accreditation.
Now in the middle of a second round of reviews, the program is no longer seen by hospital CEOs as a regulation in disguise. Some hospital chiefs say the visits initiate needed conversations about quality, Weiss said.
Hospital administrators need to be bring their younger doctors into the quality improvement process, said Swamy.
"The important thing is to really engage your younger physicians who have trained in the broken system and encourage them to help you design a safe and more efficient system," he said. "You can't do it from the C-suite alone. You really need to go to the place where things are happening."
Instead of complaining about quality ratings it received from U.S. News & World Report, Rush University Hospital did something about it.
When Rush University Medical Center launched a major push to ensure patient safety, it was happy with the results. The Chicago system was ranked No. 2 by the University Healthcare Consortium and did equally well on other measures.
Then U.S. News & World Report (USN&WR) released its 2015 hospitals rankings, reporting that Rush, a not-for-profit, 664-bed academic medical center in Chicago, had earned the lowest marks possible for patient safety.
"We didn't think much of it," said Omar Lateef, DO, the chief medical officer at Rush. "For us, it's a consumer publication and it isn't validated."
Then, the hospital's orthopedic doctors showed up at his door. They were upset that the rankings were hurting their program's reputation, he said. That launched a deep dive into Rush's clinical data, a collaboration with USN&WR, and the subsequent correction of a glitch linked to the limitations of Medicare data.
Instead of complaining about external quality ratings, Rush, did something about it.
And instead of brushing the hospital off, USN&WR welcomed the feedback and used it to correct a flaws in its analyses.
The case suggests that there may be a middle ground where academics and consumer-level quality analysts can meet. The recent uproar in the medical community over the Surgeon ScoreCard produced by the investigative journalists at ProPublica suggests otherwise.
But those who rely on peer-reviewed findings need to recognize that data journalists have moved beyond sorting spreadsheets. For better or worse, what was once called "computer-assisted reporting" has evolved into advanced statistical analysis.
USN&WR has been crunching hospital data since 1995. It uses the same Medicare numbers that academics and other analysts use. And it has engaged in a constant effort to improve the process, says Ben Harder, the chief of health analysis at USN&WR.
'Known Limitations'
"All data and all quality measure have limitations and that is something that we are eyes-wide-open about," he said. "We have engaged for many years with hospitals and various other quality measure stake holders around how to address the known limitations in the data sets we use and how to identify any previously unknown limitations we need to be aware of."
So, when Rush University Medical Center came calling, USN&WR listened, Harder said.
Rush had flagged a limitation of the data that had not been identified by the Centers for Medicare & Medicaid Services or its partner, the Agency for Healthcare Research and Quality, Harder said.
In short, Rush was being held responsible for problems patients had when they arrived at the hospitals, conditions known in statistical terms as "present on admission," or POA.
"We decided these were newly identified limitations and there were some ways we could address them. So we made a number of methodology changes," Harder said. "(Rush) felt appreciative that we had understood and addressed their concern, not just for Rush but for the entire analysis we do for more than 4,000 hospitals."
Bala Hota, MD, the chief research information office at Rush put it this way: "US News was great. They really wanted to get to the bottom of what was going on and solve this. "
A Call for An 'Audit Requirement'
Still, he and Lateef offered words of caution in a paper outlining their analysis. "Consumer groups and lay publications that seek to measure and rank hospitals should be commended for the ambition to bring order to the confusing business space of health care, but the enormity of the task being undertaken by these entities should be acknowledged and the potential pitfalls of nontransparent data analysis recognized," they wrote in the October issue of The Joint Commission Journal on Quality and Patient Safety.
USN&WR offers only one of a number of hospital ranking programs. The others range from CMS to the private LeapFrog Group, to the consumer-driven website Yelp. Data sources and methodology vary, and their findings don't always correspond.
An editorial in the same journal as the Rush paper calls for standardized measures and an "audit requirement that would apply to any entities that grade providers." It's not likely to happen soon. In the meantime, there are advantages to having competing quality measurement programs.
