Des Moines Register Archives | Heartland Health Research Institute

Another Study Regarding Hospital Mergers – Not Good for Patients

Posted on: 02.11.20 By: David P. Lind

This past September, I wrote an Op-Ed piece for the Des Moines Register and a blog discussing the important drawbacks of the proposed merger between Sanford Health and UnityPoint Health. In early November, this merger was abruptly called off, with the Sanford Health CEO indicating that the UnityPoint board “failed to embrace the vision of a new health system of national prominence.”

For more than three decades, many hospitals around the country have been on one huge shopping spree, buying-up their competitors – both big and small. The common rationale cited by hospital executives (and their powerful associations) are that hospitals will become better health systems, patients will benefit with better quality-of-care, and that costs will go down. In short, they pitch that this buying behavior is a win-win for everyone.

Bottom line – this behavior usually favors the merging hospitals and NOT the payers and patients. It’s quite simple: Hospitals don’t consolidate to cut their prices, they do it to gain market dominance when negotiating with insurance companies. Numerous national studies validate this fact.

New Research on Mergers Refutes Hospital Mergers

A newly-released study, “Changes in Quality of Care after Hospital Mergers and Acquisitions,” published in The New England Journal of Medicine, refutes the too-often-argued pitch that mergers will improve patient outcomes. In fact, this new report suggests four dimensions that run contrary to the hyped-claims offered up by the hospital industry:

“Acquired hospitals experienced a progressive decline in patient experience measures after the ownership change.”
Acquiring hospitals with a lower ‘baseline’ of patient experience performance will subsequently spread this lower performance to the newly-acquired hospitals. Additionally, there was no evidence that higher-performing acquiring hospitals will boost the patient experience ratings for the acquired hospitals.
Insignificant impact on 30-day readmission or mortality rates for the acquired hospitals.
Any improvement that acquired hospitals had in their clinical process measurement performance happened BEFORE the ownership change, suggesting the acquisition was not a causal reason for the improvement.

The study basically suggests that, relative to hospitals that were not acquired, acquired hospitals did not improve quality of care in the following ways:

Patient Experience WORSENED.
Patient Outcomes showed NO IMPROVEMENT.
Clinical Processes for improved performance are INCONCLUSIVE.

The National Institute for Health Care Management (NIHCM) provides a helpful slide show on the implications of hospital mergers that do not support the arguments made by the hospital community. Additionally, a very helpful podcast about hospital mergers, Tradeoffs, discusses the implications that mergers are actually harmful to the public, and any proposed mergers in the future should be highly scrutinized by local authorities and the general public. Tradeoffs, by the way, is supported by the Robert Wood Johnson Foundation and the California Health Care Foundation.

Regardless of the rationale they used, the board of directors at UnityPoint should be commended on nixing the proposed merger with Sanford Health. Having a ‘new health system of national prominence’ sounds like a verse from the P.T. Barnum hymnal of marketing slogans. Without question, healthcare requires less hyperbole-sounding slogans and more patient (and payer) centric action.

If hospitals really desire to lower their prices, they will find ways to eliminate clinical redundancies and increase productivity. This does not require the pursuit of mergers, but rather, demonstrate the willingness to embrace Economics 101 of keeping overhead affordable.

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Iowa DOT and Volvo Can Teach Medical Establishment a Thing or Two about Safety

Posted on: 11.19.19 By: David P. Lind

Before I comment about the never-ending problem of patient safety in our state and country, I want to provide kudos to the Iowa Department of Transportation (Iowa DOT) and Volvo for doing a great job of keeping vehicle drivers more safe.

Iowa Department of Transportation

When you drive on Iowa highways, particularly on our interstates, you will invariably see snarky, but clever, messages on 79 electronic message signs that may force a chuckle. You can thank the Iowa DOT and the public for these creative messages. The signs are designed to grab the driver’s attention with messages that are part of the ‘Zero Fatalities’ program the DOT launched back in 2014. The DOT promotes this program through blogs and social media. Additionally, the Iowa DOT pulls together safe driving and improved trauma care through a program called TraumaHawk.

Every Monday, the DOT messages change and relate to five driving categories such as buckle up, drive sober, stay alert, pay attention and slow down. But another statistic is commonly updated – sharing the latest number of fatalities on Iowa roads since the beginning of the year. This one always has my attention. Maybe it’s just me, but I am curious to know whether or not we have fewer fatalities.

I’m impressed that not only are the fatalities counted, but they are quickly shared with the public in ‘real time.’ According to the Iowa DOT website, a ‘fatality’ is considered “crash-related” when death occurs within 30 days (720 hours) of a crash. Complex crash investigations can delay the official fatalities report, so the numbers for the current months are preliminary and can change considerably.

Relating road fatalities with preventable medical error fatalities may sound like a stretch – but it’s not. The federal government and all 50 states have made vehicle fatalities and serious injuries a major safety priority. The design and manufacture of the vehicles we purchase are a direct result of these priorities.

