Prescription drug price increases appear to be the biggest driver of healthcare spending, while spending for physician and hospital services decelerated.
Hospital prices grew 3.8% last month, when compared with February 2017, the highest growth rate in more than a decade, according to Altarum's Health Sector Economic Indicators.
"We are puzzling over this significant jump in hospital prices in recent months based upon the hospital produce price indexes from Bureau of Labor Statistics,” said healthcare economist Charles Roehig, with Ann Arbor, MI-based Altarum .
"Hospital prices averaged 1.6% growth in 2017, increasing to 3.5% during the first 2 months of 2018. Further, growth has accelerated for each of the three main payers: Medicare, Medicaid, and private health plans," he said.
For all of 2017, national health spending grew by 4.6% from its 2016 level.
"Year-over-year spending growth has remained close to this moderate but still not sustainable rate in each month since July 2017," Altarum said in its analysis. "We see 22 consecutive months where the healthcare spending share of GDP has not fallen below 17.9% nor risen above 18.1% including the most recent 3 months of the share being 18.0%."
The primary driver for the uptick in healthcare prices is prescription drug spending, which grew 1.3 % in 2016 but rebounded to an estimated 5% in 2017.
However, the 5% growth estimate does not account for possible changes in prescription drug rebates, Roehrig said, which could lead to a significant downward revision in the growth rate when the Centers for Medicare & Medicaid Services releases 2017 estimates in December.
The cost of physician and hospital services slowed from 4.8% to 4.4% within that timeframe.
Other findings:
At $3.58 trillion, national health spending in January 2018 was 4.8% higher than it was in January 2017. Year-over-year spending increased in all major categories, with home healthcare growing the fastest, at 7.7%, and dental services the slowest, at 3.2%.
Healthcare added 18,500 new jobs in February 2018, fewer than the 12-month average of 24,000 new jobs per month. Half the health sector job growth was in hospitals, which added 9,300 jobs, above the 12-month average of 7,200. Job growth in ambulatory settings was lower than usual at 8,100 new jobs, about half the 12-month average of 15,500.
Azar outlines plans to give patients control over health data through HIT; push transparency from providers and payers; test value-based models in Medicare and Medicaid; and remove government burdens that impede the transformation.
Health and Human Services Secretary Alex M. Azar II on Friday offered gushing praise for the work of community health centers and outlined the key role they would play in transforming healthcare to a patient-centered, value-based model under the Trump administration.
"We see you not just as vital partners in our movement toward a health system that delivers quality, affordable care for all Americans—we see you as pioneers in this value effort already," Azar told a gathering of the National Association of Community Health Centers.
Azar noted the rapidly expanding care delivery role for community health centers, with saw the number of patients served increase from 10.3 million in 2001 to 25.9 million in 2016, an increase of 151%.
That growth correlates with the Trump administration’s priorities for HHS, Azar said.
"One of these priorities is transforming our health system into one that pays for health and outcomes rather than procedures and sickness," he said.
Noting that the road to value-based "has been at time a frustrating process" replete with failures, Azar said there can be "no turning back to an unsustainable system that pays for procedures rather than value."
"In fact, the only option is to charge forward — for HHS to take more aggressive action, and for providers, payers, and patients to join with us," he said.
With that in mind, Azar said providers can expect to see "bold new rules of the road" from the Trump administration that will include four areas of emphasis.
"First, giving patients greater control over health data through interoperable and accessible health information technology," he said. "Second, encouraging transparency from providers and payers; third, using experimental models in Medicare and Medicaid to drive value and quality throughout the entire system; and fourth, removing government burdens that impede this transformation."
Azar said community health center are easily outstripping most private physician groups and hospitals when it comes to price transparency.
"Try calling up a major physician group to ask how much a self-pay patient might owe for a typical physical, I have two words for you: Good luck," he said. "Walk into or call up a community health center and ask the same question. The answer is often one word: the price—plus, of course, the assurance that what you actually owe will be based on income."
"This level of transparency is essential to have across our entire system," Azar said. "When it comes to bigger medical procedures, just about all Americans are looking at significant financial decisions—and yet information about these big decisions can be incredibly hard to come by."
