First, the good news.
Indiana’s hospitals are getting better at preventing harm to patients and sparing them from avoidable hospital visits. And they’re saving money while doing it.
Over the past three years, 116 Indiana hospitals cut out nearly 4,700 patient harms, saving $22.3 million over three years, as part of a coordinated effort to make hospitals safer and prevent patients from having to come back.
“When I first saw the financial results, I didn’t believe them. I had my staff check back and say, ‘Were these for the whole country or just for Indiana?’” said Doug Leonard, CEO of the Indiana Hospital Association. “That really shocked me how well the program has done. Hospitals are showing meaningful ways to bend the cost curve.”
The three-year program, called Partnership for Patients, was part of a national effort funded by the Affordable Care Act. President Obama’s health-reform law, along with help from a budget-conscious Congress and belt-tightening employers, have been pushing hospitals to improve quality and reduce costs—largely by holding the line on paying for mistakes or poor results.
But the Affordable Care Act also provided some funding to help hospitals adapt to this new reality. The Indiana Hospital Association received an initial grant, which allowed it to hire seven additional staff, to help hospitals work to improve patient safety in 11 key areas.
Hospitals deserve to celebrate a bit with the results.
Nearly half of the savings came from preventing 1,254 readmissions of patients over three years. Indiana hospitals focused on their transitions of patients out of the hospitals to nursing homes, home health agencies or to private care, so patients and their non-hospital caregivers knew and actually did the right things.
Another $2 million was saved by preventing 110 venous thromboembolisms. Those are blood clots that, in patients that don’t move around much, can travel to the heart or lungs, and causing serious harm or death.
Indiana hospitals reduced the number of early-elective baby deliveries 76 percent. Before that reduction, it was estimated that 10 percent to 15 percent of all births nationally were done by C-section or induction between weeks 37 and 39 of pregnancy for no medical reason. But that was leading to health complications for both mothers and babies, which often led to longer (and expensive) hospital stays.
Hospitals worked to reduce infections caused by catheters and central lines, falls, severe bed sores, surgical site infections, ventilator-associated harm, obstetric harm and giving patients wrong medications or drugs that conflicted with other medications.
The hospitals not only worked internally, but they also joined regional coalitions—modeled on the Indianapolis Coalition for Patient Safety—and even interacted with hospitals in about 30 other states also participating in the Partnership for Patients program.
“It’s very exciting. We’re finally getting our arms around things that we can improve and should improve,” Leonard said. “In running a hospital, there are a thousand things to focus on. I’m sorry to admit, but I think a lot of us didn’t realize our performance could improve.”
But there’s some bad news here, too.
Savings of $22 million are miniscule compared with the roughly $50 billion Hoosiers and their health insurance plans spend on hospital care over a three-year period.
It should be noted that the 116 hospitals are only about 70 percent of the hospitals in Indiana, and maybe only half the revenue. That’s because the St. Vincent Health hospitals did their own patient safety program with their Ascension Health parent organization. Also, some public and academic hospitals joined national groups of similar hospitals in working on patient safety.
Even so, the savings are still a drop in the bucket, less than one-tenth of 1 percent of annual hospital spending.
The second bit of bad news is this: If hospitals want to save meaningful amounts of money, their current areas of focus won’t get them there. The really big ways that hospitals and doctors harm patients—both their bodies and their budgets—are not addressed by programs like this.
Dr. Atul Gawande has a new article in The New Yorker, titled “Overkill,” about how U.S. patients are over-tested and over-treated, and how it harms their health and wastes billions as a result.
“Virtually every family in the country, the research indicates, has been subject to overtesting and overtreatment in one form or another,” Gawande wrote. “The costs appear to take thousands of dollars out of the paychecks of every household each year. Researchers have come to refer to financial as well as physical 'toxicities' of inappropriate care—including reduced spending on food, clothing, education, and shelter. Millions of people are receiving drugs that aren’t helping them, operations that aren’t going to make them better, and scans and tests that do nothing beneficial for them, and often cause harm.”
But the other problem is from missing a diagnosis. A 2013 study published in JAMA Internal Medicine found that out of 190 cases handled by primary care physicians, the doctors missed 68 diagnoses.
Of those missed diagnoses, 5 percent led to minimal or no harm and 10 percent led to minor harm. But 38 percent led to considerable harm or remedial treatment, 35 percent led to serious or very serious harm and 14 percent led to immediate or inevitable death.
"Diagnostic error is probably the biggest patient-safety issue we face in health care, and it is finally getting on the radar of the patient quality and safety movement," Mark Graber, a longtime Veterans Administration physician and a fellow at the nonprofit research group RTI International, told the Wall Street Journal in 2013.
A local doctor sent me that Journal article a few months ago, saying that overtreatment and missed diagnoses account for more harm than all the preventable errors the hospitals, at the encouragement of the federal government, are focusing on.
Hospitals are certainly aware there’s more work to do, Leonard said. Which is why there will likely be a second round of the Partnership for Patients program, and why Leonard wants to launch a similar Indiana-specific project focused on patient safety.
But it looks like deeper changes in medicine will be needed before the biggest and costliest buckets of mistakes are addressed.