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Healthcare Waste – Time to Remove the Blindfold

By: David P. Lind

A recent blog published on my David P. Lind Benchmark website broached the major components of healthcare waste in the U.S. and how it is estimated to impact Iowa employer health insurance premiums that we all pay. A quick summary from that blog provided the following:

According to the 2019 Iowa Employer Benefits Study©, annual premiums paid by Iowa employers and their employees in 2019 are $7,017 for single coverage and $19,335 for family coverage.  Of this amount, an estimated 34 percent may be considered wasted, unnecessary money spent with little to no value. That means in 2019, Iowans are paying an estimated wasted amount of $2,400 for those with single coverage and $6,600 for family coverage – EACH YEAR!

Healthcare waste is endemic of the inefficiencies and the misguided incentives laden within our healthcare ‘system.’ Of course, the ‘waste’ that each of us pay is broadly known as ‘revenue’ and ‘income’ to others. It will be difficult for the healthcare infrastructure to change its way when there is about $1 trillion annually found at the feeding trough of entitlement.

After writing this particular blog, a new survey was released by Kaiser Family Foundation regarding the U.S. Public’s perspective on prescription drug costs. The infographic found within this study is of great interest to me, particularly as it relates to what the public sees as the top contributors to high healthcare costs. It is no surprise that drug companies are considered to be the largest reason why people’s healthcare costs have risen (78 percent), yet, fraud and waste is tied in second place (along with hospitals charging too much) at 71 percent – narrowly nudging out insurance companies profiteering (70 percent).

For our healthcare system to evolve into what the public hopes and demands, engaged discussion must ensue about the waste that is baked into our system. Without this discussion (and outrage), little will change. Removing the public blindfold to begin making these demands is imperative for change to occur.

I was very happy this recent study revealed that the public is now beginning to acknowledge the inherent problems of a poorly-managed healthcare infrastructure that requires a major reboot to keep costs more affordable and tied with better care outcomes.

Although difficult and problematic, reducing and eliminating healthcare waste is the low hanging fruit that we must immediately address.

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‘Surprise’ Medical Billing Must End NOW!

By: David P. Lind

‘Surprise’ Medical Billing Must End NOW!

A big topic in healthcare these days – beyond high costs and expanding insurance coverage through ‘Medicare for All’ – is patients unknowingly incurring ‘surprise’ medical bills at hospitals. This happens more frequently than we may typically believe. It happens anytime and everywhere.

Why does this matter? Because after receiving medical care by a supposedly-covered doctor or facility, we or a family member, may receive an unexpected and very expensive charge not covered by our insurance plan. The surprise comes when another non-network provider has contracted with your in-network provider to perform services on you, the patient. Unfortunately, your insurance plan does not accept this ‘third party’ as in-network, meaning that your liability for their services go beyond what your insurer accepts and pays.

One example of this is having an emergency appendectomy at your local hospital, which is listed as an in-network provider under your health insurance plan. Sometime after this event, you learn of the cost for this procedure, typically by receiving an explanation of benefits (EOB) from your insurer, and any invoice sent to you by the health provider showing your liability (e.g. deductible, coinsurance, non-covered charges, etc.).

However, there is a much larger invoice that sneaks through the mail, from an anesthesiologist, who is not employed by the hospital. The anesthesiologist is an ‘out-of-network’ provider with your insurance company, which means that your insurer will only pay up to the predetermined allowable amount, while the non-covered provider can balance bill you the remainder of their list price (full charges). In some cases, the difference in price can be grossly substantial. The point is, during your surgery, you (and any family member) had no input on which provider(s) would be included in your procedure.

Research by Stanford University discovered that 39 percent of 13.6 million trips to a hospital’s emergency department by privately-insured patients resulted in an out-of-network bill. In fact, during the period studied, from 2010 to 2016, the likelihood increased nationwide from about a third of ED visits in 2010 to about 43 percent in 2016. Additionally, for patients admitted to in-network hospitals, this same study found that 37 percent of 5.5 million admissions resulted in at least one out-of-network bill during this same time period.