Azar said EHRs have provided patients with some access to their own personal health records, but they haven’t gone far enough.
"It's not just that the benefits of health IT haven't always been apparent to patients — it's that unless we put this information and technology in the hands of patients themselves, the real benefits will never arrive," he said.
"We're not interested in micromanaging how the goals of interoperability and patient usability are achieved. We are much more interested in setting out simple goals: Patients ought to have control of their records in a useful format, period," he said. "When they arrive at a new provider, they should have a way of bringing their records, period. That's interoperability—the what, not the how."
Data gleaned from electronic health records suggests that patients diagnosed with heart failure, stroke, infertility, and kidney failure could actually be suffering from rare and undiagnosed genetic diseases.
Researchers at Vanderbilt University Medical Center are using genetic data in electronic health records to identify diseases such as heart failure in large populations so treatments can be tailored to the actual cause of the illness.
The implications for the findings, reported this week in the journal Science, are broad and numerous, the researchers said, because 14% of patients with genetic variants affecting the kidney had kidney transplants and 10% with another variant required liver transplants.
If their genetic cause had been diagnosed, those transplants might have been avoided.
"We started with a simple idea: look for a cluster of symptoms and diseases to find an undiagnosed underlying disease," said Josh Denny, MD, professor of Biomedical Informatics and Medicine and director of the Center for Precision Medicine.
"Then we got really excited when we saw how we could systematize it across thousands of genetic diseases to figure out the impact of millions of genetic variants," he said.
The new method, developed by Denny and a team of collaborators, creates a phenotype risk score to find patterns of symptoms that may be caused by an underlying genetic variant — including some genetic variants whose effects were previously unknown.
The researchers theorized that many patients currently diagnosed with issues such as heart failure, stroke, infertility or kidney failure might actually be suffering from a rare genetic disease. If that underlying disease could be identified, it may have a specific treatment preventing the symptoms from recurring or getting worse.
By merging traditional resources with newer data mining techniques, the researchers assigned scores to 21,701 individuals based on how well their symptoms fit the clinical description of each of 1,204 different genetic diseases. The resulting phenotype risk score is high for individuals who are a close match and low for individuals who lack keys features of the disease.
"What the phenotype risk score shows us is that if you start with specific combinations of symptoms, the chances of finding a potentially causative genetic variant are pretty high," said co-author Dan Roden, MD. "This is a really important step to using clinical genotyping to assess patient risk and inform more precise prevention and treatment of common conditions."
The researchers found 18 associations between genetic variants and high phenotype risk scores. Some are well known to geneticists, such as two variants that cause cystic fibrosis, but most of the associations were for variants that have not previously been described.
Individuals for this discovery study were drawn from BioVU, one of the largest repositories of its kind linking DNA samples to de-identified electronic health records. The team then replicated their results at a second biobank at the Marshfield Clinic and confirmed them through tests in labs at VUMC and the University of Oklahoma.
The research also provides an important insight into the nature of disease inheritance. Until now, physicians have assumed that recessive genetic diseases require two mutations -- one from each parent -- to become symptomatic. The researchers found that only one variant was enough for some diseases to impact a patient’s health.
"In view of our findings, familiar medical categories such as 'complex' versus 'genetic,' or 'dominant' versus 'recessive' begin to appear more like continuums," said coauthor Lisa Bastarache, lead data scientist with VUMC’s Center for Precision Medicine.
Bastarache said study shows that looking at outcomes in EHRs can be helpful in deciding if a variant might be disease-associated.
"Phenotype risk scoring can easily be applied in any electronic medical record system that is linked to DNA," she said. "Our work looked at only a small sample of the human genome, about 6,000 variants. The opportunity for additional discoveries using this method is huge."
The commission wants Congress to adopt a Voluntary Value Program that eases the administrative burden on clinicians, and provides a more objective assessment of the value of care delivered based on population health metrics.
The Medicare Payment Advisory Commission (MedPAC) on Thursday issued its massive, semiannual report to Congress, with a recommendation that lawmakers end the Merit-based Incentive Payment System (MIPS).