"I think there would be a major risk of harm if we simply said CMS is doing it, they have a process, and we are going to abdicate our responsibly as journalists or as the public and let them do it, because if they were doing it wrong, we would never know," Harder said.
The healthcare system is working to regain the trust of African Americans with help from the family of Henrietta Lacks, who was an unwitting participant in medical research in the 1950s.
The ongoing story of the late Henrietta Lacks, the African-American woman who unwittingly provided cells for years of medical research, has much to offer those battling disparities in healthcare, according to family members who spoke in Boston last week.
That message, delivered at a panel discussion, came from Lacks' grandson David Lacks, Jr. and her great granddaughter Victoria Baptiste, RN, as well as Joseph Betancourt, MD, director of the Disparities Solutions Center at Massachusetts General Hospital.
Baptiste said that older African Americans still distrust hospitals.
For years, rumors persisted in Baltimore that John Hopkins Medicine sent out "body snatchers" to find live subjects for use in medical experiments, she said.
It was at Hopkins that doctors harvested Lacks' cancer cells in the 1950s and created a widely used HeLa cell line. (Lacks did not survive the cancer.) In later years, doctors sought blood samples from surviving Lacks family members, but never told them why, Baptiste said.
Since the 2010 publication of the best-selling book on the case, "The Immortal Life of Henrietta Lacks," much has changed. The family is now involved when decisions are made about the use of the cells' DNA sequence, Baptiste said.
And, African Americans are working to regain trust in the healthcare system, she told a full house at Boston's historic Faneuil Hall.
Familial Oversight, Input
"It is up to our generation to try to break down some of those barriers," she said. "The more educated we are... and the more we see representations of people that look like us – (that) will help us to have a better relationship with hospitals and medicine in general. "
The Lacks family members now sit on an NIH committee that oversees the use of the cells' genomic information. After a researcher sequenced the HeLa genome in 2010, ethical issues emerged about family privacy and the publication of the complete genome online.
Learning that the family had not been consulted, the National Institutes of Health stepped in, brought Lacks family members up to date on research into the genome, and formed the oversight committee.
David Lacks, Jr., who is a member of that committee, and Baptiste said they were pleased to finally be brought into the discussion about the use of the HeLa cells for research.
"We were able to have a seat at several tables to see how the wrongs are being corrected for future generations," Baptiste said.
Betancourt said he thinks the involvement of Lacks family in the ongoing work with the cells is "a story of hope, healing, and transformation… I think it's that type of energy and enthusiasm we need as a nation. And certainly healthcare leaders need to work with their communities to make a difference."
The system is making progress toward correcting health disparities, but it is never fast enough, because lives hang in the balance, Betancourt said.
"I don't think I'll ever be satisfied, and I don't think we should be until we are really sure that everybody is getting the best we have to offer, we don't have situations like this happening and patients can feel cared for and trusting," he said.
The government is not going to increase its reimbursement rates, says Stuart Altman, PhD. "There's a general feeling that the gap is about as wide as it can go."
After years of working on the federal level, Stuart Altman, PhD, a Brandeis University healthcare economist, is now head of the Massachusetts Health Policy Commission. In the second of a two-part conversation, he talks about issues facing community hospitals.
HLM: You said that cost-shifting is over, that patients and private payers can no longer bear the costs of what hospitals say are shortfalls in government spending. Can you talk about how that might play out?
ALTMAN: Everyone is trying to function in this new world because they think it is the right thing to do. There is also fear that if inflation were to really jump out again, these systems couldn't afford it anymore.
The government is not going to increase its rates. Therefore, the only way the hospitals could get more money is to continue to jack up private rates.
There's a general feeling that the gap is about as wide as it can go. I think most hospitals realize that their ability to generate more revenue from the private sector is really limited.
HLM: They argue that the public programs like Medicare and Medicaid are not paying enough to cover costs.
ALTMAN: The question is, what are the costs? From the hospitals' point of view—and I can very much appreciate it—the costs are what the costs are.
The government isn't paying its share, and therefore it has to get [it's money] from the private (payers). The government is saying, 'this is all we can pay.'
It's already a much higher amount than every other country. You mean to tell me that you can't provide good quality care with less?