A Kaiser Family Foundation Health Tracking Poll conducted in early September indicates that nearly eight in 10 Americans support legislation to protect people from surprise medical bills. In fact, BOTH Republicans and Democrats actually agree legislation should be passed to protect patients. But true to form, lobbyists are fighting this movement because they feel their livelihood is at stake. These detractors are not only medical professionals, but also private equity and venture capital firms that employ doctors and contract them out to healthcare facilities.

A true case in point is ambulance services. Studies suggest that between half and two-thirds of ambulance rides are out-of-network (see graphic by USC-Brookings Schaeffer Initiative for Health Policy).

 

Years ago, large hospitals owned helicopters that would be included in the hospital billing – and covered as ‘in-network’ by insurance companies. However, primarily due to high overhead costs, hospitals gradually sold their ambulance services to private companies. Air ambulance bills began to inflate substantially. For example, according to Dr. Marty Makary’s recently published book, “…between 2007 and 2016 alone, the average price of an air ambulance transport charged by one company went from $13,000 to $50,000.” The examples found in Makary’s book about the grotesque pricing is alarming. In Texas, one air ambulance company charged $43,514 to fly a patient to another hospital that was 50 miles away. The patient’s Blue Cross and Blue Shield plan paid $13,827 of this amount, but the patient was billed the balance of $29,687. This sounds like déjà vu all over again – as we learn what has been happening with prescription drug markups.

Air ambulance companies have increased by 1,000 percent from the 1980s to 2017. For-profit air ambulances aggressively seek to win referrals from EMTs, paramedics, first responders, nurses and emergency physicians, often providing financial incentives for such referrals through informal agreements. According to Makary, the kicker is this: “Eighty percent of the more than half a million air ambulance flights a year (1,300 per day) in the U.S. are NOT emergencies but are much more like routine transfers. In other words, most of the time, these helicopters are taking stabilized patients from one facility to another…” These trips could be performed at a much lower cost with a ground ambulance.

Government payers, such as Medicare and Medicaid, make up a large percentage of air ambulance flights. But by law, private air ambulance companies cannot bill Medicare or Medicaid patients for any amount above what the government pays. It is only the privately-insured patients who are affected by this predatory medical billing practice. This price-gouging is done to people when they are at their most vulnerable. Even if asked up front, most air ambulance services will not share their egregious price before hauling you off into the sky.

Restoring trust in healthcare begins with ending surprise medical billing. Billing practices must be honest, transparent and fair. Ending kickbacks and implementing patient protections is a good start for any provider or service to be allowed to assist patients and the public. State lawmakers can help protect consumers by requiring prices to be at least published – if not controlled. Laws should require air ambulances to inform patients and family members how much the flight is going to cost BEFORE being used. Finally, developing a database that identifies the person or organization who made the decision to summon the air ambulance company will expose hidden conflicts of interest.

Enough is enough with the various industry players hiding behind the cloak of secrecy demanding grossly unreasonable prices to vulnerable patients. This is one ‘entitlement’ program that must go away soon.

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“Alexa, diagnose my cough” – Part 2

By: David P. Lind

Last April, I published a blog about potentially using cloud-based voice services, such as Amazon Echo (Alexa) or Google Home, to serve as artificial intelligence (AI) when seeking a healthcare diagnosis based on symptoms we experience. By merely sharing our medical symptoms with a smart-voice service, we could receive a diagnosis that is based on the latest peer-reviewed medical literature available.

As pointed out in the blog, one cautionary note about using such a tool was the ‘legal liability hurdles,’ such as being HIPAA-compliant (a U.S. health privacy law) – making sure that our private-patient information is being securely transmitted.

This particular hurdle appears to have been cleared. On April 4, the publication STAT reported that Amazon unveiled HIPAA-compliant software allowing pre-selected healthcare companies to build Alexa voice-program tools giving patients access to personalized information such as progress updates after surgery, prescription delivery notifications, in addition to learning nearby urgent care facility locations. Health firms can use Amazon’s Alexa Skill Kit to build voice programs that can create products to transmit and receive patient data.