Volvo’s Promise

At least one manufacturer, Volvo, has made safety it’s branded message – and market differentiator. This has been a huge success for Volvo when competing against a crowded field of car manufacturers. One of the visions listed by Volvo on its website is truly an eye opener:

No one should be seriously injured or killed in a new Volvo car by 2020.

There it is. Volvo has declared a zero tolerance for manufacturing unsafe vehicles. Quite an impressive Big Hairy Audacious Goal (special thanks to authors James Collins and Jerry Porras for coining the ‘BHAG’ term).

What About the Medical Care We Receive?

Why shouldn’t we have the same amount of commitment from the medical establishment, the federal government and all 50 states on tracking and reporting unsafe medical care? Great question, but we don’t.

Twenty years ago, the Institute of Medicine’s To Err is Human report was published, sending shock waves around the country that at least 44,000 and as many as 98,000 people die in hospitals due to preventable adverse events. The authors of this report called for developing a mandatory, nationwide system for reporting adverse events causing death or serious harm. Yet two decades later, we still have no system in place on a national basis. About two dozen states require providers to report adverse events, but these events are a narrow range of “never events,” which cover only a fraction of all harm events and errors. Iowa is not one of these states.

Tracking and reporting unsafe care boils down to disagreements on how to accurately measure patient harm. Arguments evolve around defining medical errors and avoidable harm, determining whether deaths were caused by errors or other factors, and heaven forbid, the inconvenience of having to collect this data.

Additionally, there is disagreement about the effectiveness of having healthcare staff voluntarily report adverse events or use other means, such as having automated harm surveillance tools embedded in the electronic health record (EHR). According to a 2011 Health Affairs article, voluntary reporting missed 90 percent of adverse events. It’s impossible to fix safety problems if only 10 percent of errors are observed and reported. Further, surveillance tools in EHRs can be manipulated to suit preference of results.

Apparently, ‘inconvenience’ seems to outweigh any perceived benefits of providing safer care. Seeking better measurements, however, should not hold up patient safety improvement efforts. Provider resistance to public reporting of errors is a big roadblock to making preventable medical errors a necessary reality. Unlike the Iowa DOT and Volvo initiatives, we have no ‘Zero Tolerance’ goal in eliminating preventable medical adverse events in Iowa or the U.S.

A New Relevant Role for Insurance Companies

Because the medical establishment and policymakers are unlikely to move forward to proactively improve healthcare outcomes and eliminate preventable medical errors, true payers – taxpayers, employers and their employees – must take charge. They must insist that ‘middlemen’ such as insurance companies implement initiatives, as I have outlined in my Des Moines Business Record article (2018), to proactively learn more from Iowa patients about their experiences with Iowa hospital and clinic encounters.

As an example, Wellmark can play a much greater, more relevant role – similar to the Iowa DOT and Volvo – and become the insurance company committed to the safety of their members – and not just function as a transactional player that processes claims with unknown outcomes. The premiums paid by Iowa employers and their employees should already include this ‘safety’ pledge that is not being acted upon. When you think about it, insurance companies are the stewards of our hard-earned money. We depend on them to use this money wisely.

Similar to our highways in Iowa today, imagine walking into your local hospital and seeing an electronic display showing real-time results of the ‘zero-tolerance’ program that reports preventable adverse events for that hospital. Now that would be a BHAG!

The next steps we take in Iowa will define our ethical commitment to this public health crisis.

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Dependence on China – The ‘Weaponization’ of our Medicine

Posted on: 02.19.19 By: David P. Lind

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:

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.
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.
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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Disparate Views on Patient Safety Progress

Posted on: 04.14.16 By: David P. Lind

When it comes to patient safety progress in the U.S., are we better off today than we were 17 years ago, when the Institute of Medicine’s seminal report “To Err is Human” was published?

Depending on the source (and their particular perspective), the answer to this question can vary widely.

As outlined in our ‘Silently Harmed’ white papers, the measurement of medical errors within hospitals is, quite frankly, abysmal. However, there are pockets of success – such as infection rates – that have dropped in hospitals. This past December, the Agency for Healthcare Research and Quality (AHRQ) issued findings that indicate decreases in infections, medicine reactions as well as other complications from 2010 to 2014 that have resulted in 2.1 million fewer incidents of harm – and 87,000 fewer fatalities.

In Iowa, an editorial by Dr. Tom Evans in the Des Moines Register acknowledged that preventable medical errors do exist – but that “significant improvements” have been made over the past 10 years. Further, data suggests that adverse drug events were virtually eliminated (99.9 percent), pressure ulcers were reduced by 89.4 percent, central line-associated infections decreased 34.7 percent along with many other improvements that were made in less than four years. These “downright impressive” results brought an avoidance of 3,310 adverse events, 15,603 fewer days in the hospital, and more than $50 million in cost savings.

Such public messages appear to be a good start, but make no mistake, we should refrain from performing a celebratory dance in the end-zone as if a game-deciding touchdown was scored. Continuing our football analogy, some notable national experts may suggest that the ball has advanced only a few yards, but far shy of reaching a new set of downs.

The fact is, when it comes to actually reporting adverse events, we don’t know what we don’t know. In other words, we can only measure what is being reported.