The government is saying, 'we can't and we won't pay.'
[Healthcare] is already the biggest item in every state budget. It's already a big item on the federal level. It's the main reason why we have a deficit.
You're just not going to get more money from the government. I don't say the hospitals are inherently wrong, if you accept the cost structure. The government people and the analysts are saying the cost structure is too high.
HLM: The Health Policy Commission just published a report on community hospitals. Can you talk about the issues smaller, independent facilities face?
ALTMAN: It is extremely difficult in this era for community hospitals to stay independent. [They] are facing a whole set of problems. They do not have the bargaining power, vis-à-vis the insurance companies, that the big systems do.
They face the perception that they are lower quality because they don't have the fancy new equipment and they don't have the high priced doctors.
They are perceived as lower quality and they get less money.
If you have an insurance policy that will pay you whether you go to a [less expensive hospital or a] hospital that costs 50% more, and you perceive that the [one that charges] 50% more means higher quality, and it doesn't cost you anything, why go to the lower costs facility?
So, these community hospitals are facing declining patient loads, reduced occupancy, and [the perception of] lower quality.
I say perceived—in many case the quality of the institutions is good, if not better for certain types of illness. You go into these big academic institutions, while they may be great for very exotic things, for basic things, they often don't do as good a job. The quality measure back that up.
Bigness does have some advantages. That's the argument being made by these big systems. They are the only ones that can really put together these needed organizations that can make ACOs work and so on.
The problem is whether they really use their bigness to make things better, or if they just use it to generate higher revenue.
There is a lot of evidence that they are just using it to make revenue, that they are not that much more efficient or efficient at all because they are tied into a big mother shop that needs to be fed.
HLM: A lot of people are very optimistic about ACOs, value-based payments, and other changes built into the ACA. You don't sound optimistic.
ALTMAN: I'm not super negative, but I've been around a long time. I don't want to be too cynical. I believe ultimately the only way to slow the costs is to slow the revenue.
The healthcare system in America is a big money machine. I don't blame the hospitals; I don't blame anyone alone. But we are all a part of the big money machine and it is very expensive on a lot of levels.
If you compare American to other countries, it's not that we use too much healthcare. It's that the prices are much too high.
If anything, I think the American system is more efficient than Europe in many respects. We don't go to the hospital as often. We have shorter lengths of stay; we don't go to the doctor as much. But, what we do do is very expensive.
The former head of CMS advocates for a single-payer system and for bringing "pride and joy" to the workplace among physicians, nurses, administrators, and executives who are all involved in doing the work of caring.
This article was originally published on January 14, 2016. This is the second of two parts. Read part one.
When Donald Berwick, MD, president emeritus and senior fellow at the Institute for Healthcare Improvement, was a candidate for the head of Centers for Medicare & Medicaid Services, opponents seized on his admiration of Britain's National Health Service.
Donald Berwick, MD
In the second part of Berwick's interview with HealthLeaders, (read part one), he spoke about his support not just for the Patient Protection Affordable Care Act, but for a single-payer health system. Both, he says, recognize health as a right and represent a needed "moral" approach to care. He also calls for a push to bring "pride and joy" to the workplace. The transcript of the interview has been lightly edited for clarity.
HLM: Do you think the provisions of the Patient Protection and Affordable Care Act will lead to quality improvements?
Berwick: I think it's a great step forward. [It's] not perfect, though. Part of the ACA is the insurance law. It's the attempt in our country to make healthcare a human right, to take a step in that direction. I thoroughly support it; I wish we could go further faster.
It's been productive and could be more productive. The decision to do this with private insurance systems was a political decision. We could have done it with an expansion of Medicare and Medicaid. But, we should be proud that the country is trying to make health a human right.
I wish the Medicaid expansions were occurring in all states. I wish the exchanges had gone smoothly and had been more supported and had been more active in defending the rights of beneficiaries. But, all of those are improvements in a basically sound approach to improving healthcare coverage
On improvement, there is good news and news that could be better. There has been a lot of investment in transparency; remember, I'm not an enemy of transparency. There are parts of the law that are urging more access to Medicare data on the part of people who want to improve.