In its place, MedPAC recommends establishing a Voluntary Value Program that it says would be less taxing on physicians, and which would more objectively assess the value of the care provided by using broader population health metrics.
The recommendations in the 563-page report follow the commission’s vote at its January meetingto eliminate MIPS. Congress is free to either take up the recommendations or ignore them.
"We came to this determination based on a two-year analytic work in which we started out examining ways in which MIPS might be improved," MedPAC Executive Director James Mathews said in a media conference call on Thursday.
"Over the course of two years we came to the conclusion that there were certain fundamental flaws in the premise of MIPs that suggest could not be improved," he said.
Mathews cited a number of flaws in MIPS, which he said makes the program "inequitable among physicians."
"Physicians get to choose their own measures under MIPS and the incentive is going to be for each physician to choose measures upon which they will likely succeed and perform well," he said.
He said MIPS also imposes a significant time and money burden on clinicians.
"CMS estimated a compliance cost of $1.3 billion in first year and costs of well over $500 million in years going forward," Mathews said. "We believe these expenditures will not result in a meaningful assessment of clinicians' performance such that it provides the basis for Medicare to move dollars around under MIPS."
Mathews called MedPAC's proposed replacement for MIPS—the VVP—a more streamlined approach that leaves the heavy lifting of data compilation to Medicare.
MIPS allows clinicians to choose six from 300 different quality measures, and the vector in which their performance gets reported. "Then Medicare makes a determination of whether their performance exceeds a performance threshold," Mathews said.
"What we have in mind is a system in which physicians would not be measured on an individual basis but would come together as a group to be measured on a much smaller set of population-based outcomes measures," he said.
"This would be on a voluntary basis where all of the physicians in a multi-specialty practice could volunteer to be measured as a group, or all of the physicians on a hospital staff could voluntarily be measured as a group, or all of the members of a county medical society could say 'we want to be measured,'" he said. "It would be purely up to the physicians themselves to make this determination of whether they wanted to be measured."
The smaller set of population health outcomes could include hospital admissions, mortality rates in the population they serve, and Medicare spending per beneficiary for the patients they touch.
"These would largely be measures that were not within the ability of any individual to influence how they were reported," Mathews said. "These are things that the Medicare program would be able to measure independently on the basis of claims or beneficiary satisfaction surveys. There would be no administrative burden associated with being measured under the VVP. Instead, it would all be conducted with readily available administrative or survey data."
Mathews says physicians would have two primary incentives for participating in VVP.
"One, obviously, is this program is going to provide quality bonus payments to physicians operating in fee-for-service Medicare," he said. "We are talking about those physicians who do not elect to join or form APMs (Alternative Payment Models). Those bonus payments have to be funded. We have suggested that the funding could come in the form of a withhold that would apply to all clinicians. We suggested something in the vicinity of 2% as a potential starting point for this withhold."
"Any given physician would see their payments under the fee schedule reduced by 2% and in order to have any potential of getting that withhold back or getting bonus payments on top of that withhold, they would want to raise their hands and volunteer to be measured under the VVP," Mathews said.
Another incentive makes the quality measures proposed in the VVP applicable under the Advanced APM performance assessment.
"This program would provide a stepping stone to get groups of physicians who are not necessarily ready to take on financial risk to nonetheless start to become measured under the same construct that would apply under AAPMs,” Mathews said. “Basically, it provides greater incentives for them to continue down that path, which would hopefully result in true delivery system reform, which we do not see as a real outcome under the current MIPS construct."
A former health insurance industry executive turned critic likens the new CEO at AHIP to the captain of the Titanic, with daunting challenges ahead as the trade association fights to remain relevant.
America's Health Insurance Plans announced this week that industry insider Matt Eyles will become the next CEO when Marilyn Tavenner retires on June 1.
The change in leadership comes as the trade association for the healthcare industry adjusts to a shifting healthcare landscape. In the past three years AHIP has seen the departure of three of its biggest members, UnitedHealth Group, Aetna, and most recently Humana.
Eyles, whose resume includes jobs at the Congressional Budget Office, Pfizer, Eli Lilly, and Coventry Health Care, has been with AHIP since 2015, and now serves as its COO.
