Patient Safety Blog

Deaths from preventable medical error kill as many people in the nation's capital as guns, and far more than motor vehicle crashes, according to a new report from the D.C. Department of Health.

The report, the first of its kind in the District of Columbia, analyzed the 5,168 total deaths reported to health officials in 2007. It determined that fully half of the deaths could have been prevented. Among the leading causes of preventable death:

1. Tobacco: 860 deaths
2. Poor diet and physical inactivity: 780 deaths
3. Infections (not counting HIV): 240
4. Alcohol abuse: 150
5. Firearms: 140
6. Medical errors: 140
7. Poisons (and pollution): 110 deaths

Motor vehicle deaths were a distant 10th place on the list of leading preventable causes of death, with 30 deaths in D.C. in 2007, according to the Health Department.

Another interesting number: The Department estimates that as many people died from lack of health insurance -- which discourages access to medical care -- as motor vehicles -- 30 people in 2007.

The estimate of deaths from lack of health insurance is based on the number of uninsured people in D.C. and uses methodology from a report by the Kaiser Family Foundation. The estimate of deaths from medical error was made by applying D.C. population numbers to estimates that were made in 2000 by the Institute of Medicine, part of the National Academy of Sciences.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Insurance , Medical Error , Medical Malpractice , Preventive Care

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It ought to be so easy. Congress waves its magic wand, makes it illegal for health insurers to discriminate against sick people by charging them higher premiums or excluding their "pre-existing conditions," and voila, there you have it -- reform that everyone wants. But here's the downside, and here is why health insurance reform is not easy without tough and unpopular mandates on healthy people.

If insurance discrimination against the sick was outlawed without any requirement that everyone buy health insurance, then many people would take a chance and "go bare" of insurance while they're in good health. After all, they couldn't be punished financially once they got sick and really needed the coverage. More and more, the only people buying insurance would be the ones with big medical bills. And without the premium money from the healthy to subsidize the bills for the sick, the insurance companies would have to raise rates, and this would discourage more people from buying insurance, and soon we would have what economists call "the death spiral" of ever higher premiums and ever fewer insureds.

So no health reform has ever succeeded without a wide base of financing where the healthy and the sick alike contribute to the money pool, whether through insurance premiums or taxes.

Uwe Reinhardt, the Princeton health economist, explains this in a recent "economix" blog post in the New York Times.

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Posted In: Insurance

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A new study documents how lack of health insurance can be fatal to sick children -- not because they are denied care once they get to the hospital, but because they get into the care system too late.

Researchers at Johns Hopkins Children’s Center crunched the numbers of two decades' worth of children's hospitalizations -- more than 23 million hospital stays. They found that compared with insured children, uninsured children faced a 60 percent increased risk of dying.

The authors estimate at least 1,000 hospitalized children die each year for lack of insurance.

As quoted in a New York Times account of the study, which was published in The Journal of Public Health, one co-author said:

“If you take two kids from the same demographic background — the same race, same gender, same neighborhood income level and same number of co-morbidities or other illnesses — the kid without insurance is 60 percent more likely to die in the hospital than the kid in the bed right next to him or her who is insured,” said David C. Chang, co-director of the pediatric surgery outcomes group at the children’s center.

The kids without insurance tended to arrive at the hospital through the emergency room, and tended to die in less than a day after admission, suggesting they were sicker than insured children, according to the authors.

Dr. Peter Pronovost, another co-author and a patient safety advocate at Hopkins, said:

“The striking thing is that children don’t often die. This study provides further evidence that the need to insure everyone is a moral issue, not just an economic one.”

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Posted In: Insurance

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More and more doctors and patients are recognizing the link between affordability of medical care and safety. One problem that plagues fee-for-service medicine is that doctors are rewarded financially for ordering excessive tests and treatments, which are both dangerous and wasteful.

Geoff Berg, an internist in Rhode Island, put it this way in a letter to the editor in the New York Times:

"The problem with fee-for-service is not merely that it pays providers to provide service; it pays them to create service as well. It is this almost limitless ability of doctors to create service that makes our per capita health care costs twice that of any other developed country. If physicians were salaried employees with modest incentives for productivity and outcomes, we could, in very short order, have affordable health care for all."

Electronic medical records, if properly used to communicate key information among doctors and with the patient, also could help cut wasteful and pain-inflicting treatments, as letter writer Margie Parko wrote in the Times about her mother-in-law's experiences in the last 18 months of her life.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Accessibility of Healthcare , Insurance

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It's always intimidating to undergo an MRI scan or CT scan. The machines are loud and enormous and seem to swallow your body. For all the trouble and expense, patients deserve the very latest scanning equipment and should have their images read by only the most highly qualified doctors. Alas, there is a quiet scandal in the $100 billion/year medical imaging industry. Patients cannot count on the best unless they insist on it.

As quoted by Gina Kolata in the New York Times, radiology leaders say, in the words of one: "The system is just totally, totally broken." That from Dr. Vijay Rao, chair of radiology at Thomas Jefferson University Hospital in Philadelphia. One big problem is that insurers pay standard rates for scans, even if a scan on a 10-year-old machine produces a blurry image and results in patients undergoing unnecessary surgery or missing a diagnosis. There is also no financial incentive for scanning facilities to have the images interpreted by sub-specialists with more expertise in the body part being studied. But there is a big financial incentive for doctors to own their own scanning equipment, and that results in many unnecessary referrals for scans when the doctor's judgment about the patient's needs is clouded by financial conflicts of interest.

