Medical Staff

Quality and Performance Improvement

Medical Staff Affairs Monthly, September 23, 2005

Dear Colleague,

Fall is beginning across the country, but residents in much of the nation won't notice as they battle the ravages of the hurricane season. The gale winds have stripped away more than just roofs and trees. They have also uncovered the frailty of the social infrastructure and safety net that so many Americans depend upon.

Government statistics released this month show that the ranks of the medically uninsured continue to swell, nearing fifty million. Almost a quarter of the nation will spend some part of the year without health insurance. And these numbers do not include a count of the under-insured, a contributor to the fact that medical bills are the major impetus for personal bankruptcy in America. In the face of these figures, health care costs continue to climb and those of us in this business are going to feel continuing pressure to prove the value of our activities.

In "Health Spending in the United States and the Rest of the Industrialized World" (Health Affairs, July/August 2005), Gerald F. Anderson and colleagues analyze data from more than 30 industrialized countries. They explore-and reject-two commonly proposed explanations for why health costs in America so far outpace the rest of the world:

  1. Other countries have restricted the supply of health care resources, which has led to waiting lists and lower spending.
  2. The threat of malpractice litigation is much more common in the U.S., resulting in increased malpractice insurance premiums and the associated costs of "defensive medicine".

Their work found that higher prices for health services such as prescription drugs, hospital stays, and doctor visits, are the main reason for higher U.S. spending. Of interest is that the authors discovered that, despite the lack of waiting lists, Americans do not have access to a greater supply of health care resources than people in most other industrialized countries. In fact, the U.S. has fewer per capita hospital beds, physicians, nurses, and CT scanners than the median for the 30 nations studied.

This report is just one of a flood of studies that challenge the medical shibboleth that "America has the best health care in world". This oft repeated mantra is used reflexively by too many physicians to justify business as usual. I continue to find substantial resistance from doctors who believe that compliance with "core measures" is just a political hoop they shouldn't have to leap through. These same physicians are quick to point out the limits of "evidence based medicine" so they won't have to bring their practices into line with the substantial data supporting "best practices". But in this information age, with quality data more and more available to all, such physician opposition seems more and more self-serving.

Recently the CMS Hospital Compare Web site (www.hospitalcompare.hhs.gov) added information on the steps hospitals are taking to prevent surgical infections. With the addition of a new measure on pneumonia, there are now twenty measures being tracked on this public database. Have you looked at your hospital's data on this site recently? Are physicians at your hospital seeking top ratings on this website or busy sniping at its value?

A new option is looming for medical staffs that want to take the bull by the horns on quality and performance improvement. On July 28th, the Patient Safety and Quality Improvement Act of 2005 became law (http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_public_laws&docid=f:publ041.109). One aspect of this piece of legislation is its promotion of "patient safety organizations" (PSOs). While I wince at yet another acronym introduced into the health care lexicon, we may begin to see cutting edge medical staffs adopting PSO status. The law provides PSOs with a new layer of protection from discovery for credentialing, peer review, and quality improvement information, regardless of your state peer review statute. In the months ahead we will learn whether this statue creates an exciting new avenue of opportunity for our medical staffs and hospitals or whether it just adds to the bureaucratic overload which consumes so much time and money in health care.

Finally, as the mop up from Katrina continues, new light is being shed on the realities of two class medicine in the nation. One place that spotlight is aimed is on the country's growing number of specialty hospitals. This summer three members of the House and Ways Committee requested that CMS investigate whether these hospitals practice racial discrimination. Recent class action suits against not-for -profit hospitals alleging inadequate care to the poor seem to be losing steam. But the issue may get some renewed vigor as the nation seeks to learn all of the lessons this hurricane season has wrought.

As autumn progresses and much of nature turns dormant, let's hope that hurricanes do the same. And I'm reminded of that old warning not to knock the weather. If it didn't change once in a while, nine out of ten people couldn't start a conversation. the previous seventy-three day record set by opposing counsel in the same case.

Best regards,

Todd Sagin, MD, JD
National Medical Director
The Greeley Company

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