Wendell Potter, a former health insurance industry executive turned ardent critic, likens Eyles' new job to "steering the Titanic." He said the new AHIP leader will face daunting challenges in his tenure as the trade association fights to remain relevant.
Potter spoke with HealthLeaders Media. The following is an edited transcript.
HLM: What do you think about the choice of Eyles?
Potter: Given his background, I wasn't surprised that they went with someone like him. He is going to have a very challenging job. He clearly knows his way around Capitol Hill and that is what is most important. At the end of the day, it’s mainly a lobbying and PR job. He is trying to continue to sell the relevancy of the health insurance industry going forward and he is going to have his job cut out for him. I wouldn't want Matt's job. He is steering the Titanic.
HLM: What sort of challenges do you foresee?
Potter: First of all, the health insurance business is changing quite a bit and AHIP has lost some of its biggest dues-paying members. They are not seeing that organization as relevant as it used to be. Many have decided they can do their own PR and lobbying just fine and their interests are not aligned with the remaining members of AHIP, whose base is not as big as it once was. It no longer includes some of the biggest players, so their revenues are not what they used to be.
Plus, the industry itself is changing. In the past several weeks we have seen news of CVS and Aetna wanting to combine, and Cigna and Express Scripts too. So, you've got middlemen insurance companies and PBMs looking to tie-in and become different kinds of companies, not just health insurers.
That said, there may remain a number of traditional health insurers in AHIP, but that is a world that is not going to be around much longer.
HLM: Do you see the traditional role of the health insurer as an anachronism?
Potter: Exactly! When I saw the CVS/Aetna deal and the Express Scripts/Cigna deal I was thinking about different dinosaurs morphing to try to perpetuate their existence a while longer. PBMs and health insurers as we've known them are dinosaurs that will both be disintermediated. Those mergers are a way for those companies to get bigger and extending their relevancy for a while longer.
You've got people like Warren Buffet, Jeff Bezos and Jamie Dimon looking at healthcare and they have come to the realization – and most business will come to it a bit later on – that the system doesn't work. Employers are waking up to the fact that they've been served a bill of goods by these middlemen. They are not necessary, and so the big employers are already direct contracting with healthcare providers and using health insurers for back-end operations.
HLM: What do you make off Marilyn Tavenner’s tenure at AHIP? She seems to have kept a low public profile.
Potter: It's interesting. It may have been because of what was going on in Congress. Karen Ignagni seemed to be more willing to be a visible spokesperson for the industry and she was quite effective.
I didn’t see Marilyn playing that role. She probably worked behind the scenes meeting with members and staffers on the Hill and the administration in a nonpublic way, which may have been her way of doing things. What we saw with her and what you are seeing with Matt is the typical Washington revolving door: Marilyn coming out of CMS to a trade association to make a few more bucks before calling it quits.
HLM: Can AHIP adapt to this changing landscape?
Potter: That's their biggest challenge. I don't know how they are going to remain relevant as they once were. They've got a shrinking base of potential members. There will probably be more consolidation in the industry. Cigna and United and the other companies have different business lines and different profit centers. In fact, health insurance is becoming less important to these big companies.
Maybe there could be a tie-in between the Blue Cross Blue Shield Associations and AHIP. I don't know if that can be done, but AHIP is a combination of different organizations that have come together in the past. AHIP's predecessor was the Health Insurance Association of America and when I first started working in the insurance world, HIAA’s predecessor was the Group Health Association of America. That gives you an idea of how things have evolved over the past 20 years. AHIP is the third name of the organization that I am aware of. They may have to re-invent themselves again.
Female doctors earned 28% less than their male colleagues from 2016 to 2017. There is no medical specialty in which female doctors earn more than male doctors.
Physicians saw an average 4% wage increase nationally from 2016 to 2017, but compensation varied significantly across metropolitan areas, between genders, and across medical specialties, according to anew survey from Doximity.
The report is based on responses from more than 65,000 physicians.
"Considering the increasing concern about potential doctor shortages, having a clear understanding of physician compensation is more relevant than ever," said Nate Gross, MD, co-founder of Doximity.
