Your hospital is going to harm a patient. I know you don't want to hear that, but unfortunately it's true. It might be an improper medication dosage. A surgical infection. A nasty fall on a slippery floor. Whatever the case, no matter what extensive safeguards a provider organization implements, when human beings are involved, true perfection is not attainable. Errors might be minimized or even rendered almost nonexistent, but they will happen. Sooner or later.
And then comes the complicated part: fessing up. Error disclosure historically has been a touchy subject for many providers leery of legal repercussions and fearful that disclosure generally can cause more harm than good. While such concerns persist in some circles, hospitals and health systems have certainly made strides in their efforts to discuss medical mistakes with patients and families. Still, according to at least one study, one component of the disclosure process remains lacking: nurse involvement.
A survey of roughly 100 nurses found that they were often excluded when physicians talked to patients about serious errors. Or to be more precise, they might have disclosed their own errors to patients, but participating in the discussion of others' mistakes was another story. The consequences of not having nurses involved in the disclosure process, contends the study in last month's issue of The Joint Commission Journal on Quality and Patient Safety, affect patient and nurse alike. The patient doesn't get as complete of an explanation and is left with more questions. And later, when the nurse is still attending to the patient while the rest of the team has moved on, the nurse appears evasive when he or she can't answer those follow-up questions because he or she wasn't included in disclosure planning sessions.
The study's contentions make sense in many ways—nurses shouldn't be put in comprising situations because they haven't been given adequate information, and patients deserve a complete explanation when a mistake occurs, not a partial one. At the same time, though, it seems to me that having multiple people explaining an error could actually be confusing for a patient if the caregivers have different assessments of the situation. I've thankfully never had to hear a provider's explanation of a medical error, but I'm trying to picture myself sitting in a hospital in that exact situation. Would I rather see and hear one person explaining the situation to me, or would I rather see and hear a group of people? And another question: Are all nurses trained in talking to patients and families about serious mistakes?
Such training is actually part of the study's recommendations, along with a team-based disclosure process that follows specific guidelines. Ultimately, as long as the patient hears a compassionate, accurate version of what happened, the question of how many caregivers actually participate in the discussion with the patient may be less important than the way caregivers communicate with each other: what happened, why it happened, and what can be done to keep it from happening again. That's a discussion in which every caregiver should play a part.
Jay Moore is managing editor for HealthLeaders magazine. He can be reached at jmoore@healthleadersmedia.com.
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The following are some conflict-reducing techniques outlined during Physician Health Services' seminar "Managing Workplace Conflict: Improving Personal Effectiveness" held in November 2008.
The techniques provide an overview of how to effectively reduce conflict in a healthcare setting by outlining how both sides can handle the problem to reach a peaceful conclusion:
Review the facts:
How does your story differ from the other side's?
Where do your data come from?
Know your assumptions
Realize it takes two to tango
Use honesty
Inquire, inquire Delay discussion when necessary
Handle emotions with care:
Is there too much emotion or too little?
Don't counterpunch
Know when to back off
Sense when your temper is rising and practice self-calming
Work with meanings:
Reframe the problem
Brainstorm possible solutions
Define mutually acceptable outcomes
See and express the problem as a neutral consultant might
Show respect
Adapted from Physician Health Services' seminar "Managing Workplace Conflict: Improving Personal Effectiveness." This article originally ran in the February 2009 issue ofThe Doctor's Office, a HealthLeaders Media publication.
With a stroke of his pen, President Barack Obama on Tuesday effectively eliminated physicians' biggest barrier to widespread EHR adoption.
For years physicians have cited the costs of implementation as a rationale for delaying adoption—including in our own Industry Survey—and considering the average initial investment somewhere in the $30,000 range, it has been a legitimate obstacle for most practices.
Not anymore. The American Recovery and Investment Act sets aside $19 billion to support healthcare IT, including up to $42,000 for each individual provider.
Here's how it gets doled out: Physicians who are "meaningful" EHR users can receive up to $18,000 if they are eligible in 2011 or 2012 ($15,000 or less if the first year is after that). Payment ceilings drop to $12,000 in year two, $8,000 in year three, $4,000 in year four, and $2,000 in year five. Payment limitations are 25% higher for eligible providers in areas designated as health professional shortage areas, and the incentives do not apply to hospital-based physicians.
Physicians wanted federal help with the healthcare IT costs, and here it is. Problem solved?
Not quite. It's better to think of EHR adoption as a starting point than a finish line, says David C. Kibbe, MD, MBA, senior advisor for the American Academy of Family Physicians and chair of the ASTM International E31Technical Committee on Healthcare Informatics. The real goal should be to improve quality and coordination of healthcare, not just to outfit every physician with new technology. The stimulus package's ultimate effectiveness depends on how some of the details in the provisions are executed in relation to that long-term goal.
