DCMedical News: Wednesday, January 25, 2023
DCMedical News is published every day both the House and the Senate are scheduled to be in session.
THE BIG STORY Wednesday, January 25, 2023
Patient Safety Progress Questioned in New England Journal of Medicine Thirty Four Years On
David Bates and colleagues (here) represent their study to be an update of the famous 1991 Harvard study of safety in 561 New York State hospitals (here, in two parts), also published in NEJM, whose lead author was Troyen Brennan, later chief medical officer of Aetna and then of CVS.
This study, of patients in 11 Massachusetts hospitals in 2018, found “In a random sample of 2809 admissions, we identified at least one adverse event in 23.6%. Among 978 adverse events, 222 (22.7%) were judged to be preventable and 316 (32.3%) had a severity level of serious (i.e., caused harm that resulted in substantial intervention or prolonged recovery) or higher. A preventable adverse event occurred in 191 (6.8%) of all admissions, and a preventable adverse event with a severity level of serious or higher occurred in 29 (1.0%).”
In addition, “There were seven deaths, one of which was deemed to be preventable. Adverse drug events were the most common adverse events (accounting for 39.0% of all events), followed by surgical or other procedural events (30.4%), patient-care events (which were defined as events associated with nursing care, including falls and pressure ulcers) (15.0%), and health care–associated infections (11.9%).”
The conclusion of the Bates study is that “Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement.”
The conclusion of the 1991 study was that “There Is a substantial amount of Injury to patients from medical management, and many Injuries are the result of substandard care.” The results of that study were that adverse events occurred In 3. 7 percent of the hospitalizations and 27.6 percent of the adverse events were due to negligence. Although 70.5 percent of the adverse events gave rise to disability lasting less than six months, 2.6 percent caused permanently disabling injuries and 13.6 percent led to death.”
In a commentary (here) accompanying the Bates study, Donald Berwick writes “A direct comparison of the quantitative findings of this study with those of the HMPS [Harvard Medical Practice Study] is tempting but is not warranted. Bates and colleagues used search methods that were guaranteed to identify more injuries than the methods used in the HMPS, and their definition of an adverse event was broader. However, the incidence of adverse events that were identified (23.6%) does not suggest dramatic progress. On the contrary, these findings suggest that the safety movement has, at best, stalled.”
According to Berwick, “The 2022 National Steering Committee for Patient Safety, as well as the authors of a national action plan for patient safety sponsored by the Agency for Healthcare Research and Quality, reached the same conclusion. The President’s Council of Advisors on Science and Technology has been preparing recommendations for the President to reignite an effective safety movement. This effort could hardly be timelier.”
With regard to the role of leaders, Berwick writes “Senior executives and boards of directors in health care systems today may feel overwhelmed by an onslaught of urgent priorities . . . They may not welcome the duty to push patient safety back to strategic prominence. Nevertheless, ‘first do no harm’ remains a sacred obligation for all in health care, and success requires ‘constancy of purpose for improvement.’ Without renewed board and executive leadership and accountability for safety and without concerted, persistent investment in and monitoring of change, a summary study 34 years from now may again look all too familiar, with millions upon millions of patients, families, and health care staff paying the price for inaction.”
DOCTORS, NURSES AND OTHER HEALTH PROFESSIONALS
For-Profit Hospitals Increase Numbers of Resident Physicians, and Payments
Researchers publishing in JAMA (here) compared physician residency positions in for-profit hospitals in 2011 and 2020. “Graduate medical education (GME) is largely subsidized by Medicare, which in December 2021 authorized 1000 new residency slots. While historically GME was organized by nonprofit hospitals, for-profit hospitals are increasingly sponsoring residency programs.”
The results: “Between 2011 and 2020, nonprofit hospitals received the majority of GME payments. Although nonprofit hospitals’ participation increased by 13.4% (from 798 to 905 facilities), their subsidies decreased by 6.5% (from $9.42 billion to $8.81 billion). During this period, for-profit hospitals’ participation in GME increased by 49.2% (from 124 to 185 facilities) and their subsidies increased by 47.3% (from $565.2 million to $832.8 million).”
The researchers commented that “These findings suggest that the health care industry increasingly values GME as an asset rather than a money-losing endeavor” and that “However, the effect of profit status on educational outcomes remains unknown due to the lack of performance measures for GME.”
MEDICARE, MEDICAID AND COMMERCIAL HEALTH INSURANCE
Baby Kicks and Medicaid Maternity Payment Kicks
A Research Letter in JAMA Internal Medicine (here) describes the importance of “Kick” payments by States to Managed Medicaid programs covering new mothers.
“Medicaid managed care (MMC)—wherein states contract out the provision of Medicaid to private health insurers—provides coverage for 70% of pregnant Medicaid enrollees and finances about 41% of all births in the US. Medicaid managed care plans receive per-member per-month capitated payments from states to cover a defined benefit package. This arrangement poses financial risk to MMC plans for covering pregnant people, who are higher cost than other enrollees and often enrolled for short durations before delivery. To mitigate this risk, states use one time “kick payments” to MMC plans that are triggered by a delivery event. State kick payment rates may influence whether MMC plans want to attract or avoid enrollees who are pregnant, potentially shaping maternity care access and quality in state Medicaid programs.”
Results: “Of the 38 states and the District of Columbia using comprehensive MMC to deliver Medicaid coverage during the study period, 33 (85%) used maternity kick payments to supplement capitated rates. The majority of states (n = 24 and the District of Columbia) that use MMC to deliver coverage set kick payment rates to offset only the cost of delivery services, while a minority (n = 8) set rates to offset both the cost of delivery and perinatal services.”
Also, “Kick payment rates for delivery services varied 5-fold between states, ranging from $2,838 in New Hampshire to $14,493 in Maryland. Variation in kick payment rates were not explained by the amount of Medicaid payments to physicians or obstetricians nor by variation in Medicaid FFS payments, suggesting that kick payments may exceed the cost of delivery hospitalizations in some states and be less than the cost in others.”
PUBLICATION SCHEDULE FOR DCMEDICAL NEWS
January 26, 27, 30, 31
February 1, 2, 6, 7, 8, 9, 27, 28
March 1, 7, 8, 9, 10, 22, 23, 24, 27, 28, 29, 30
Notes to Fred Hyde, MD, JD, MBA, news@dcmedicalnews.org