The following are among the findings:
Physician gender wage gap
In 2017, the national gender gap for physicians increased as female doctors earned 28% less ($105,000) than their male counterparts. The disparity in 2016 was 26.5% when female doctors earned $91,284 less.
There is no medical specialty in which female doctors earn more than male doctors. Additionally, women earn less than men in all of the top 50 metro areas.
From 2016 to 2017, the metro areas with the largest increase in gender wage gaps were: Charleston (8.6%); Ann Arbor, (8.2% increase); Riverside, CA (8% increase); Providence (6.4% increase); and Indianapolis (6% increase).
In 2017, the metro areas with the largest gender wage gaps were: Charleston, (female physicians earn 37% or $134,499 less); Kansas City (32% or $131,996 less); Nashville (32% or $118,706 less); Providence (31% or $108,796 less); and Riverside (31% or $115,991 less).
In 2017, the medical specialties with the largest gender wage gaps were: hematology (female physicians earn 20% or $78,753 less); occupational medicine (20% or $59,174 less); urology (20% or $84,799 less); orthopedic surgery (19% or $101,291 less); and gastroenterology (19% or $86,447 less).
Compensation by metro area
The five metro areas with the highest average annual salary in 2017 were: Charlotte ($402,273); Milwaukee ($398,431); Jacksonville ($379,820); Indianapolis ($378,011); and San Jose ($376,585).
The five metro areas with the lowest average annual salary in 2017 were: Durham ($282,035); Ann Arbor ($302,692); Baltimore ($304,002); New Haven ($308,262); and Rochester, N.Y. ($312,503).
From 2016 to 2017, the metro areas with the largest increase in physician compensation were: Charleston, S.C. (11.6% or $33,182 more); Milwaukee (7.3% or $52,601 more); Austin (7.2% or $45,605 more); San Francisco (6.9% or $58,184 more); and Las Vegas (6.7% or $47,256 more).
Compensation by specialty
The five medical specialties with the highest average annual salary in 2017 were: neurosurgery ($662,755); thoracic surgery ($602,745); orthopedic surgery ($537,568); vascular surgery ($476,300); and plastic surgery ($473,212).
The five medical specialties with the lowest average annual salary in 2017 were: pediatric infectious disease ($191,735); pediatric hematology and oncology ($208,524); pediatric endocrinology ($214,911); pediatrics ($221,900); and preventive medicine ($231,838).
The four biggest sources of excess healthcare costs account for two-thirds of the overall per-capita spending gap, and should be the prime targets of cost-reduction policies.
High drug prices, the excessive use of imaging and surgery, and excessive administrative burdens are the bulk of this country’s healthcare overspending, says healthcare policy expert Ezekiel J. Emanuel, MD.
In an essay this week in JAMA, Emanuel, chair of the department of Medical Ethics and Health Policy at the Perelman School of Medicine at the University of Pennsylvania, says Americans average $9,403 per person in annual health care spending. By comparison, Germans and Dutch, average $5,182 and $5,202 respectively.
While America's higher prices tend to get most of the attention, there are also big differences in the volumes of healthcare purchases.
"There are twice as many caesarean deliveries per capita in the United States compared to the Netherlands, for example," Emanuel said. "That difference in volume clearly is a major contributor to the overall spending discrepancy—$62 per capita for caesareans in the US vs. $9 in the Netherlands."
Administrative costs are another big contributor, Emanuel said, accounting for $752 per-capita of Americans' annual healthcare spending, versus just $208 in the Netherlands, and $232 in Germany.
If healthcare policy in America reduced these major drivers of excessive spending, he said it would free up hundreds of billions of dollars for better social uses.
The editorial referenced a new analysis from other researchers in the same issue of JAMA which included a comparison of healthcare expenditures in the U.S. and ten other wealthy countries, most in Europe.
That study showed that, on per-capita basis, the U.S. spends roughly twice as much as these peer countries. Using the data from this analysis as well as from other sources, Emanuel highlighted several key drivers of this huge spending difference.