As mentioned in STAT, “The move will embolden hospitals, insurers, and other healthcare firms to expose Alexa to more sensitive details of patients’ lives and medical conditions, and potentially embed the technology deeper into clinical settings.”

Developments like this one may not be highly-visible to the casual observer, however, it might be similar to a simple mist that ultimately results in a torrential downpour, causing a Tsunami of change.  Who knows, perhaps in just a few short years, ‘Alexa’ and other cloud-based services may actually simplify our daily lives that, today, seem complex and frustratingly lost in unchartered waters.

Hold on tight for the next rush of change that will no doubt disrupt how we will eventually live.

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National Trend – Insurance Companies Investing in Affordable Housing Projects

By: David P. Lind

National Trend – Insurance Companies Investing in Affordable Housing ProjectsIn 2016, Dr. Yogi Shah and I co-wrote a blog about moving ‘upstream’ to make investments in population health, more specifically, the social determinants that impact our health. As indicated in our work, when compared to other industrialized countries, the U.S. spends disproportionately large amounts on medical services, while largely ignoring the living environment that greatly affects the health of our population. We spend considerably more for medical care, yet our outcomes compare unfavorably to those countries.

In the U.S., we have done a great job of ‘medicalizing’ our social problems. But instead of focusing on how to pay for medical care, we would be wise to re-direct our limited resources toward improving basic social determinants of health, such as education, housing, nutrition and poverty.

UnitedHealthcare, the nation’s largest health insurer, and a division of UnitedHealth Group, announced this past week that their program of investing in affordable housing projects has now surpassed $400 million. Since 2011, UnitedHealthcare has invested in 80 affordable-housing communities across 18 states with more than 4,500 new homes for individuals and families in need.

It should be noted that the shortage of affordable housing greatly impacts population health. It limits choices about where people live, often pushing lower-income families to substandard housing in unsafe, overcrowded neighborhoods with higher rates of poverty and fewer resources for healthy outdoor and exercise activities. Further, unaffordable housing can prevent people from meeting other basic needs including nutrition and healthcare.

Not to be outdone, other insurers are also making affordable housing investments. The nation’s second largest insurer, Indiana-based Anthem, has committed about $380 million developing affordable housing over the past decade. Kaiser Permanente, a California-based healthcare provider that also sells health insurance, has invested $200 million to address housing stability, homelessness and other community issues. Blue Cross and Blue Shield of Minnesota, HealthPartners and UCare, all in Minnesota, are also supporting smaller projects to do the same. I’m sure there are other insurers making similar investments elsewhere.

As we all know, healthcare payers are having difficulty controlling escalating healthcare costs. One mindset change is to look ‘upstream’ and find local priorities that are linked to poor health outcomes needing attention. According to one study brief, social determinants account for about 80 percent of health outcomes, meaning that the majority of our healthcare costs can be attributed to non-clinical factors.

Research continues to confirm that unmet social needs are associated with higher rates of hospital admissions, readmissions, and emergency room use. One prime example is that supportive housing has been shown to decrease Medicaid costs by up to 67 percent, which includes reduced emergency room visits and inpatient admissions. Such outcomes can positively impact the private-payer ledger by saving monies paid to medical providers who care for the low-income population.

Investing ‘upstream’ is a smart alternative to the avoidable problems that become more expensive ‘downstream.’ It is good to see that more insurers are also taking this approach.

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Dependence on China – The ‘Weaponization’ of our Medicine

By: David P. Lind

China Rx - Exposing the risks of America's dependence on China for medicince.Almost five years ago, due to an introduction by a mutual acquaintance, Rosemary Gibson walked into my office for a visit. Prior to our meeting, thanks largely to the internet, I crammed to learn as much as I could about her. Rosemary, I quickly learned, had co-authored four highly-trusted books about healthcare, and I was halfway through her first book, “Wall of Silence,” when we first met. Her research prowess and writing style had me immediately hooked. In a blog that followed our meeting, I called her a healthcare ‘Rock Star.’