There is support for the Center for Medicare and Medicaid Innovation, which has been doing brilliant and immensely important work with HENs (hospital engagement networks), which are providing hospitals the chance to learn from and teach each other.
There is support for continuity. There are major investments in community-based care transitions medical homes, ACOs, bundled payments. All of these are attempts to change payments to be more supportive of the real needs of patients.
One the other side, I wish we had more national support for the work of improvement. Even better and stronger networks for change, maybe a little less reliance on measure, measure, measure and maybe a little more reliance on health, health, health.
HLM: You've taken a position in support of a single-payer approach to health coverage. Can you talk about why you think a single-payer system would improve care?
Berwick: Correctly managed it would. The first way would be by reducing the administrative burden. Right now, it's north of 15% of the money we spend on healthcare. It is going to manage paper. That's a function of a pluralistic insurance systems without coordination. Coding schemes, billing procedures, benefits structure, they vary. It's a zoo of challenges.
It leads to a lot of paperwork for everybody. For patients, families, government, hospitals, and doctors. A single payer system would be simpler to manage. People in other countries with consolidated payment systems can't believe the amount we've been spending on administration.
The second advantage of single payer is what I would call 'customer voice.' It allows the payer, if it is publically accountable, to sit at a table and on behalf of the public at large, and make requests and demands that would benefit the public.
As Medicare Administer, I could do that for 47 million beneficiaries and 50 million Medicaid beneficiates. I could see the data and say, 'we are doing a bad job on safety in nursing homes,' or 'we need to do more on care coordination between inpatient and outpatient care.'
I could go to the delivery systems and insist on the importance of protection for beneficiaries. In a multi-payer system, that gets much harder to do. There is no consolidated representation of the interests of the public.
In the single-payer system I got to run, Medicare, the focus was on the needs of beneficiaries and not the needs of shareholders. The organization runs very lean in terms of salary and staff. And it tries to make sure that the resources are used for beneficiaries.
Insurance companies argue for 15% of their revenue to be used for non-care purposes. In fact, their financial health is graded according to medical loss ratios.
The other thing that single-payer system allows is sensible transparency. All the data are in one place and you can begin to look at care in a more holistic, more thorough way and make that information readily available to the people who give care.
Right now we have a terrible problem of coming up with a unified view of the flow of money and the quality of care because there are so many different players who own so many different data sets. It gets really hard to manage quality in that environment.
HLM: You've also called for a more "moral" approach to the delivery of care. Could you explain what that would entail?
Berwick: If you think about the pursuit of health as the ultimate goal of the investment we are making, in our case about 18% of our gross domestic product, it would lead you to ask what creates health and what disturbs it.
The answers are pretty clear that among the great disrupters of health are injustice, inequity, racism, and a failure to regard healthcare as human right. These, to me, are moral issues. The commitment to a fair and just society, one in which equality is embraced, [is one] in which responsibility for each other is part of the fabric.
To me it sounds right. It matches my ethical frame. It also sounds smart because what you are interested in is people who can live lives at the highest level of function and be productive in society and enjoy their lives.
The relationships between poverty, injustice, racism and inequity on one hand, and health status, function, and longevity on the other hand, are very well described. I think health professionals need to be advocates for social justice. Hospitals need to inspect their processes of care to see that they are sensitive to issues of social determinants of health and social supports that people need in order to stay out of the hospital. That needs to be woven into the fabric of hospital care.
The wonderful work Rebecca Onie is doing at Health Leads is an example of equipping healthcare providers, in this case medical students, to reach out to patients and understand the full spectrum of their needs and not stop at the boundaries of job descriptions or the walls of the institution.
That's why integrated health systems, in the end, will have a better shot at success than hospitals. This does demand that hospitals reach outside their walls to give people the support they need.
HLM: The IHI Leadership Alliance is made up of 40 organizations working to pursue the triple aim: better care, better health and lower costs. You've said another area they will target is "joy in work." Can you describe that effort?
Berwick: You'll see in the work of the IHI an increasing focus on joy and pride in work as an essential goal. I would say any sensible hospitals leader has to realize that it is on the critical path to success.
