Why Hospitals Perform Procedures They’re Not Equipped to Do

Hospitals love new technology and new treatment initiatives because using them can result in better outcomes for patients. But hospitals also like them because they can charge more for an expensive or complicated surgical tool or protocol, and leverage that use for promotional purposes.

Unfortunately, as we’ve often pointed out, new and complicated treatments sometimes don’t work right. Sometimes they’re used by people insufficiently trained. Sometimes they cause grievous harm to patients and qualify as malpractice. So, many policy experts are calling for hospitals to prove they’re capable before they engage in certain surgical practices.

“As the U.S. health-care landscape advances toward rewarding quality rather than quantity, just buying a new high-tech surgical tool or hiring skilled surgeons may not be enough to support offering the new service,” according to a recent story in Modern Healthcare. “Facilities should more frequently be asked to prove not only the ability to achieve good clinical outcomes, but that there is a community demand for the service in the first place, [health quality and policy leaders] say.”

Implementing new surgical programs sometimes is the result of misguided priorities (see our blog about proton beam technology). Devon Herrick, senior fellow at the National Center for Health Policy Analysis, told Modern Healthcare, “They don’t establish [such programs] because they have a competitive advantage or are especially skilled in the area. [They do so] because there are patients who have insurance that will reimburse for these lucrative services.”

He also said that if hospitals don’t compete on price, they probably don’t compete on quality either.

According to the Centers for Disease Control, congenital heart defects affect about 1 in 100 (about 40,000) births per year in the U.S. About 1 in 4 of those babies are sick enough to require surgery. One medical center that performed them for four years suspended elective pediatric congenital heart surgeries earlier this month because of too many poor outcomes.

In those four years, St. Mary’s Medical Center in West Palm Beach, Fla., performed only 132 separate heart procedures on a total of 90 patients after receiving approval by Florida’s Agency for Healthcare Administration in 2011. Florida, Modern Healthcare explained, requires a Certificate of Need (CON) before a facility may expand, offer a new service or purchase certain kinds of equipment.

When St. Mary’s got the approval, it made sure people knew: “No other hospital in Florida has received such approval in more than 15 years,” it announced, claiming that congenital heart defects are fairly common and that local folks could now access the “unique minimally invasive treatment option right here in the local community.”

But given the CDC data, was there ever a demand for this service in this community? As we’ve noted, the more often a provider performs a certain procedure, the likelier it is that its patients will get the best outcomes. “Families and insurers could have sent patients to already established facilities that have specialized pediatric cardiovascular care teams and in some cases average more than 800 of the procedures each year,” Modern Healthcare noted.

“Ask a parent if they would prefer a place that does that many, or one that does one every other week. I don’t think it takes a genius to figure that out,” Dr. Edward Bove told Modern Healthcare. He’s head of the divisions of pediatric and adult cardiac surgery at the University of Michigan Health System, and collaborates with Joe DiMaggio Children’s Hospital, where a few patients from St. Mary’s had been transferred for additional care.

St. Mary’s wanted the cachet and the revenue from pediatric heart surgery, but it appears that it didn’t have the chops, regardless of what the state decided.

In places where hospitals must receive a CON before a new service can be offered, some industry experts believe they should be required to prove that they have the resources to establish a program as well as a sufficiently high volume of such cases in order to remain proficient.

It’s not as if St. Mary’s was surprised that its reach exceeded its grasp. Concerns over its suitability to perform pediatric heart surgeries were raised during public hearings for its CON process. At the time, reported Modern Healthcare, the hospital’s open heart surgery program was expected to generate 64 cases in the first year and 66 cases in the second, both of which are low numbers. Still, the hospital managed only 46 and 44 respectively in those years.

Cardiac surgeons told Modern Healthcare that hospitals doing these procedures must provide specialized cardiac teams around the clock. “You really need an entire city of people, it’s an enormous technical undertaking,” Bove said. “You don’t just go out and hire a surgeon.”

It’s not clear whether St. Mary’s had that expertise. Documents in support of its CON said its on-call policies would enable the rapid mobilization of surgical and medical support for emergency cases, and that the hospital would recruit staff with appropriate experience and training in pediatric open heart surgery.

Legal claims filed last year by at least four families whose infants underwent cardiac care at St. Mary’s accused the hospital of not being able to quickly recognize and treat the complications during and after their surgeries. They alluded to “systematic failures.”

According to Modern Healthcare, The Joint Commission, the nonprofit that accredits U.S. hospitals and conducts unannounced onsite surveys, said the situation at St. Mary’s is something it “will likely take a look at.”

Conventional wisdom would deem that sort of review necessary before a facility performs the surgery. The view from hindsight is much more likely to reveal collateral damage that never should have been inflicted in the first place.

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