Rosemary Gibson
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Is health care safer now?

12/3/2014

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This blog cross-posted at The Gazette
This month marks the fifteenth anniversary of the landmark report from the Institute of Medicine of the National Academy of Sciences that estimated up to 98,000 Americans die from preventable mistakes in hospitals every year. It is time to know if health care is safer now.

Many hospitals are working diligently to reduce medication errors, hospital-acquired infections and other causes of harm. Progress has been made.

A wake-up call in 2013 raised the stakes. The Journal of Patient Safety published new estimates that up to 440,000 lives may be lost annually in hospitals due to errors, making health care the third leading cause of preventable mortality in the United States. This is equivalent to the combined populations of Cedar Rapids, Des Moines and Ames. Many more people are injured during their hospital stay.

Stresses and strains are making health care unsafe. Physicians, nurses, pharmacists and other health care professionals are forced to meet demands for higher productivity. They see more patients and do more, leaving little time to talk with patients and each other. Communication breakdowns ensue and patients fall through the cracks.

The performance of any system with unsafe conditions that is forced to operate at a faster pace has only one way to go, and that’s down.

On top of that, health care has become more complex with a steady stream of new equipment, devices, medications, and electronic health records entering the sacred space of patient care. Human ability to safely use this bounty is strained beyond capacity.

The time has come to stop relying on estimates of health care harm. The public should know the unvarnished truth. Are we better off than we were 15 years ago?

The federal government counts the number of deaths from all causes — including cancer, heart disease, vehicular accidents, and smoking — except medical harm. Counting the causes of mortality shows that society cares about every life cut short.

The numbers, and the human stories behind them, motivate people to act to reduce the burden caused when lives end too soon. Decades of sustained work to prevent and treat disease, design safer cars, and reduce smoking has extended life for countless numbers of people. Objective progress is reported to the public that is deeply satisfying. The lesson is that when a problem is measured and reported, it is more likely to be fixed.

A public commitment to transparency and zero patient harm from hospital governing boards and senior leadership would strengthen the public’s trust. The public will know that someone is in charge, is counting, and is accountable.

Right now, the public sees only a black box behind a wall of silence. Another 15 years will pass with the same result. We are obliged to do better.

Progress in reducing patient harm would give well-deserved attention to the highly skilled health care professionals who go to work every day to make health care better and safer for us all. That would be a good thing.

• Rosemary Gibson is Senior Advisor to The Hastings Center and has authored four books, including Wall of Silence, and numerous articles on health care issues. David P. Lind is founder of David P. Lind Benchmark, an employee benefits and health care research organization in Clive. Comments: david@dplindbenchmark.com

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It's time for an answer: Is health care safer now?

11/30/2014

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This blog cross-posted at Des Moines Register
This December marks the 15th anniversary of the landmark report from the National Academy of Sciences' Institute of Medicine that estimated up to 98,000 Americans die from preventable mistakes in hospitals every year.

It is time to know if health care is safer now.

Many hospitals in Iowa and elsewhere are working diligently to reduce medication errors, hospital-acquired infections and other causes of harm. Progress has been made, pockets of excellence created and people go home from the hospital alive and well.

A wake-up call in 2013 raised the stakes. The Journal of Patient Safety published new estimates that up to 440,000 lives may be lost annually in hospitals due to errors, making health care the third leading cause of preventable mortality in the United States. This number is equivalent to the combined populations of Des Moines, Cedar Rapids and Ames. Many more people are injured during their hospital stay.

Stresses and strains are making health care unsafe. Physicians, nurses, pharmacists and other health care professionals are forced to meet demands for higher productivity. They have to see more patients and do more, leaving little time to talk with patients and each other. Communication breakdowns ensue, and patients fall through the cracks.

The performance of any system with unsafe conditions that is forced to operate at a faster pace has only one way to go, and that's down.

On top of that, health care has become more complex with a steady stream of new equipment, devices, medications and electronic health records entering the sacred space of patient care.

Human ability to safely use this bounty is strained beyond capacity. Technology has become the new patient. Precious time is taken away from the real patient, the purpose of this whole enterprise.

The time has come to stop relying on estimates of health care harm. The public should know the unvarnished truth. Are we better off than we were 15 years ago? How many people go home alive and healthy when they may not have back then? How many do not because health care fell short?