One consists of high-price, high-volume surgical procedures such as caesareans, knee and hip replacements, coronary artery bypasses, and angioplasties. Americans per-capita spend 2 to 6 times more on these procedures than their peer country counterparts.
"Just the top 25 of these high-margin, high-volume procedures, with cost differences of $20-$40 per capita, explains approximately 20% of the per-capita healthcare spending difference between the U.S. and other high-income countries," Emanuel said.
Administrative bloat in this country is another major spending driver, with per-capita costs that are three- to five-times higher than costs in peer countries, he said.
Medical imaging procedures, meaning mostly CT scans and MRIs, are a third major driver of spending differences, and also involve both high prices and high volumes.
"CT scans alone account for $220 in annual per-capita spending in the U.S., compared to $23 per-capita in the Netherlands," he writes.
The fourth major driver, pharmaceuticals spending, is the only one where high prices are the dominant factor. Americans spend $1,443 per capita on pharmaceuticals, versus $566 for Swedes, for example, yet this huge excess is almost entirely due to higher U.S. prices, not higher volume.
Doctors cost more in America and their average salary is higher than the averages in most peer countries. Yet Americans’ net per-capita spending on doctors’ salaries isn’t much greater than in peer countries, because there are proportionately fewer doctors in the U.S.
"There are just 2.6 physicians per 1,000 citizens in the U.S., whereas in Germany the ratio is 4.1 per 1,000 and in Sweden 4.2 per 1,000," Emanuel said. "The difference in per-capita spending on doctors' salaries accounts for only 4% of the overall health spending gap."
Emanuel emphasized that the four largest drivers of excess U.S. spending should be the prime targets of cost-reduction policies.
Such policies should include government regulation to force down drug prices; mandatory shared decision-making among doctors to reduce the overuse of expensive procedures and imaging; Medicare-style reference pricing to lower per-procedure costs; and automated/electronic record-keeping to reduce administrative costs.
Even if such policies were to achieve proportionately only a modest amount of reduction, they would liberate very large sums, given the scale of the problem.
"If we in the United States could lower the prices and per-capita volumes of our CT scans, MRIs, and just the top 25 high-volume-high-price surgical procedures to those of the Netherlands, for example, we would see savings of about $425 per capita, or a total of $137 billion," Emanuel said.
Hospitals are having trouble finding qualified help in clinical and management areas. A survey suggests there just aren't enough qualified people to fill all those jobs.
Recruiting, staffing and retention challenges are hardly breaking news in the hospital sector.
Now a new survey from the healthcare staffing firm Leaders for Today suggests that the problem is not a matter of offering more pay and perks, but that there simply aren't enough qualified people to fill all the jobs.
"Data from our newest survey shows that while the healthcare industry continues to have a number of challenges when it comes to staffing, the absence of qualified candidates remains far and away their loudest concern – a far larger issue than originally anticipated," LFT said.
The survey of 204 hospital executives found that shortages affect senior positions at all hospitals, regardless of their size or location, and the inability to find qualified candidates is putting a strain on hospital operations.
Key findings:
31% of respondents said their hospital could not find enough candidates.
24% had a quick turnaround on candidate searches but questioned the qualifications of the candidates hired.
Only 8% had positive things to say about their hospital's staffing process.
52% rated their hospital’s ability to find good people in a reasonable amount of time as "not very good."
70% said replacing management positions took anywhere from four months to one year.
The survey suggested that the shortage has strained hospital human resources departments. In large hospitals of 250 beds or more, for example, 77% of recruiters said they were asked to manage 10 or more searches at a time, and 20 or more searches 47% of the time.
Healthcare job growth has been robust throughout the new century, and so have staffing challenges.
The Bureau of Labor Statistics reported that the healthcare sector grew 19,000 new jobs in February, including 9,000 in hospitals, and that the healthcare sector has added 290,000 jobs over the past year.
There is nothing to indicate that job demands will slow anytime soon. At its current pace, federal actuaries project healthcare spending will reach $5.7 trillion by 2026 and consume nearly 20% of the gross domestic product.
Earlier this month, Moody’s Investors Service warned that "an extreme nursing shortage" and other staffing issues will negatively impact not-for-profit hospital margins.
