Your Nov. 1 cover story on patient safety underscored the need to increase the quality and safety of healthcare and lauded the technologic advances that will support that goal ("Patient safety proves elusive," p. 6.). Though progress has been made in the years since the publication of the Institute of Medicine report, the studies we have conducted in a network of 30 hospitals in rural healthcare settings can help us understand why the goal of patient safety has proven to be so elusive.
Our data show that healthcare providers face complex problems that are compromised by uncertainty and are not easily managed within the current patient-safety paradigm. We found that within and among disciplines, healthcare providers do not share the same definitions of error, do not systematically recognize errors and do not agree on attribution of responsibility for increasing patient safety. Neither do they agree on appropriate actions regarding charting, reporting or disclosing errors to one another or to patients, or on who belongs on the patient-care decision-making team.
As a result, even when healthcare providers believe their hospitals are concerned about safety and encourage the reporting of errors, actual recognition and reporting of errors appears limited. Most providers aren't sure the data they do have are accurate.
When given case studies depicting various adverse events and errors, healthcare providers showed little agreement as to whether or not an error had occurred and what action to take in terms of reporting and disclosing to the patient. As one healthcare provider noted: "We haven't gone there yet."
Given the large disparities among the healthcare professions in their perceptions of what constitutes a medical error, it is difficult to devise approaches that would significantly reduce them. We are easily sidetracked and find ourselves creating and trying to resolve a new range of problems-such as those that accompany new technologies-while continuing to sweep the old, intractable problems under the carpet.
If our data are correct, the current emphasis on tracking and reporting errors misses some essential and basic considerations. Before starting to count, we have to move toward a healthcare system that has at its foundation shared experiences, open lines of communication, a willingness to question when facing uncertainty and a commitment to act when corrective actions are warranted.
Ann Cook
Director
Helena Hoas
Research director
National Rural Bioethics Project
University of Montana
Missoula
Get in the reform game
So was healthcare a winner or a loser in the recent national and local elections ("Special report: Election 2004," Nov. 29, p. 24)? The presidential and congressional candidates agreed that our healthcare system is sorely in need of repair and improvement, but of course their proposed solutions differed widely. And we all know that campaign promises are usually forgotten once the votes are counted. But our country's healthcare problems continue to worsen, so will the pols act for a change?
Probably not is my bet. Oh sure, they'll tinker with the current inefficient system, but it seems doubtful that President Bush or his Republican Congress will spend their "political capital" to try to develop a seriously needed complete overhaul of our U.S. healthcare delivery and reimbursement system.
Why? Bush has some other equally daunting reforms of other domestic programs that are broken and need immediate help, such as Social Security, education and tax programs and the deficit. And he'll take on these massive, contentious reforms while he continues to direct our war against terrorism.
The only hope is that the constantly warring constituencies in the healthcare industry come together to demand reform. It's certainly in their best interests. The American public is demanding healthcare reform, and hospitals, employers and employees all suffer from continuing double-digit increases in healthcare costs, a lack of access to care, unpaid bills, a need to improve patient safety and convenience, and the information systems to help achieve new savings.
So, leaders of the healthcare industry, isn't it finally time for reform?
Rick Kneipper
Chief administrative officer, co-founder
PHNS
Addison, Texas
Gain-sharing hypocrisy
I have been reading with great interest your articles on physician "gain-sharing" programs ("No gain-sharing in N.J.", Nov. 1, p. 18.) These have been actively pursued by health systems and hospital associations but have been frowned upon by policymakers. In this approach, hospitals offer incentives to physicians to reduce costs.
The concern among legislators and regulators is that this type of incentive program may hurt the quality of patient care. In my opinion, the rationales on both sides of the argument are valid. However, hypocrisy and inconsistency in policy decisions are never healthy. If policymakers believe pay-for-performance programs may adversely affect patient care, could you not argue that the government's prospective payment system, which caps the amount of reimbursement per procedure, could also impair the quality of patient care as well?
Physicians did not stop providing high quality care when DRGs arrived more than 20 years ago and they will not curb the care they give under physician gain-sharing programs. They will, however, pay more attention to the efficiency of care, but the patient will not suffer as a result, in my opinion.
The bottom line is that if you are going to promote a DRG/prospective payment system as a way to contain cost without sacrificing quality of care, there should be no reason that physician gain-sharing programs should be anything but encouraged and fought for by the CMS. Today, the messages seem to be in conflict with one another.
Tim Jacobson
Senior vice president
Corporate sales
Medline Industries
Mundelein, Ill.
