When President Clinton last week recommended ways to reduce medical errors by hospitals and physicians, he did more than advocate the mandatory reporting of adverse events.
He also put the hospital lobby in the awkward position of fighting for more Medicare dollars while battling against mandatory error reporting.
Last year, hospitals and other providers won a generous $16 billion in relief from Medicare spending reductions imposed by the Balanced Budget Act of 1997. This year, the American Hospital Association is asking for another $25 billion in relief.
Somehow, hospitals have to make these two policy pieces fit neatly to form a pretty picture for lawmakers. That may be their most daunting task in a shortened legislative season.
For starters, not all provider groups agree whether mandatory reporting would help or hurt efforts to identify and prevent errors (See chart, p. 3).
Perhaps most significantly, the Joint Commission on Accreditation of Healthcare Organizations, the accrediting body for most providers, favors mandatory reporting as long as the information is kept confidential.
That puts the Joint Commission at odds with some of its own board members, who are appointed by the AHA and the American Medical Association. Both groups oppose mandatory reporting, as does the American College of Surgeons, which not only has a representative on the JCAHO board but founded the organization in 1951.
AHA President Richard Davidson's first move was to turn down an invitation to last week's White House event to roll out Clinton's plan, despite standing side-by-side with Clinton two months ago and pledging to work with the government on medical errors.
Davidson declined MODERN HEALTHCARE's request for an interview.
"Usually attendance at events like that indicate endorsement (of the policy)," said Carmela Coyle, the AHA's senior vice president of policy. "We didn't get the details of the president's proposals until that day, so we were unable to make that (endorsement) decision."
James Conway, chief operations officer at 30-bed Dana-Farber Cancer Institute in Boston, did attend Clinton's announcement last week. Conway said he agrees with most of the recommendations and does not oppose mandatory reporting.
Dana-Farber is already familiar with mandatory reporting under Massachusetts law. Plus, the hospital is still grappling with its own public medical error. In December 1994 a woman being treated for breast cancer was mistakenly administered quadruple the amount of prescribed chemotherapy, causing her death.
"Dana-Farber is at a different place than other institutions," Conway said. "We were closely scrutinized by HCFA, the Joint Commission and the state Department of Public Health. But the fact that they were in our face was not the issue. The people we were `forced to report to' were very helpful to us."
It is this difference among its members-hospitals with mandatory reporting experience compared with those hospitals that fear such a system-that complicates the AHA's already arduous task.
"The AHA and the AMA have the burden of moving their constituencies," Conway said. "Their members are at different places, and their leaders need to figure out how to move appropriately."
John McMeekin, president and CEO of five-hospital Crozer-Keystone Health System in Springfield, Pa., also said he does not oppose mandatory reporting but would prefer to try voluntary reporting first.
"I'm in a state where we have mandatory reporting, and we haven't done too well on that," said McMeekin, who is also an AHA board member. "The mechanics of how we respond ought to deal with what gets us furthest the fastest. If that's mandatory reporting, then we ought to have peer-review protections. Mandatory vs. voluntary reporting is not the issue; it's a blameless vs. a blaming environment."
Clinton's recommendations, which are available on the Internet at www.quic.gov, include:
* Developing state-based error-reporting systems to collect standardized information on preventable errors that result in death or serious harm. Patient and practitioner information would be kept confidential, but public reports would include the name of the hospital or health system. The administration wants all 50 states to set up error-reporting systems within the next three years.
* Extending peer-review protections to encourage reporting.
* Requiring hospitals to have a medical-error reductions plan in place as a condition of participation in Medicare. HCFA intends this year to publish regulations in the Federal Register explaining the proposal in more detail.
* Developing new labeling and packaging standards for drugs through the Food and Drug Administration.
John Eisenberg, M.D., administrator of the Agency for Healthcare Research and Quality, said hospitals were overreacting to one portion of the task force's report.
Eisenberg, who as operating chair of the task force delivered the recommendations in testimony before the Senate Health and Education Committee last week, said, "Frankly, (providers) have been reading press releases and summaries that don't give them the true flavor of the report."