China Rx

Five years later, in a recent op-ed piece for the Des Moines Register, Rosemary and I co-wrote an article about a subject that was not on our radar five years before – China’s growing influence on becoming the “pharmacy of the world.” Through Rosemary’s tenacious appetite to reveal important subject matter that affects Americans, she spent a few years researching, and subsequently writing the book, “China Rx: Exposing the Risks of America’s Dependence on China for Medicine.”

This book is full of examples about how and why China was able to cajole the manufacturing of key active ingredients for many of our medicines away from the U.S. and other friendly countries. This is a critical problem today because, as former government and industry officials have shared with Rosemary, “…if China shut the door on exporting many of these necessary therapeutic ingredients to the U.S., within months, pharmacy shelves in the U.S. would be empty and hospitals would cease to function.” Even India, a top country that manufactures generic drugs, is dependent on China for the active ingredients and raw materials in many of the medicines it makes, not only for its own people, but also for exports.

To borrow a term from the ‘Apollo 13’ movie, “Houston, we have a problem.” No wait, we have a BIG problem!

The China Problem

According to China Rx, a major event occurred in the year 2000 that triggered the U.S. to rely more on China for the supply of medications. Congress and the White House agreed to grant China access to the U.S. market, and also permitted China to join the World Trade Organization. Shortly after, China developed the penicillin and Vitamin C ‘cartels,’ by basically replacing American manufacturers by dumping low-cost product in our country. As a result, American manufacturers could no longer compete against China’s government-financed manufacturers. China’s monopolizing behavior is also commonly seen in many other manufacturing products found in other industries.

In 2004, Baxter Healthcare switched suppliers for Heparin, an important blood thinner agent. The new supplier, now China-based, began controlling this market. A contaminated ingredient was found in Baxter’s Heparin product – “a deliberate contamination for economic-motivated reasons.” From this, 250 deaths in the U.S. resulted from this contamination.

Having a high concentration of our medicine coming from just one country, no matter the country, can become a major strategic health and security risk to our population. To function, the U.S. (and any other country) relies on having appropriately manufactured medicine of high-quality with safe ingredients, reasonably-priced, and readily available. In fact, by ceding the manufacturing of medicine elsewhere, any country could become victims of a new warfare that has never been waged in the past – the weaponization of medicine.

In addition to the on-going trade ‘war’ with China, tensions in the South China Sea continues as an international hot spot. During any of these disputes, China could strategically reduce (or cut-off) the exportation of medicine that we depend for our livelihood, including our health and safety.

How Dependent Are We on China for Medicine?

China Rx does a splendid job of explaining how reliant Americans (and other countries) are on China as it relates to our key medicines. In fact, due to poor quality, the Food and Drug Administration (FDA) banned 29 different medicine products being imported from China. However, because the U.S. is so dependent on these medicines, the FDA had to exempt 14 of those products from its own ban. Some of these products included antibiotics, ingredients for antibiotics and ingredients for chemotherapies. This happened because the FDA was concerned about drug shortages in the U.S.

Below is an excellent video from C-Span in which Rosemary Gibson discusses many issues and implications about relying on China to be the sole supplier of many of our medications.  Additionally, two former international trade officials corroborate the findings of China Rx, giving this discussion a troubling, yet powerful vibe about our current reliance on China for our medicine.

China Rx
Rosemary Gibson talked about the risks of the U.S. depending on China to supply the essential ingredients for many of our most widely used medicines.

A stunning finding from Rosemary’s book is that even when American companies have their own plants in China, they frequently do not meet the quality and safety standards that we would all come to expect. China products can be initially cheap because they hope to capture the market and drive their American competitors out. This can be done because the Chinese assume no liability for what they make – a ‘buyer beware’ mentality.  The problem is that most Americans have no idea that the medications they use come from a relatively unregulated country. One hidden price of cheap drugs is the lack of consumer protections. However, once American competitors are no longer competing, the prices can be (and are) arbitrarily increased with no particular reason – other than greed – and control.