Bottom-line business
The current debate surrounding the effect of specialty hospitals on community hospitals will continue to occupy our attention for the foreseeable future because we all have vested interests ("The case for specialty hospitals," Nov. 22, p. 21). What I have found to be an interesting yet little-discussed conundrum is: Why does it require ownership and an oversight role in a facility in order for physicians to be motivated to design and operate highly efficient care systems to meet the needs of a greater population?
John Casey ends his commentary by writing "In our world, helping patients is always the bottom line." To me, the terms "bottom line" and "efficiency" seem more closely associated with profits than patient care. So the debate continues.
Roger Pearson
Administrator
Ellsworth County (Kan.) Medical Center
The cost conundrum
In his Nov. 8 editorial, Todd Sloane accurately lists many problems of the U.S. healthcare system but fails to mention the root cause of the seemingly endless trend of spending ever more on healthcare ("Still a priority," p. 37). The system doesn't promote health, nor can it, I'm afraid.
We fix unhealthy people who increasingly have caused their misfortune due to poor decisions. We are not given the task of improving personal accountability of the masses.
When you eat poorly, sleep minimally, exercise rarely and don't have strong social relationships, your health declines. My guess is that less than 25% of Americans get an "A" in these four categories and at least 25% get a "D" or "F."
Sloane notes, "Healthcare costs continue to grow at roughly twice the rate of inflation." Yup. Is the system to blame for the root cause? Nope.
Don Ickler
Manager
Therapy services
Barnes-Jewish St. Peters (Mo.) Hospital
A long-term problem
I am truly perplexed by the circular rea-soning of the CMS on long-term acute-care hospitals.
These facilities were an outgrowth of a prospective payment system that promoted their development. For about $2 million and six months' labor, a short-term acute-care hospital can build and host an LTAC hospitals within its walls. The patient who comes in for knee surgery and the surgical site gets infected will have a place to go for proper medical treatment.
The short-term hospital will get paid for the surgery and the LTAC hospital will be paid for management of the surgical infection, thus avoiding outlier costs for the short-term hospital.
Somehow, the CMS is under the impression that this is an abuse of the Medicare system.
New regulations state that LTACs within other hospitals may only accept 25% of their patients from the host and still get full payment. These hospitals are generally only about 25 beds in size. The CMS apparently believes that constructing a $20 million facility outside hospital walls to accommodate these longer-staying patients is more fiscally sound than a far less-expensive, contained facility.
The result of this policy is going to be agreements involving costly transfers of patients from one hospital to distant facilities. It is precisely this kind of circular reasoning that keeps attorneys such as myself busy.
Jack Grewer Jr.
Consultant
Murer Consultants
Joliet, Ill.
The interim life
A couple of thoughts on interim healthcare executives ("For a limited time only," Oct. 18, p. 6):
Like Lowell Johnson, who is profiled in your piece, I have been doing interim work since 1996 by choice. Having spent more than 20 years as a hospital chief executive, I chose this life as the best way to give back to my profession and to help organizations that needed an experienced hand. This is not a lifestyle that fits everyone's needs.
So many organizations often call for help when it is too late. Our profession should come up with a resource directory of interim managers that groups could access before things deteriorate to a point where a rescue isn't possible.
John Rinset
Interim vice president
Post-acute services
Stamford (Conn.) Health Systems
Unlisted
We were very disappointed to find that our firm, MSA Executive Search, wasn't listed among your "Top retained executive search consulting firms" (Sept. 20, p. 32).
MSA's 2003 revenue of $2.3 million should have placed us in a tie for 14th place on the ranking.
With more than 20 years of serving only the healthcare industry, a track record of success with hundreds of clients, and continual revenue growth and superior client satisfaction ratings, we are pleased and proud to be among the nation's top firms.
James Groves
Managing principal, senior vice president
MSA Executive Search
Clark Consulting Healthcare Group
Kansas City, Mo.
Mischaracterized
Your article on pharmacy benefit managers contains some valuable information that employers can use to evaluate and select PBMs, but the headline misrepresents the intent of the writer ("The shadowlands of PBMs," Nov. 8, p. S4). The headline might have been intended as an attention grabber, but instead it communicated a bias on the part of the editors.
PBM practices are no more "shadowy" than those of group purchasing organizations, Medicare providers or hospitals. There are customary business practices in virtually every industry. The dedicated professionals in pharmacy benefit organizations focus on the improvement of patient outcomes, the application of rational, evidence-based evaluations of care standards and improved access to pharmaceuticals through careful cost and incentive techniques.
I would suggest that in the future you restrain from gratuitous mischaracterizations.
Judith Cahill
Executive director
Academy of Managed Care Pharmacy
Alexandria, Va.
What do you think?
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