"An aging population, increased incidents of chronic disease and alternative employment options, such as nurse staffing and traveler agencies, drive increased demand. Although the supply of nurses is expected to improve with the expanded nurse training programs and increase in the number of eligible nurse educators, it will still take three to four years for the supply to meet expected demand," Moody's analyst Safat Hannan said.
Hannan said some hospitals are attempting to reduce the need for expensive contract labor with internal nursing pools, which has its own set of drawbacks. Nursing pools can reduce the reliance on pricey contract labor, but they may lead to higher attrition and lower productivity if nurses are not effectively trained across service lines.
"Labor is the largest hospital expense and is increasing faster than total expense growth while outpacing revenue growth," Hannan says. "The lack of qualified nurses will compound these expense pressures and negatively affect hospital margins."
Medical liability expert says breakdowns in cognitive and process factors often aren't captured in adverse events reports, and only come to light for physicians when they're named in a lawsuit.
Misdiagnoses are the root cause of one-third of all medical liability claims and account for nearly half of all indemnity payments, according to a new report by Coverys.
The report from the medical liability insurer analyzed more than 10,500 closed medical liability claims from 2013-2017 and found that:
Diagnosis-related events are the single-largest root cause of liability claims. The 3,466 closed claims with diagnosis-related allegations from 2013-2017 account for 33% of all claims and 47% of indemnity payments.
35% of diagnostic errors occur in non-emergency department outpatient settings, such as physicians’ offices.
33% of diagnosis-related claims allege the decision-making breakdown happened as a result of a failure during the patient evaluation.
The four phases of testing -- ordering, performance, receipt/transmittal, and interpretation―account for 52% of diagnosis-related claims.
Among diagnostic failure claims, the largest number of cases involve a missed or delayed diagnosis of cancer, especially breast, lung, colorectal and prostate cancers.
Of the claims that cited an EHR issue, 58% had an injury severity considered high―a category that includes death.
Study author Robert Hanscom, vice president of business analytics at Coverys, spoke with HealthLeaders Media about the findings. The following is a lighted edited transcript.
HLM: What leapt out at you with your findings?
Hanscom: Clearly we don’t know enough about diagnostic error, which is often hidden from the view of physicians and other providers.
Generally, when we see them in malpractice they are missed and delayed cancer diagnoses that would miss any adverse event reporting system, which is often the way that providers learn about mistakes. These are non-events that actually take providers by surprise sometime later down the road.
There is not a lot of intelligence out there, in terms of helping physicians understand where their vulnerabilities are with respect to these errors.
HLM: So, the first time providers learn about these misdiagnoses is when they’re sued?
Hanscom: Absolutely! If it's a missed or delayed cancer diagnosis allegation, it may take them completely by surprise. It may happen that their patient may have gone elsewhere, for example, because the symptoms hadn't gone away, or they wanted to try a new physician. Ultimately, when the actual diagnosis was made, and sometimes it is not made until they are advanced in the progression of the cancer, the physician may get a notice of a suit for a situation that he or she may have very little recollection about. This happens quite frequently.
HLM: Is there a common theme with these missed diagnoses?
Hanscom: There are both process and cognitive factors that are in play here. Those first two steps are where a huge amount of our malpractice activity comes from.
First, we know that cognitive variability is a big problem. Some physicians are really good diagnosticians. They get their rule outs. They get their differentials. But, that has become an artifact of old time medicine when doctors had lots of time to do it. Much of today's world cheats the doctor on their ability to do what they were trained to do, so the cognitive ability is significant.
Second, getting that history and physical and fully evaluating the patient is a process issue, because there needs to be that full evaluation and the time taken to do that. If they are looking at the patient's clinical history, they are making sure that there is a full capture of what is going on with that patient on every visit, which can be done efficiently, that will cut into that cognitive variability.
HLM: Talk about the importance of documentation.
Hanscom: There are two facets. From the legal perspective, if we have to defend cases at a later point, documentation means everything. If it is not documented, it’s very difficult to convince all the people who adjudicate these cases that the care happened in the way the physician is remembering it and wants a jury or some other arbiter to believe it happened. Documentation should be a habit that needs to occur.