A recent report from Leapfrog Group and Castlight Health finds that computer systems in hospitals fail to flag 13 percent of potentially fatal mistakes, while about 40 percent of the most common medication errors were not caught when tested. In 2014 alone, the Centers for Disease Control and Prevention (CDC) indicates that a life-threatening bacterial infection, called Clostridium difficile (C. diff) has sickened over 100,000 American hospital patients. The CDC reports this particular infection has increased by four percent between 2013 and 2014, while other research suggests that 450,000 people, both inside and outside of U.S. hospitals, are affected by this infection each year, resulting in 29,000 fatalities.

I have periodically heard that patient safety experts in academia are not living in reality, as they tend to use their own theoretical acumen and measurements that seldom match up with the ‘real world’ of care delivery. Perhaps this may be true in some cases, but many of these same ‘academia’ experts also practice medicine for a living and have a great deal of passion to ‘simply do the right thing.’ They avoid projecting a false sense of security that our care is safer than it really is. Doing so can be disingenuous – if not grossly misleading.

A short list of highly-accomplished individuals that are on the forefront of patient safety in the U.S. and worldwide include: Dr. Ashish Jha, Harvard School of Public Health; Dr. Martin Makary, Johns Hopkins University; Dr. Peter Pronovost, Johns Hopkins; Dr. Atul Gawande, surgeon at Brigham and Women’s Hospital (Boston); Dr. Lucian Leape (retired from Harvard); Dr. Robert Wachter, UCSF Medical Center; etc. This list is long and impressive. They are not fearful about holding up the mirror to other clinicians and provider systems and challenging them to measurably improve their outcomes based on what is most important to patients.

On March 23, ProPublica held a webcast forum to discuss the value of the Surgeon Scorecard that became available to the public in 2015. Given the lack of specific risk-adjusted data we have on individual clinicians, it was interesting to hear arguments on both sides about the evolution of clinician scorecards available for public use. Toward the conclusion of the forum discussion, Dr. Jha was asked to summarize the progress of patient safety since the IOM report went public 17 years ago. This particular comment was quite revealing:

But at the end of the day, are we measurably and meaningfully safer today than we were 17 years ago? Personally, I would argue the data suggests we are not. We are not meaningfully safer than we were.

Again, time to ‘huddle-up’ and find new ways to advance the ball down the field. Let’s hope that a celebration will eventually take place in our collective future!

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Voices on Hospitals: ‘Trust’

Posted on: 07.09.14 By: David P. Lind

Regardless of the role we serve – whether personally or professionally – the ‘trust’ factor is critical. In business, trust must be earned. It’s the power-brand that represents the DNA of any organization.

However, I’m not so certain that it’s occurring in our current healthcare ‘system.’

In healthcare, many times trust is blindly given when it is not warranted. To better illustrate this point, the Des Moines Register recently published a story, “Ex-staffer: Risk to 2 patients hidden.”

The story is about Robert Burgin, an infection-control specialist for Mercy Hospital in Council Bluffs. Mr. Burgin resigned his position because his employer was unwilling to tell the truth to patients whose health may have been compromised due to medical mistakes. Based on this article, I commend Mr. Burgin for holding firm with his beliefs that patient safety is paramount.

Secrecy in healthcare hasn’t changed much in 15 years since the Institute of Medicine’s ‘To Err is Human’ book was published. The practice of health providers suppressing similar stories from public knowledge is reprehensible. As patients, we trust our providers to do the right thing, regardless of the circumstances involved. Medical organizations that are sincere about pursuing and maintaining an enduring culture of trust should establish initiatives to emotionally connect with their patients to perpetuate that trust.

Indicator #5: Trusting our Hospitals
‘Trusting our Hospitals’ is our fifth performance indicator. Overall, Iowa employers give statewide hospitals an un-weighted score of 7.2, or a grade of ‘B-.’ When segmented into five regions using size-weighted scores, four regions received a ‘mid-to-high C’ grade while the northwest region graded at a ‘B-.’ Keep in mind, these are ‘average’ scores/grades — some hospitals have better-than-average grades, while others have below-average grades.

Going forward, Iowa hospitals must address whether or not having mid-level grades on ‘trust’ are acceptable. Since competition can be fierce within certain markets, low trust in a particular hospital can adversely impact hospital revenue over time.

Hospitals may advertise their quality – perhaps a national publication has included them in one of their quality rankings. But merely telling the public they provide quality is far different from consistently demonstrating this over the long term.

Given the pressure that Mr. Burgin was under to keep this information hidden, he should be recognized for his courageous intent on maintaining the public’s trust. Why not create a special award for those who demonstrate this selfless quality? We could call it “Profiles in Health Care Safety Courage,” to promote similar actions by other health care workers. I would like to think that this on-going award would be recognized by the media and others who want to help promote the ‘trust’ factor in healthcare. It’s certainly something to think about and I welcome any ideas you may have on this topic.

Trust should NOT be something we randomly give away. It is one performance indicator that can be greatly improved through a systematic and transparent approach. Isn’t it time to do so?

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