The federal government counts the number of deaths from all causes, including cancer, heart disease, vehicular accidents and smoking — except medical harm. Counting the causes of mortality shows that society cares about every life cut short.

The numbers, and the human stories behind them, motivate people to act to reduce the burden caused when lives end too soon. Decades of sustained work to prevent and treat disease, design safer cars, and reduce smoking has extended life for countless numbers of people.

Objective progress is reported to the public that is deeply satisfying. The lesson is that when a problem is measured and reported, it is more likely to be fixed.

A public commitment to transparency and zero patient harm from hospital governing boards and senior leadership would strengthen the public's trust. The public will know that someone is in charge, is counting, and is accountable.

Right now, the public sees only a black box behind a wall of silence. Another 15 years will pass with the same result. We are obliged to do better.

Progress in reducing patient harm would give well-deserved attention to the highly skilled health care professionals who go to work every day to make health care better and safer for us all. That would be a good thing.

Rosemary Gibson is senior adviser to the Hastings Center and has authored four books, including "Wall of Silence," on health care issues. David P. Lind is founder of David P. Lind Benchmark, an employee benefits and health care research organization in Clive. Contact: david@dplindbenchmark.com.

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When Patients are Overtreated

7/1/2014

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This blog cross-posted at AAPHM
Have you seen patients who are overtreated? If so, you are not alone.

A list of medical care services that are overused was compiled by the National Priorities Partnership, which is convened by the National Quality Forum. Non-palliative services at the end of life is included in the list. In addition, specific tests and surgeries are noted such as x-rays, cardiac CT scans, heart bypass surgery, back surgery, knee and hip replacement, prostatectomy, angioplasty and hysterectomy.

To learn more, go tohttp://www.nationalprioritiespartnership.org/PriorityDetails.aspx?id=598

What exactly is overuse? The Institute of Medicine defines overuse as when the potential for harm of a health care service exceeds the possible benefit.

Palliative care clinicians have been quiet observers of overuse. Dr. David Weissman, professor emeritus at the Medical College of Wisconsin, says, “The continued use of chemotherapy by my peers, as the end-of-life approached, was one of the reasons that drew me to the new field of palliative medicine in the late 1980s.”

Patients are speaking up. This month, Consumer Union’s Safe Patient Project launched a “Share Your Story” survey of patient experience of overtreatment across the lifespan. Go to www.treatmenttrap.org and click on “Share Your Story”. What do you think about patients sharing their stories of overtreatment?

Palliative care enables patients to receive the care they need, no more and no less. That’s why the National Priorities Partnership included palliative care and end-of-life care as one of its six national priorities.

As a health care professional, if you have seen patients overtreated, what do you do? How do you ensure patients receive only the care that will benefit them?

The writer is the author of The Treatment Trap (March 2010) and was chief architect of the Robert Wood Johnson Foundation’s palliative care strategy.

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Letter to Mount Sinai's Heart Surgery Factory: Learn a Lesson From Downton Abbey

6/12/2014

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This blog cross-posted at Huffington Post
It's time for the health care aristocracy to fade into the sunset.

That's the lesson from the scathing article last week in Bloomberg News about New York's Mount Sinai Hospital whose headline screamed, "A Heart Surgery Factory With 'Obscene Levels' of Pay."

According to the Bloomberg account, Mount Sinai climbed out of a multi-million dollar financial hole in part by ramping up the volume of cardiac stent procedures, doubling the number performed during the 2000s to become New York's top stent factory.

Mount Sinai has had a troubled financial history. Its ill-fated merger with New York University Hospital that began in 1998 and resulted in a divorce five years later yielded junk-bond status credit ratings and combined debt of $670 million. It's hard to imagine, or perhaps not, that this would happen to a hospital whose board of trustees is comprised of Wall Street financiers and whose address is Gustave Levy Place, named for the founder of Goldman-Sachs.

Mount Sinai is not alone in ramping up surgery volume to pump up the bottom line. The health care system is perfectly designed to be abused.

High priced hospital consulting groups like the Advisory Board Company tout volume growth as a "ticket" to profitability and advise clients on how to "grow" profitable procedures.