A Few Recommendations

For the future, China Rx provides three recommendations to the China problem:

  1. The U.S. must change its mindset about our medicines. Medicine should not be viewed as a ‘cheap’ commodity. Currently, it is. We must view medicine like we do our food and energy resources, such as oil – it should become a strategic asset.
  2. We must have a tracking and forecasting system available of noting where drugs are manufactured and how much supply is available at any one time.
  3. The U.S. must maintain manufacturing capabilities at home. Provide incentives to U.S. manufacturers to keep their plants in our country. We are the ONLY industrialized country in the world that does not have an industrial policy.
The medicine we depend on must be affordable, manufactured safely with trusted third-party oversight, and always be in supply for our country. Rosemary Gibson is on to something very important – indeed, crucial.

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A Reason to Donate Anonymously?

By: David P. Lind

A Reason to Donate Anonymously?When donating to your favorite charities (or candidates), do you usually allow your donations to become acknowledged publicly or do you prefer to give anonymously? Perhaps your answer depends on the specific charity or candidate, or maybe it depends on how much you are donating. By the way, there really is no right or wrong answer to this question. However, you may change your views after reading this post.

What would you think if your donation history to various charitable causes may determine whether or not you will be ‘targeted’ by your local nonprofit hospital to become a donor to their organization?

Nonprofit Hospital Fundraising

Research shows that this happens relatively frequently. In fact, you may even be a patient at the time you are ‘solicited.’ Through highly-defined prospect research results on your past-giving behaviors, you may qualify to receive a visit by a hospital administrator or someone representing the philanthropic arm of the hospital. The donations sought are to supplement income streams hospitals have from other sources, such as private and public insurance payers and money raised through more traditional (and transparent) methods, such as charity golf tournaments, galas, etc.

This issue caught my attention recently after reading a Kaiser Health News article. According to the article, ‘many’ nonprofit hospitals across the U.S. conduct “nightly wealth screenings” of their patients. They use software “that culls public data such as public records, contributions to political campaigns and other charities – to gauge which patients are most likely to be the source of large donations.” According to this article, these programs “are becoming commonplace, particularly among the largest nonprofit hospitals.” This practice is also known as ‘Grateful Patient Programs.’

If Solicited as a Patient, It’s Legal

Protected health information (PHI), which is part of the Health Insurance Portability and Accountability Act, is usually a good thing for patients. In fact, PHI was designed to be given only to authorized individuals and organizations. Yet, since 2013, certain healthcare providers are allowed greater flexibility to use PHI for fundraising purposes, such as the nature of the services a patient received or the identity of his or her physician. According to The Giving Institute, healthcare organizations may use the following patient’s PHI without having their authorization for fundraising purposes:

  • Patient demographic data (name, address, phone/email, date of birth, age, gender, etc.)
  • Health insurance status
  • Dates of patient services
  • General type of department in which a patient is serviced
  • Treating physician information
  • Outcome information
Written patient authorization is required prior to fundraising under the following:

  • Diagnosis
  • Nature of services
  • Treatment
The 2013 change in federal health privacy law made it easier for hospitals to target their patients for donations, enabling the hospital records department to share with staff fundraisers some personal details of patients, as outlined above. When admitted to a hospital, patients (or a family member) are required to fill out paperwork permitting the hospital to use PHI for fundraising purposes. The federal law does require hospitals to inform patients they have the right to decline being solicited, but few patients are aware of this due to the bevy of legal paperwork they are given during the time of admittance.

Major Des Moines Medical Centers?

This rather opaque process of soliciting qualified patients for donations prompted me to contact the media relations departments of Des Moines’ two largest hospital systems: Mercy Medical Center (now MercyOne) and UnityPoint Health Des Moines. As of this post’s publication, neither organization has responded to my emails to confirm whether or not they have such a program in place.

Hospitals are granted a tool that allows them to legally solicit donations from patients and family members, especially when they are held ‘captive’ within their facilities due to medical purposes. The Kaiser article does raise a question that many of us may ponder: Will care be affected depending on whether a large donation is possible or not? In other words, could we potentially have a two-tier care system, one for the wealthy and one for everyone else?