Wise patients should ask pointed questions before submitting to any imaging scan. Here is a list, adapted from Patrick Malone's new book, The Life You Save: Nine Steps to Finding the Best Medical Care -- and Avoiding the Worst, available at Amazon.

1. Is the scanning machine the latest generational available? If not, is there another facility nearby that has the latest generation? (In MRI scans for example, the stronger magnets on newer machines make for crisper images.)

2. Does the doctor who wants me to have this scan own the scanning equipment or the scanning facility? (If so, get an opinion from another doctor with no financial interest about whether you need the scan at this facility.)

3. Who will interpret the images? Is that doctor a sub-specialist in what's being studied? (Examples of radiology sub-specialties include musculo-skeletal, neuroradiology (brain and spine), abdominal and chest.) If not, can we get a second reading from a sub-specialist?

4. Is the scanning facility accredited by the American College of Radiology? (This ensures that basic standards are met, such as the technologist who runs the scanning machine being certified and the machine being regularly inspected for proper functioning.)

Involved patients will also want to sit down with the doctor and look at the images together. You will notice how much more detail comes out when the scan has been done on an up-to-date machine by well-trained personnel. In the New York Times article, you can see in a knee scan how the ligament is blurry on the left-side image but comes out clearly in the image on the right -- a slanting striated structure that connects the middle of the top of the tibia to the back of the femur.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Disclosure , General , Insurance , Medical Error , Testing

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A new report from George Mason University of Virginia and the Urban Institute finds that the uninsured pay $30 billion each year out of pocket for health care costs.

Others who provide for the uninsured are the government, physicians who donate time and forgo profits, and private charity.

The lead researcher points out that failure to cover the uninsured in the short term would only lead to greater costs for society in the long term.

From the article:

On average, an uninsured American pays $583 out of pocket toward average annual medical costs of $1,686 per person, Hadley's team reported in the journal Health Affairs. The annual medical costs of Americans with private insurance average far more -- $3,915, with $681, or 17 percent, paid out of pocket, the report found.

"The uninsured receive a lot less care than the insured, and they pay a greater percentage of it out of pocket. Contrary to popular myth, they are not all free riders," Hadley said.

One big problem that has been recognized for years with lack of universal health coverage is that people without good insurance sometimes put off going to the doctor or hospital until they are much sicker and need much more intense treatment.

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The Toledo Blade has a good article with stories from patients whose crucial treatments, ordered by doctors, have been denied or delayed by insurance companies.

It begins with the harrowing story of Randy Steele, who died after the kidney-liver transplant that could have saved his life was stalled by his insurer.

Even if patients do not die as a result of these repeated denials and delays, they often end up unable to follow their doctors' instructions and their health suffers seriously as a result.

The Blade conducted interviews with 100 physicians and did a survey of 920, which you can read more about by clicking the above link. The results of both the interviews and the survey show that doctors believe that insurers countermanding or stalling their orders is creating a crisis in health care. Of the survey's 920 respondents, more than 99 percent said that insurers had interfered in their medical decision-making.

Clearly doctors are more qualified to make medical decisions than insurance companies. Any health care system that allows a bureaucrat working for an insurance company to make these calls will inevitably end up creating the tragedies that this article describes.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Accessibility of Healthcare , Doctor-Patient Relationship , Insurance

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Unsurprisingly, there are wide global disparities in survival rates of cancer patients. This is partly because of the relative wealth of different countries. However, there are huge disparities within the United States as well:

In the United States, the lowest survival rates are in New York City, except for rectal cancer in women, where Wyoming scores worse. The best survival rate for cancer in the United States is in Hawaii, the researchers found.

Idaho also has a high survival rate for rectal cancer, and Seattle has the highest survival rate for prostate cancer.

But, there's a big disparity in cancer survival rates between whites and blacks in the United States, and it favors whites. The differences range from 7 percent for prostate cancer to 14 percent for breast cancer. This disparity is most likely due to differences in the stage of cancer when it is diagnosed, the researchers said.

We have discussed the impact of race and region on health care quality before on this blog. Unfortunately, not everyone can count on getting the appropriate kind of service from their health care providers depending on their circumstances, as this new study re-affirms.

Posted by Patrick A. Malone | Permalink | Email This Post

Posted In: Accessibility of Healthcare , Cancer , General , Insurance

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In California, regulators ordered insurers to reinstate the policies of 26 patients who allegedly lied on their applications.

As Michelle Andrews notes in the linked article, insurers will often claim that a patient "lied" about something that was either an honest mistake or the result of the insurer using strange definitions. For instance:

...one woman I spoke with on this topic had answered "no" when asked if she'd been treated for cancer in the past 10 years. Later her policy was yanked because the insurer claimed that regular blood work she had to ensure her earlier cancer hadn't returned constituted cancer treatment.

One might guess that this phenomenon occurs in other states as well. Andrews comments that patient advocates suspect it does.There is certainly no evidence indicating that it is confined to California.

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Posted In: Insurance

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