More importantly, documentation helps subsequent providers completely understand what was decided and what was done. That is critical to continuity of care, and making sure that there is not a lapse in the care and the decision-making that needs to continually be made, that of course the treatment plan.
HLM: You also encourage documenting coverage denials.
Hanscom: Document the denial. If we can show a jury later that you considered it, you tried to do it, but there was a denial and you had to take an alternate path, that is important to make sure that the full story is being told.
HLM: Does fear of malpractice lead to unnecessary testing?
Hanscom: Getting those differentials does not constitute unnecessary testing. That is how physicians were trained in medical school and they need to be allowed to do it. There needs to be a fine balance. We recognize that there is pressure on costs and doctors not to do more than they have to. That doesn't take away from the fact that doctors need to make differential diagnoses to ensure that the true diagnosis is not being missed.
We see that in many cases the patient will present with certain symptoms and the doctor will say 'I think I know what this is,' and start to run with it. But, if they don't get differentials, if they don't ask what else could it be, then not only does that doctor get anchored in a diagnosis that has a degree of uncertainty, but other providers behind him get anchored as well.
HLM: What other actions could reduce liability?
Hanscom: Pay attention to the process categories. That is where resources need to be invested to make sure that good diagnosticians are not defeated. And, there needs to be attention paid to decision support that helps providers make sure that they’re considering everything that might be possible.
We have often seen that good diagnosticians get defeated by bad processes. More often we see both; physicians who are not as good with diagnoses and bad processes as well. That is the perfect storm.
It is also true with managing referrals. We see many cases where patients will refer to a specialist but the patient kind of drifted away from the primary care provider. There wasn’t a real process in place to make sure that the patient was looping back to the primary care provider.
Obviously, test result management is big. If test results are getting lost and the ordering provider is not getting the information they need to make that diagnosis, which is another major process issue.
HLM: Anything else?
Hanscom: I’ve looked at this data for 20 years and these data points have not moved very much. We really have to start a fire here with people thinking creatively and innovatively about how to put some very serious prevention to these tragic cases. These are high-severity injury outcomes. The time for innovation is really now. We need to think differently about how to help providers work their way through these complex scenarios.
Older patients are more vulnerable to postoperative delirium and cognitive dysfunction, but a few simple techniques could help to ease the transition.
The American Society of Anesthesiologists has developed a list of pre- and post-surgery tips to limit confusion for older patients.
"The aging brain is more vulnerable to anesthesia, but there is research that provides guidance to decrease these risks," said ASA President James Grant, MD.
"Older patients should talk with their physician anesthesiologist prior to surgery about their entire medical history and any memory problems they’ve had in the past, so an anesthesia plan can be developed," he said.
In particular, older patients are more susceptible to two anesthesia-related surgery risks, Grant said.
Postoperative delirium is temporary and causes the patient to be confused, disoriented, unaware of their surroundings, and have problems with memory and paying attention. It may not start until a few days after surgery, may come and go, and usually disappears after about a week.
Postoperative cognitive dysfunction is a more serious condition that can lead to long-term memory loss and make it difficult to learn, concentrate and think. Because some of these problems are already common in elderly people, the only way to determine if a patient actually has POCD is to conduct a mental test before surgery, Grant said.
Conditions such as congestive heart failure, lung disease, Alzheimer’s disease, Parkinson’s disease and having had a previous stroke, increase the risk for POCD.
ASA has put forward six tips that older patients and clinicians can take to reduce post-surgery confusion:
The physician should conduct a pre-surgery cognitive test of the patient and use the results as a baseline for comparison after surgery.
A caregiver or family member should stay with patients as they recover to observe physical and mental activity after surgery and report problems to the physician.
Physicians should know beforehand which medications a patient is taking after surgery, especially those medications that can affect the nervous system.
If the patient wears hearing aids or glasses, they should be made available as soon as possible after the procedure.
When possible, the patient should be in a recovery room with a window so they can tell whether it's day or night.
If the patient stays overnight in the hospital, they should pack a family photo, a clock and a calendar, or other familiar objects from home to help readjust.