This fundraising approach does allow one to reason that perhaps more of our future personal donations should be made anonymously.

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It’s Time for ‘Health Literacy,’ but What is It?

By: David P. Lind

Let’s be honest, healthcare is complex. It affects each of us in many ways, some more than others. Despite our desires, we cannot ignore it and assume it will go away, it just won’t. Ben Franklin once wrote, “Nothing is certain except for death and taxes.” Well, let’s tack an addendum to that quote with the following: “Nothing is certain except for death, taxes and healthcare fatigue.”

Healthcare fatigue?

In its simplest form, ‘fatigue’ describes “extreme tiredness resulting from mental or physical exertion or illness.” Fatigue is found in healthcare at many different levels. We are now beginning to learn more about how medical providers – physicians, in particular – are increasingly experiencing job ‘burnout,’ a problem so alarming that a recent Harvard report is calling it a public health crisis. According to this 2018 survey, 78 percent of over 8,000 physicians polled ‘reported feeling burned out at least sometimes.’ Another recent Medscape study revealed that nearly half of 15,069 responding physicians reported they were burned out – female doctors reported at a higher rate than their male counterparts.

This horrific finding is extremely troubling for the physicians (and family members) who fight three main symptoms:

  1. Emotional exhaustion.
  2. Sense of depersonalization and disconnection from work.
  3. Feeling a lack of efficiency at work.
Equally disturbing is how provider-fatigue may adversely impact patients who rely on their doctor’s clear judgement when receiving appropriate care. If one physician is battling a form of ‘burnout,’ the domino-effect on patients from that doctor becomes a multiplier effect.

Patients, for their part, must seek healthcare by using a labyrinth of passages or paths that are not often intuitive, especially when acute or chronic health conditions undermine the decision-making process.  Patients have their own form of ‘healthcare fatigue.’ They must arm themselves with tools and resources needed to make informed decisions regarding preventive, routine, emergency and end-of-life care. For this to be successful, patients must become health literate.

Health literacy is about having the ability to make informed choices in any healthcare situation. Due to the complexity of the U.S. healthcare delivery system, most Americans lack the information-gathering and decision-making skills to effectively cope with today’s complexities. Jo Kline, founder of the Iowa Institute for Health Literacy, succinctly states that “The public has never been offered the health literacy tools they need. Teaching the skills of informed decision-making to those directly affected – such as 133 million Americans of all ages with chronic medical conditions – is a long-overdue first.”

If we believe our interactions with medical practitioners are a ‘monologue,’ meaning that the practitioner talks and we should only listen, we are grossly mistaken. Instead, we should be having a ‘dialogue,’ in which a healthy conversation develops between the practitioner and the patient, allowing for both sides to clearly understand what the other party is saying. Literate patients and family members must not be afraid to ask questions – and then ask more. This is, however, just one part of being health literate.

Kline explains in her recent press release, “The state of Iowa mimics what America at large is facing: aging demographics and shrinking healthcare resources. Ten thousand Baby Boomers turn 65 every day and Iowa will have an additional 158,000 seniors by 2030.” During this same time period, Kline indicates that “one-third of healthcare professionals are retiring, so the workforce will shrink and waiting times will grow – for patients of all ages.” With this inevitable challenge, being health literate is imperative for all of us.

How can employees and their family members become more health literate? A great way to start is by attending Kline’s first-in-the nation seminar on Wednesday, March 6, at the FFA Enrichment Center (DMACC Campus) in Ankeny. From this, you will discover the fundamentals of health literacy, such as reducing the risks of polypharmacy with an annual “Brown Bag Checkup” of all medications, keeping your medical history up-to-date for any new provider or emergency, and understand the vital role that palliative care can play in treating any serious illness.

Being health literate is extremely important to each one of us. We will be better equipped to recognize when, how and where to access, process and understand basic health information and services needed to make informed decisions in a particular healthcare situation.

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Wisdom We Can All Live By – From Dr. Martin Luther King Jr.

By: David P. Lind

Every now and then, I will stumble across a poignant quote with sage advice that cuts deeply to my inner being. A powerful quote can become so clear, as if it was only directed to me. Truth be known, the following timeless gem should resonate with each of us, as it provides the essence of why we exist.