There is growing evidence of problems of morale and burnout in the workforce, [among] doctors, nurses, administrators, and even executives. It is a signal of a problem that is very toxic to quality. In any service industry, let alone one that is dependent on compassion, the customer, the person you are helping isn't going to experience excellence in the hand of a demoralized staff.
Understanding what generates pride and joy is crucial. Understanding what generates pride and joy is not easy and the theory and approach are still very much under development, especially in an era of austerity. But it it's possible.
We will be making a big mistake if we continue on a trajectory of healthcare which continues to erode the energy and self-confidence and joy—that's the right word—of the people are doing the work of caring.
Health policy veteran Stuart Altman, PhD, is hopeful, but not optimistic, about healthcare delivery reforms and thinks hospitals will be forced to bring costs down because patients won't tolerate any more cost shifting.
Ten years ago, the Commonwealth of Massachusetts enacted an approach to universal health insurance coverage that became the model for the Patient Protection and Affordable Care Act.
The next step: to control costs.
In 2012, the Bay State established the Health Policy Commission, an independent agency that monitors healthcare costs against "growth benchmarks." At its helm, Stuart Altman, PhD, a Brandeis University healthcare economist who has advised presidents from Nixon to Obama.
He's seen it all, from DRGs to HMOs to the ACA. HealthLeaders Media talked with Altman about what the Massachusetts cost control effort could mean for hospitals across the nation.
He is hopeful, but not optimistic, about the ACA's delivery reforms and thinks hospitals will be forced to bring costs down because patients won't tolerate any more cost shifting. The transcript below has been lightly edited.
HLM: What are the major challenges facing the hospital industry?
Altman: We're dealing with a situation where spending, or costs, are still an overriding issue. There is constant pressure on hospitals to spend more money, whether it is providing good patient care, buying drugs, buying devices, paying high salaries, or modernizing their facilities. It is a high costs product on one side.
On the other side, you have government that is increasingly limiting the amount of money that it is willing to spend for the hospitals.
We also have this situation, which is a good one, where government patients on Medicare and Medicaid have equal access to all hospitals, just like private patients. Hospitals need those patient because we've developed a capacity that cannot sustain itself if you only had private patients.
Costs are high and revenue coming out of 50% to 80% of the patients who are government (insured) is not keeping up with those costs. What hospitals have been doing for the better part of 20 years is charging their private patients higher and higher rates.
So the gap between private rates and government rates is now, by some averages, a difference of 75%. The hospitals feel they have to use the higher private rates in order to maintain an overall revenue flow which is commensurate with their costs.
HLM: How is Massachusetts trying to address high costs?
Altman: First of all, it is the only state that has recognized that it should be involved in total state spending. Some other states that are closer are Vermont and Maryland. But the Massachusetts state government is really acknowledging that it has responsibility for not only what it spends on Medicaid, but that it should be concerned with total spending.
How it deals with trying to do something with total spending is a politically complicated issue. There were strong forces who wanted to go to a form of price regulation. They included both the governor (Deval Patrick at the time) and several key members of the (State) House.
But the decision was made not to have a very formal regulatory system and instead put in place a set of measures and new organizations to try to keep spending in line with the state's income.
Prior or 2010, healthcare spending both in Massachusetts and around the country had been growing 2% to 2.5% beyond income.
And Massachusetts was among the most expensive states in the country. We also have a reputation for having very good hospitals -- we probably have, per capita, more teaching hospitals than any other part of the country.
We train a lot of the country's physicians and we do a lot of the country's research. There is reason why we are expensive. That said, the cost of doing all these things for the country is disproportionally falling on the backs of the private patients.
HLM: How are hospitals in Massachusetts responding to the effort?
Altman: We have a hospital industry that has been very innovative and willing to participate in a lot of these new efforts. And we have a hospital industry that, I think it is fair to say, has been more than willing to be actively engaged with state government to try to makes things better in a way that, from their perspective, doesn't destroy the hospital industry.
They're not openly hostile to government having a role.
So, what are we trying to do? We are trying to maintain as much competition as we can by not allowing one or two organizations to totally take control of the delivery system.