Profitable, indeed. The director of Sinai's interventional cardiology, who oversaw the growth in stent procedures, was paid $4.8 million by the hospital in 2012, more than the CEOs of Microsoft and Amazon, according to Bloomberg.

The health care industry has created its own aristocracy with multimillion-dollar lifestyles at public expense.

Far away in Yorkshire, England, home to the wildly popular, made-for-TV "Downton Abbey," the aristocratic Crawley family has had a similar share of financial distress, also of its own making.

A few seasons ago, the Earl of Grantham, lord of the abbey, invested the family fortune -- which came from the dowry of his wife, Lady Cora -- in an ill-fated Canadian railway venture that went belly-up. The family laid out a plan to eliminate the servants' jobs and downsize. At the last minute, they are saved by the largess from an inheritance.

In the post-World War I era setting of the PBS series, many large estates in England were in financial tatters. Downton Abbey is forging a new path to sustainability, thanks to the sensible proclivities of the Crawley family's former chauffeur and now son-in-law, Tom Branson, the anti-aristocrat who married Sybil, daughter of Lord and Lady Grantham, who died during childbirth.

Under Branson's sober stewardship, the lands of the estate are now home to a herd of pigs that will bring home the bacon. For post-war England suffering from a food shortage, Downton is feeding its sausage-loving compatriots while putting itself on the path to self-sufficiency, at no one's expense, except that of the pigs.

No surprise that Branson came from the world of real work for a day's wage, never dreaming of having reams of other peoples' money to blow up.

Palatial buildings and lavish lifestyles are rarely sustainable over generations, whether in a fictional aristocratic Yorkshire family or in a hospital along Manhattan's Fifth Avenue.

Downton Abbey's Crawley family is portrayed as having a sense of duty to its ancestral Yorkshire home. Likewise, hospitals feel a duty to keep a vital community resource intact.

Neither is an excuse for profligacy. At least the Crawleys were blowing up the money of their rich relatives.

Too-big-to-fail hospitals blow up the money of the working men and women of America, the people who work "downstairs" -- the tireless Mrs. Patmores and Mrs. Hughes' of the world.

Dependence on other peoples' money becomes an addiction.

Rather than pare back the excessive paychecks and eliminate wasteful spending that keep the peace among fractious fiefdoms, the health care aristocrats impose their own kind of "tax" on the little people, those forced to fork over an ever-growing share of their paychecks to pay for the modern-day steel castles and the lords who preside over them.

The scary part is how shamelessly unsuspecting patients are reeled in, tests and surgeries done on them, to fill in a financial ditch and reap obscenely high pay.

Even the Downtown Abbey aristocrats would recoil from such a prospect.

It's time for the health care aristocracy in the United States to fade into the sunset. The fiefdoms and their misplaced sense of entitlement to the public's money need to be gone with the wind.

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The human cost of overuse

5/6/2014

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 Full post at The BMJ
Rosemary Gibson looks to the small town of China, Maine, to see the impact that escalating health costs have on a community

State and local governments in the United States are making financial trade-offs as healthcare spending, fueled by overuse, consumes an enormous and growing share of their budgets.

In Massachusetts, state government spending on education and other essential services declined during the past 10 years while healthcare spending jumped 59%, according to Donald Berwick, president emeritus of the Institute for Healthcare Improvement.

Fifteen thousand pairs of used shoes
Similar trends can be found in a suburban New York town where health insurance premiums for the school district jumped 27% in one year. This increase was a factor in the decision to close two schools, including this author’s grammar school. Teachers were laid off. The community held fundraisers to save afterschool music and sports programs. For one of the fundraisers, students collected 15 000 pairs of used shoes, 7 tons of them, to raise $6000 (£3500; €4300).

In an economy with lackluster growth, healthcare employment may increase as spending jumps, but only at the expense of jobs in other sectors such as education—a “robbing Peter to pay Paul” scenario.

The situation in China, Maine
Communities around the country are making trade-offs as healthcare consumes a larger share of their resources. Dan L’Heureux is the full time town manager of China, Maine and understands the trade-offs small …

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May 04th, 2014

5/4/2014

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 Full post at Modern Healthcare
Springtime in Washington brings the annual federal budget ritual. This year, President Barack Obama's budget for 2014 included a proposal to increase Medicare premiums for higher-income seniors. Other ideas to sustain Medicare are cross-pollinating across the political aisle. Both Republicans and...
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Count the Dead From Medical Harm

10/8/2013

 
This blog cross-posted at Huffington Post

The military counts its dead and wounded even though politicians would prefer to hide the truth.