You may be 38 years old, as I happen to be. And one day, some great opportunity stands before you and calls you to stand up for some great principle, some great issue, some great cause. And you refuse to do it because you are afraid… You refuse to do it because you want to live longer… You’re afraid that you will lose your job, or you are afraid that you will be criticized or that you will lose your popularity, or you’re afraid that somebody will stab you, or shoot at you or bomb your house; so you refuse to take the stand…Well, you may go on and live until you are 90, but you’re just as dead at 38 as you would be at 90. And the cessation of breathing in your life is but the belated announcement of an earlier death of the spirit.

– Martin Luther King Jr. (From a November 5, 1967 sermon)

Are Generic Drugs ‘Reasonably’ Priced? Perhaps Not

By: David P. Lind

This coming January, I will have spent 35 years in the insurance and healthcare arena. During this tour of duty, I have learned that nothing surprises me anymore, especially as it relates to the trust we blindly give to those who appear to act in the ‘best interest’ of the patient and general public.

Here is yet another example – generic drugs and how they are priced.

Generic medications have proven to effectively keep our drug costs low after patent protection expires.  As proof, 90 percent of all prescriptions written in the U.S. are for generic drugs, yet generics comprise only 23 percent of total Rx costs (Source: Association for Accessible Medicines). Yet, new breaking developments suggest that, for at least 300 generic drugs, we are unsuspecting prisoners of a generic drug “cartel” that keeps generic drug costs higher than necessary – thanks largely to a friendly game of price fixing. The adage, “You scratch my back and I’ll scratch yours,” seems to apply quite well in this situation.

A December 10 article in Vox by Dylan Scott, “A groundbreaking antitrust lawsuit is ensnaring the generic drug industry,” explains how at least 16 generic drug companies allegedly rigged the market and fixed prices for roughly 300 generic medications. This article references a recent Washington Post piece that reveals most every state attorney general has now joined in a lawsuit on this ‘itchy’ topic. Have generic manufacturers become the new ‘Pinocchio’ with regulators and the general public?

When our non-healthcare markets are healthy and working appropriately, we can all benefit by paying lower prices for a higher-quality product (or service). However, in healthcare, when left unchecked, simple greed erodes the trust we have placed in a system we believed would ‘fix’ our cost conundrum. With this type of market behavior, American economic theory about consumer choice and market-based pricing mechanisms will find tough sledding in any market, especially with healthcare.

We can do better.

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Hospital Patient Safety Culture Does Matter

By: David P. Lind

A few years back, I walked into an Iowa healthcare executive’s office to discuss an idea that I thought carried a great deal of merit regarding patient safety. The executive politely listened to me. The idea was both simple and very intuitive. Because the mission of this particular healthcare organization is to promote quality and safe care, I was assuming it would be open to potentially embracing this approach in Iowa.

This idea was generated from the Hospital Survey on Patient Safety Culture, which is a staff survey designed by the Agency for Healthcare Research and Quality (AHRQ) to help hospitals assess safety culture within their own walls. When you think about it, who better to ask about quality of service within a hospital than the frontline workers themselves – staff, nurses, technicians, etc.? In fact, a 2017 report in BMC Health Services reported that hospitals with “higher staff perceptions of safety culture were associated with better overall safety, as measured by a composite of reported harms and patient satisfaction.” Additionally, when noted physician, Marty Makary and his staff performed a joint study with risk management firm, Pascal Metrics, they found “hospitals that scored well on the staff survey had lower rates of surgical complications and other important patient outcomes.”

The simple idea?  Have ALL Iowa hospitals undertake this survey every other year with the results becoming public. After all, this approach would tie nicely with the mission of the organization I visited that day. Including outpatient surgery centers would be ideal.