For instance, the range of products eligible for incentive payments will make a significant difference. "One of the keys to the bill's success is to make sure that new and innovative products are allowed to participate in this marketplace and that the monies are spent toward some of those innovations, which I think will lower costs," says Kibbe.
Many of the traditional products, including those endorsed by the Certification Commission for Health Information Technology, have been experimental and difficult to integrate. If the scope is too narrow, physicians' concerns about interoperability and effectiveness, which have previously been overshadowed by cost concerns, could reinstall some hesitancy.
The details will be up in the air, however, until President Obama appoints a Secretary of Health and Human Services and other key players, such as the newly-created Office of the National Coordinator for Health Information Technology.
But time is of the essence. The bill is designed to make physicians act relatively quickly—in 2015, physicians without a meaningful EHR will receive only 99% of payments for professional services. The next year, another percentage point is shaved off, and another after that.
Physicians have been taking a wait-and-see approach long enough. The money is on the way; it's time to start shopping.
Elyas Bakhtiari is a managing editor with HealthLeaders Media. He can be reached at ebakhtiari@healthleadersmedia.com.
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A typical primary care physician who treats elderly Medicare patients must coordinate care with 229 other physicians working in 117 different practices, according to a study by researchers at the Center for Studying Health System Change, Memorial Sloan-Kettering Cancer Center, and the Dana-Farber Cancer Institute. "The logistical challenges to care coordination are daunting given the fragmentation of care and the large number of peers that physicians must interact with when treating Medicare patients," said Hoangmai H. Pham, MD, MPH, the study's lead author and an HSC senior health researcher.
In Canada, the economic crisis is forcing some physicians to delay retirement plans or work longer hours than they had planned, according to this blog posting. According to Manfred Purtzki, a Vancouver financial adviser, the average physician-held portfolio has shrunk by approximately 30% in the last year, the blogger notes.
The single-payer healthcare system was once the reform flavor of the moment, but it has been largely pushed to the rear and replaced by talk of a public insurance option and individual mandate.
Massachusetts' healthcare reform, which included an individual mandate that required residents to purchase insurance, has increased coverage, but critics charge that the plan has not decreased costs or improved access to care.
In a study released Wednesday, two organizations say the Massachusetts health system is a failure and national policymakers should not look to that model as a possible solution. Instead, they propose a single-payer "Medicare for all" system as a better alternative.
Physicians for a National Health Program and Public Citizen, which support a single-payer health system, charged the Massachusetts project has not covered as many people as claimed, not contained costs, and hurt safety-net providers like public hospitals and community clinics.
In fact, the individual mandate is merely a "new tax on the uninsured," according to the study.
"We are facing a healthcare crisis in this country because private insurers are driving up costs with unnecessary overhead, bloated executive salaries, and an unquenchable quest for profits--all at the expense of American consumers," says Sidney Wolfe, MD, director of Public Citizen's Health Research Group in Washington, DC, at a press conference announcing the study Wednesday. "Massachusetts' failed attempt at reform is little more than a repeat of experiments that haven't worked in other states. To repeat that model on a national scale would be nothing short of Einstein's definition of insanity."
The reform law, which was enacted in 2006 with unanimous support from the Democratic-controlled Massachusetts Legislature and then Republican Governor Mitt Romney, requires residents to have health insurance and fines businesses that do not provide coverage.
In the study, the two groups said the individual mandate meant more business for health insurers, but didn't address administrative costs associated with private health insurance. In fact, the Massachusetts Connector, which was created to promote the program and help link people to the health plan options, adds 4-5 percentage points to private insurer policies, according to the study.
Though the reform has added to the number of insured residents in the commonwealth, the study's authors said the total is not as high as promoted. The Urban Institute found that 2.6% of Massachusetts respondents said they were uninsured in a mid-2008 phone survey. However, two other sources claim the percentage is about twice that number, according to the study.
Jon Kingsdale, executive director of the Massachusetts Connector, says Wednesday the state is confident with the 2.6% figure because they went "to great lengths" to accurately survey the uninsured.
"This low level of uninsured is consistent with the stated goal of health reform to achieve near-universal coverage and is only a point or so above the uninsurance rates reported by many European countries with so-called universal access," says Kingsdale.
Rising costs
The study's authors say another problem with the initial Massachusetts reform is that it did not address rising healthcare costs. Healthcare costs, in turn, will increase from $1.1 billion in fiscal 2008 to $1.3 billion in fiscal 2009.
On the flip side, if the state had created a public single-payer system, it could save about $8-$10 billion annually through reduced insurer administrative costs, which could go to covering uninsured residents and improving coverage for those with health insurance, according to the study.
The major problem is that policymakers created incremental healthcare reform while maintaining the same private health insurance system, says Rachel Nardin, MD, president of the Massachusetts chapter of Physicians for a National Health Program, assistant professor of neurology at Harvard Medical School, and study co-author.