Public health officials count the deceased and injured from drunk driving. The alcohol industry might prefer to hide the mayhem by slashing public health funding, but wiser, compassionate minds prevail.

Counting the dead is a way that society says a life matters. It honors the deceased, a mother, father, sister or brother, son or daughter.

Failing to count them is to dishonor them.

In hospitals, nursing homes and other health care facilities, no one counts those who die or are injured because of preventable mistakes and infections.

In 1999, the Institute of Medicine of the National Academy of Sciences estimated 44,000 to 98,000 deaths from preventable health care harm. Courageous doctors and others took a stand. It was perhaps the first time in the history of medicine that the public was told the truth.

The 98,000 figure is more than the number of soldiers killed in the Korean and Vietnam war theaters combined, as reported in the Wall of Silence.

Still, the death toll has not compelled the government to routinely count mortality from iatrogenesis.

Parents fill the void. One of them is John James, Ph.D., a NASA toxicologist. His 19-year-old son, John Alexander James, died because of uninformed and careless medical care at a Texas hospital, according to a website Dr. James created in his son's memory. 

Dr. James conducted a study published this month in the Journal of Patient Safety in which he meticulously examines more recent studies. He estimates the number of premature deaths from preventable harm to be more than 400,000 Americans per year.

The jaw-dropping estimate means that a new Arlington National Cemetery is needed every nine months to bury the dead.

Why should the people of the United States rely on an extraordinary, dedicated private citizen to calculate estimates of a leading cause of morality in our country?

Powerful vested interests don't want we, the people, to know.

President John F. Kennedy warned the country about the dangers of secrecy in a 1961 speech, saying, "Secrecy is repugnant in a free and open society; and we are as a people inherently and historically opposed to (it) ... We decided long ago that the dangers of excessive and unwarranted concealment of pertinent facts far outweighed the dangers which are cited to justify it." 

Secrecy is unraveling the fabric of the health care system. The dishonor of the deceased is taking its toll. There is only one way out. Count the dead and the injured. Honor them as we would all wish to be honored.

Nurses as Housekeepers at Vanderbilt Medical Center: An Untold Story Behind the Story

9/24/2013

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This blog cross-posted at Center for Health Media and Policy
Hospital budget cuts became viscerally visible earlier this month when Vanderbilt Medical Center announced that nurses must now perform housekeeping duties — cleaning patients’ rooms and bathrooms.

In case you missed the video of the internal announcement secretly recorded by a nurse that aired on  Nashville’s WSMV television station, here it is.

http://www.wsmv.com/story/23364976/vanderbilt-medical-center-to-have-nurses-cleaning-up?auto&topVideoCatNo=default&clipId=9280584

It is hard to think of a worse way to demoralize professionals who want to practice at the top of their license.  Invoking Florence Nightingale’s name as a spoonful of sugar to help the budget medicine go down is no salve for deep wounds of disrespect.

For patients, they are at greater risk, an inevitable outcome as nurses spend less time at the bedside.

All of this begs the question, “Where does all the money go in hospitals, who is getting it, and what are they really doing with it?”

The direction of the budget axe is being determined by an unspoken battle between labor and capital.

Nurses, pharmacists, housekeepers and increasingly, doctors, are employed labor.

Medical equipment and supplies, medical devices, drugs, computers and information technology are the products of capital investment.  Companies that manufacture these products need constantly increasing revenue to keep stock prices and earnings per share headed north.  Stockholders and other investors – their unforgiving owners – demand bigger, better, quicker returns.

Consequently, companies are programmed to take more money for themselves, which leaves less for everyone else, especially nurses.  I wrote about the uncanny parallels between the health care industry and the banking sector in Battle Over Health Care: What Obama’s Reform Means for America’s Future.  Both have price bubbles, toxic assets, too-big-to-fail syndrome, and privatized gains and socialized losses.

Implicit tradeoffs between labor and capital are made every day.

Companies have to create a stream of so-called new, innovative products every year to pump up earnings per share.  As nurses know, new is not always better.  It might be worse.  A steady torrent of new stuff: equipment, technology and a bevy of consultants causes money to trickle up.