We don't have regulatory power to stop that, but we do have a strong relationship with the Attorney General's office, which does have that regulatory power. They will look seriously at any reports we do about consolidation that has the potential to significantly raise prices.
That's what happened with the whole Partners (HealthCare) situation.
[Editor's note: Last year, Partners HealthCare, which includes Massachusetts General Hospital and Brigham and Women's Hospital, abandoned plans to buy the suburban South Shore Hospital after opposition from Attorney General Maura Healey.
Each year, we put together a cost trend report that outlines what forces are at play in the state in terms of raising spending and we have hearings every October. We are trying to play an interesting role which is not be regulatory, but really to be in the face of the healthcare system in terms of saying, "Hey be careful. Don't go the extra mile on in spending or pricing."
We want to do it in a way that doesn't destroy or even hurt the health system. In any attempt to do that, some of the forces within the health industry scream.
But, for the most part, the hospitals have been supportive of our efforts. If we were to squeeze too hard, they would react more negatively. Everyone is engaged in a very interesting balancing act. We are trying getting the system to work more efficiently… and they are trying to control costs without destroying themselves. So far it's working.
[Editor's note: A report on state healthcare spending released last week found a 3.9% increase for 2015. The increase was lower than 4.2% increase in 2014, but higher than the state's healthcare cost growth benchmark of 3.6%.]
Proponents claim a new donor liver allocation plan would be more equitable for patients; foes say it could raise costs and close programs.
A proposal to change how donor livers are distributed has reignited the battle over which patients should be considered first for transplants.
Currently, organs donated in one of the nation's 11 designated geographic districts are generally offered to patients in a smaller area served by a designated local organ procurement agency. However, districts with many transplant candidates are not necessarily the districts with the most donors.
Although all areas of the country have long lists of transplant candidates, those in some districts must wait longer for a donor liver, or be more ill, than patients in other districts.
The OPTN/UNOS plan would create eight larger districts apportioned to allow more equitable access for those in need of liver transplant regardless of their place of residence, according to the plan.
With some exceptions, organs would be shared across these larger districts for seriously ill patients before they would be offered locally.
The current system is tilted toward keeping organs local, says Ryutaro Hirose, MD, a transplant surgeon at the University of California San Francisco Medical Center and chair of the committee that is proposing the new rule.
"A lot of us believe these organs don't belong to one area or center," he says. "Organs are national resource, not a local or provincial one."
The debate over this issue goes back 35 years, Hirose says. In 2000, the Department of Health and Human Services (HHS) instructed OPTN and UNOS to come up with a policy to address differences in access to organs.
Under the new proposal, some centers will lose volume and costs may go up in some cases, but access will be more equitable, Hirose says.
"We want to be the best possible stewards of these organs," he adds.
Opponents of the new plan worry the proposal could force some programs to close, further limiting or delaying access for some patients, says Sean Kumer, surgical director of transplantation at The University of Kansas Hospital, who opposes the plan.
According to UNOS, it would be premature to speculate on the policy's impact on the number of transplants at individual hospitals. However, Kumer says the University of Kansas Hospital's program, which performs about 100 liver transplants annually, would receive about 25 fewer organs.
Under the current plan, East Coast states north of Florida are divided into four districts. The new plan calls for a single district reaching from Maine to South Carolina.
"When you designate certain areas of the country as centers, access to care is going to change incredibly," Kumer says. "You don't take all the organs out of one area of the country and put them in another area."
Several transplant surgeons and organ procurement agencies opposing the new plan have signed on to an initiative called Collaborative for Donation Fairness. The collaborative's website echoes many of Kumer's arguments.
The group calls for a review of transplant data by an unbiased third party, such as the Institute of Medicine, and a push for more donations.
Some members of Congress have written to HHS to voice concern about the OPTN/UNOS plan's impact on their constituents.
Hirose hopes the issue doesn't play out in the halls of Congress. However, if surgeons don't take action to address access to donated organs, people with little knowledge of transplantation will act.
"If we refuse to do anything about it, it will be taken out of our hands," he says.
