This is the third in a series of posts concerning hospital rankings and comments on how we feel they could be more beneficial to patients while simultaneously reflecting a better view of reality.
First, Do No Harm
Without being overly nostalgic, we remember a time when the primary objective of medicine was to comfort, treat and cure patients and was generally delivered with a local business model where patients knew their doctors and doctors knew their patients.
While we recognize that caregivers still hold these values, they are increasingly forced to work in an environment that values shareholder’s interests and financial results above other outcomes and marginalizes staff who do not.
We want to make clear that this is not an attack on the ACA or a political reaction to it; we have been focused on these issues for decades, and especially on the challenges of Safety and Security, which represent concerns that we see as post-Cold War threats. There are several factors however that make the issues more challenging than earlier state-sponsored, Cold War threats : evolving technology has reshaped the industry to make it even more difficult to protect and ensure continuous operations. For example, supply chain integration means fewer available consumables, medicine, water and food, and loss of electrical power forces caregivers to revert to manual tasks they have not performed in many years, if ever (manual life support). Financial pressure has resulted in a collapsed organizational structure also; with outsourcing commonly used for critical functions; creating interdependencies that can easily fall apart during crisis events.
In terms of potential harm to the public there are three important types: Clinical to the health, life and limb of the patient, Physical/facility Safety and Security; protecting stakeholders while on premises and financial; keeping patients from losing their life work simply by getting sick.
On the heels of the first IOM report “To Err is Human”, there was a flurry of activity and proposed and promised fixes in the industry, however, many still insist that not only has there been a lack of improvement, we have actually slipped as more people enter and move through the system. Certainly the culture of protection within the caregiver community – particularly physicians who protect the guild – has compounded this issue. Despite repeated assertions that physician error ranked as the third cause of patient deaths, the RTI / US News survey methodology is weighted heavily towards the opinion of these physicians in its determination of ranking quality and safety in these facilities.
The Safety and Physical Security perspective is based on the ability of all stakeholders (Patients, Guests and Staff) to be safe from harm posed by the increasing threats of more robust and frequent natural disasters, evolving infectious diseases, increasing evidence of hospitals as soft targets for all those who wish to do us harm and the unabated violence within hospital settings, particularly for women caregivers. We have been advocating for this for a decade.
When examining the financial impact of the system on a disappearing middle class, Steven Brill’s essay in Time Magazine covers the topic better than others have been willing or able expose. For example; a direct quote from the article:
“Diagnosed with non-Hodgkin’s lymphoma at age 42; Total cost, in advance, for Sean’s treatment plan and initial doses of chemotherapy: $83,900. Charges for blood and lab tests amounted to more than $15,000; with Medicare, they would have cost a few hundred dollars”
The inexcusable manner of collecting this money from someone who already had insurance is well documented in our opinion of the Brill Report.
Unfortunately, while some issues such as pre-existing conditions have been addressed in ACA, an unanswered question remains on how to reign in these escalating costs.
The Carrot or the Stick?
For the non-Federal healthcare industry, voluntary compliance to All Hazards Readiness guidance has not produced positive results. This leaves us with a couple of options: Make compliance mandatory, as is being done in the Federal Healthcare Sector, or create rewards for better performance. Theoretically, hospitals and healthcare organizations are obliged to provide a safe and secure environment as a Condition of Participation in Federal reimbursement programs, however, the failure to provide a safe location has not produced any serious consequences in events such as Allison, Katrina, Joplin or Sandy.
We suggest that providing incentives for good behavior will end up with better results; whether in rankings or in terms of level of reimbursement from CMS. Some potential questions that could be asked when ranking best hospitals include:
1) Have they been fined for fraud and abuse including overcharges and blatant fraud of taxpayer funds? Have they been fined multiple times?
2) Have they taken advantage of Federally-funded programs to secure their nuclear material from theft or exposure to explosives? Have they seismically upgraded their facilities in known earthquake zones?
3) Have they increased voluntary controls on preventing the introduction of all manner of weapons into the workplace?
4) Are they engaged in predatory pricing? (Top 5% for DRG)
5) Have they failed to secure Personally Identifiable Patient Information? (HIPAA violations)
6) Have they mitigated violence in the workplace (hiring practices/outsourcing)
7) Do they have any Stark violations?
For the sake of time, we will not go into these rhetorical questions one by one, but will ask an overarching question:
Should hospitals who answer “yes” to any of the above be listed among the “Best” or “Top”, and would holding them to account by denying that coveted distinction have any impact on behavior that is clearly not in the best interest of the trusting public?
We have clear ideas about the construction of a scorecard and ranking system that could incorporate these social and safety factors into the ranking system, but it will remain up to the integrity of individual hospital’s stewardship to make the commitment.