Meanwhile, hospitals are not exactly shopping at the equivalent of Costco and getting a competitive price.  And they buy too much that ends up in landfills.  A hospital supply chain executive at a large public teaching hospital estimates that at least 10 percent of hospital purchases in inventory are expired.  Good for Wall Street investors.  Bad for people taking care of patients.

To correct the misallocation of the public’s money, transparency of billion-dollar hospital budgets would shed light on where all the money is really going.

In the meantime, we cannot let the material abundance of a few create a chasm of indifference to the plight of many.
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Beyond The Role Of Regulator

1/1/2013

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Full article posted at Health Affairs
For generations, economists, political scientists, and pundits have mused about the symbiotic relationship between government and business. Robert I. Field’s Mother of Invention adds to this rich tradition by dissecting the role of government and the private health care market in the debate surrounding the Affordable Care Act (ACA).

“Keep government out of my health care,” was the mantra of health reform’s critics. Field asserts that this perception misses a key point. His main thesis is that the government is already deeply and irrevocably ensconced in the private health care sector. Indeed, private health care businesses have reached the scale they have because government has been their chief enabler.

Field notes that the government is most often understood to be playing the role of a regulator of the private …


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Questions to ponder when dialysis clinics are for sale

6/5/2012

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This blog cross-posted at Bangor Daily News
The news that Eastern Maine Medical Center plans to sell its three outpatient dialysis clinics to one of the country’s largest for-profit dialysis companies (April 24 BDN) raises issues that will affect the health and well-being of Mainers.

Here are five questions all should ponder about what it means when ownership status changes from nonprofit to for-profit.

First, should the money that comes to Maine for dialysis services leave Maine? When health care facilities are locally owned, Medicare reimburses them for the cost of providing care to people in their communities. The money that comes to Maine stays in Maine.

When multinational corporations own clinics, some of that money leaves the community. Where does it go? It goes to corporate headquarters and is used to pay company stockholders. It pays the salaries of company executives who are working to build more business, not benefit the people of Maine. The salaries are likely to be much higher than the salaries most Mainers receive. In today’s economy, should the money that comes to Maine stay in Maine and benefit local businesses?

Second, do communities want health care businesses they cannot control? Health care facilities such as Eastern Maine Medical Center are nonprofit and tax-exempt. They are required by law to have a governing board whose responsibility is to ensure the institution serves the community and is accountable to it. When a multinational company takes ownership of clinics and hospitals, its fiduciary responsibility is to the people who own the company, not the community. There is no local board to whom the company is accountable. Communities lose control of the health care facilities when they are sold to multinational companies.

Third, do communities want a health care business that is not accountable to the people of Maine when they become patients? If a person undergoing dialysis has a problem with the treatment, who is accountable? Where does the buck stop? With a manager in a regional office? That employee is accountable to his or her supervisor, not to the community or a board that represents the public’s interest.

Fourth, do communities want doctors with divided loyalties? Health care companies have a variety of compensation schemes for doctors who refer patients to dialysis and for medical directors of the facilities. The doctors may own stock in the company or have other types of financial arrangements unique to for-profit companies. While these arrangements may be legal, it doesn’t lessen the reality of conflicts of interest. A doctor’s loyalty is divided between the interest of the patient and the interest of the company. Where do you want your doctor’s loyalty to reside?

Finally, will a multinational company headquartered far away take better care of the people in Maine than people who live in the state? Corporate executives who work in offices that are located long distances away will establish and carry out policies that affect the health and well-being of people in Maine. How can they do a better job than the people who call Maine home? Many investor-owned companies can add specialized knowledge and value to health care. What is the company doing that Mainers could learn to do just as well under local ownership?

An unanswered question is why EMMC is selling its clinics. Is it because a large dialysis company can drive out smaller providers because it has negotiating clout with a manufacturer of a drug used in dialysis treatment?

Health care is personal and all the more reason that Mainers should know the facts before deciding whether to invite a company into the house.

Rosemary Gibson led national health care initiatives at the Robert Wood Johnson Foundation, where she worked with Mainers on ways to improve health care. She is the author of “The Battle Over Health Care” on Wall Street’s impact on the future of health care.

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