"It is very hard to have effective cost control in incremental reform because it's piecemeal," says Nardin. "I think that is an extremely important lesson for national reform that comes from Massachusetts."
Kingsdale disagrees with that analysis. He says the $1.3 billion projection is from an outdated financial statement and is not actual costs. In fact, the state now projects costs to come in at about $800 million in the current fiscal year—not the $1.3 billion figure cited.
Barriers to care
To help offset state budget constraints and fund the rising costs of the health reform, Governor Deval Patrick last fall reduced funding to safety-net providers, such as public hospitals and community clinics. This has forced at least six community clinics to close and hospitals to cut the number of inpatient psychiatry beds.
This is an example of why insurance does not equal universal access to care, says Nardin.
"These safety-net services, which often lose money for hospitals even when patients have good insurance, include emergency care, chronic mental healthcare, and primary care. The public hospital where I work is busier than ever, but has just announced that it will close six community clinics, and about half of its inpatient psychiatry beds—despite critical shortages of primary care and psychiatric services," says Nardin.
Many Massachusetts residents are still underinsured. In fact, those who once used the free care system now must pay copays for medication and care, says Nardin.
One reason why the Massachusetts system, and previous state plans, failed is that the reforms maintain the private health insurance system. The reforms are incremental and merely add new public subsidies or expand Medicaid. "It is time to wake up from this insanity and enact single-payer health insurance for all," says Wolfe.
Canadian model
While opposing the Massachusetts model, the study's authors also promoted the United States National Health Care Act, which is a bill in Congress that would implement a single-payer system without private insurers.
The single-payer advocates support a system similar to the one in Canada. By eliminating private insurance overhead while spending the same amount on healthcare, the U.S. would avoid waiting lists and shortages that have been an issue in our neighbor to the north, which spends much less on healthcare, says Steffie Woolhander, MD, co-founder of Physicians for a National Health Program, associate professor of medicine at Harvard Medical School, and study co-author.
In announcing its findings, the two groups also presented an open letter to Sen. Edward Kennedy that was signed by more than 500 Massachusetts physicians and other health professionals to urge him to reject the Massachusetts model and support the single-payer system.
Responding to the study, Ian Duncan, FSA, FIA, FCIA, MAAA, a board member of the Commonwealth Health Insurance Connector Authority Board and founder and president of Solucia Inc., a Hartford-CT based consultant for the healthcare financing industry, tells HealthLeaders Media the scale of the health system problem is so great that he is not surprised that Massachusetts' experiment has faced obstacles.
Duncan adds the reform has created a "remarkable collaborative achievement on the part of the stakeholders."
"Massachusetts has achieved a remarkably low rate of uninsurance while encouraging the best aspect of the market (private bargaining between employers, employees, providers, and government payers) without some of the faults that we see too often in government systems," says Duncan.
Gov. Kathleen Sebelius of Kansas is emerging as President Obama's top choice for secretary of health and human services, advisers said. Should she be nominated, Sebelius would bring eight years of experience as her state's insurance commissioner as well as six years as a governor running a state Medicaid program. But with President Obama about to begin a drive to expand health coverage, her strongest asset may be her record of navigating partisan politics as a Democrat in one of the country's most Republican states.
New York Attorney General Andrew Cuomo has announced that WellPoint Inc. will pay $10 million to help establish a new independent database to determine the rate it pays doctors and hospitals out of its network. Cuomo said WellPoint agreed to no longer use a controversial database maintained by UnitedHealth Group Inc.'s Ingenix unit to determine the "usual and customary" rate for out-of-network insurance reimbursements. Cuomo has alleged that the Ingenix database skewed downward the "usual and customary" rates through faulty data collection, poor pooling procedures, and lack of audits, thus forcing consumers to pay more out of their own pockets for healthcare.
Atlanta's Grady Memorial Hospital and Fulton County, GA, are nearing consensus on what information the hospital must provide to get public support. Since Fulton adopted in January a 2009 budget of $76.5 million for Grady, county finance officials have so far only made the county's $17 million debt payment for Grady. The remaining operating money has been on hold as the two sides have struggled to reach agreement on accountability on indigent patient counts, services provided, costs, and revenues.
The Washington State Medical Association, which represents more than 9,000 physicians, is fighting a bill that would require doctors to screen vulnerable patients for a potentially deadly germ called MRSA. The number of hospital patients infected with MRSA has skyrocketed in Washington, but the medical association opposes any attempt by lawmakers to dictate how doctors attack the pathogen, said spokeswoman Jennifer Hanscom. The bill's sponsor, Rep. Tom Campbell, R-Roy, said the evidence is clear that doctors and hospitals have repeatedly failed to protect patients from the antibiotic-resistant germ MRSA.