The response I received from the medical executive was not what I had expected. To paraphrase his feedback: “These surveys usually occur in larger eastern (U.S.) hospitals, but not in small rural hospitals, like Iowa. The data findings from Iowa hospitals would not be statistically relevant…” I was absolutely floored when I heard this half-baked argument. What this executive failed to understand – or more likely, refused to understand – was that such surveys can be used within hospitals REGARDLESS of employee size. To be effective, the two critical cautions for this survey are:

  1. Mandatory participation of all staff within each department
  2. Assure staff that honest responses are extremely important and any retributions for this honesty will not be tolerated.
Frankly, if a hospital is large enough to care for patients, then it should be large enough to be surveyed on how it reports its organization’s patient safety culture. Clearly, the executive did not want this to become public knowledge, as the results could undermine the trust the public places within each of the state’s 118 community facilities. For those hospitals that do utilize the culture of safety survey, their identity is hidden from the general public. In fact, AHRQ shared with me that “Hospital-identifiable data from the Hospital Survey on Patient Safety Culture Comparative Database are not available for public reporting purposes per the data use agreement AHRQ has with each hospital that voluntarily submits data to the database…reporting at state level can also put hospital confidentiality at risk especially in smaller states.” This means that we don’t even know how many hospitals participate in any given state. How’s that for transparency?

Safety of care, I have learned, can be more about the optics (carefully spoon-fed to the public) than actual substance. For example, developing safety awards for hospitals who report few errors can dangerously promote behaviors to withhold adverse event reporting, a solemn fact that I have learned from trusted, first-hand sources (in Iowa). Although well-intentioned, poorly-constructed safety awards can manipulate the system for a desired outcome – giving the public a false sense of security on receiving safe care. Manipulating sacred patient trust is a gross violation of professional ethical codes.

The November issue of Health Affairs dedicated the entire publication to the latest findings on patient safety-related matter. One article by Aiken, Et al., “Nurses’ And Patients’ Appraisals Show Patient Safety In Hospitals Remains A Concern,” summarizes the process of surveying hospital nurses from 535 hospitals in four states (California, Florida, New Jersey and Pennsylvania). The survey took place in 2005 and then again in 2016. In addition, patients from those hospitals were surveyed during that same time period. The bottom line is this: “Clinical work environments in most hospitals did not improve between 2005 and 2016.” The concluding summary of this article was to the point: “Our findings confirm that patient safety remains a serious concern. Failure to substantially improve clinical work environments in most hospitals, as recommended by the Institute of Medicine, may be hampering progress toward improving patient safety.”

As stated in our ‘Silently Harmed’ white papers, preventable harm in healthcare is a public health crisis, and much of this problem stems from organizational systems tolerating (or hiding) poor safety cultures. I received a very descriptive comment from Donna Helen Crisp, who spent eight years writing a book about what happens in hospitals when things go wrong. In North Carolina, Ms. Crisp served as a nurse, nursing professor medical ethicist, dying patient, and author (Anatomy of Medical Errors: the Patient in Room 2). As an advocate, Crisp helps raise awareness about preventable medical errors and adverse events so that they can be eliminated – or at least mitigated.

Her extensive background provides a wealth of perspective that lends great credence to this topic. As she indicated, “All the time and energy spent arguing about how many medical errors occur, or how patients abuse the legal system to make money, or why doctors and surgeons deny and delay the truth, or how dying patients should not be counted in medical error statistics – all this time and energy would be better spent by pursuing the following:”

  1. Changing the medical paradigm by putting patients and families first.
  2. Learning to see and accept the problems inherent in hospital care.
  3. Developing core values to address and decrease medical errors.
  4. Improving patient safety through transparent care.
  5. Supporting clinicians who want to be truthful but fear retribution.
  6. Training clinicians how to ethically support patients.
  7. Training clinicians how to identify and ameliorate suffering.
  8. Making safe care a higher priority than training doctors or corporate profit.
Because most medical errors go unreported, it is necessary to establish baselines, however they are determined, to track future progress on eliminating these errors. But we can learn a great deal by heeding Ms. Crisp’s words.

I only hope this same courage allows others who serve in crucial roles throughout our healthcare delivery system (including those we elect) to proactively do the right thing and provide the transparency in care that we so desperately need.

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