Improving patient safety shouldn’t be a financial calculation

A recent study of medical error published in The New England Journal of Medicine reached a shocking conclusion about patient safety: Nearly a quarter century after a highly publicized Institute of Medicine report on the prevalence of patient harm sparked vows to cut the rate by half in five years, “in-hospital adverse events” remain so common that they affect roughly one in four patients. At larger institutions, the rate can be 40% or higher.

“The safety movement has, at best, stalled,” an accompanying editorial acknowledged, while urging hospital leaders to hold themselves accountable to a “sacred obligation.”

Protecting patients from harm may be sacred, but what actually happens on the front lines of care is too often profane. Harvard’s Dr. Lucian Leape, widely considered the father of the patient safety movement, bluntly summarized the situation: “In health care, safety is too often an afterthought or at best a distant second fiddle to the bottom line,” wrote Leape in “Making Healthcare Safe,” a book he prudently published only after retiring. “There is no sense of commitment, no goal of zero harm,” with even “eminent academic institutions” settling to adopt just “some” safe practices.

Leape has it exactly right — even if many of those still active in the field of patient safety wouldn’t dare be so candid.

But the best way to counter the persistent lack of commitment to patient safety is not exhortations, but exposure. The last congressional hearing on medical error was nine years ago at a sparsely attended subcommittee session chaired by Sen. Bernie Sanders (I-Vt.). Now, however, Sanders is the powerful chair of the Senate Health, Education, Labor and Pensions (HELP) Committee.

Sanders should revive HELP’s patient safety hearings. This time, though, the focus should be squarely on the murky role played by monetary incentives.

More than a decade ago, I wrote that “many hospital executives believe they make money from complications.” But it’s patients and family members who are paying the real price. Before the Covid-19 pandemic emerged, the government estimated that preventable medical errors killed some 200,000 Americans a year. Grimly, as the pandemic has begun to wind down it’s gotten even more dangerous, according to a report by senior physicians from the Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention. (Others agreed.)

The federal physicians also lamented the failure by health care executives to institute “a thorough system of safety.” I’d like to suggest that the reason is that some hospital executives figured out long ago what researchers have only gradually uncovered: that current payment structures may “reduce the willingness of hospitals to invest in patient safety”; that hospitals can ring up a “contribution margin” of as much as $39,000 extra for a privately insured surgical patient with complications compared to one without them; and that only “targeted” safety improvements are associated with a hospital having “improved financial performance.”

These aren’t merely academic musings. Financial incentives have real-world consequences, and Congress has the power to summon witnesses to show those consequences to the American public. As veteran economist Sylvester Schieber noted recently, critics believe government penalties meant to prompt hospitals to reduce patient readmissions may not be potent enough to offset the revenue readmissions can generate. I’ve heard numerous accounts of exactly that happening; sworn testimony would bring the problem into the open. Similarly, it’s common to find even financially flush hospitals figuring the return on investment from patient safety interventions that range from buying a device to detect whether post-surgery patients have stopped breathing to preventing potentially fatal central-line associated bloodstream infections in children hospitalized with cancer. How hospitals make those decisions should be made clear to the public whose lives are at stake.

The famously plain-spoken Sanders should also reach out to Carole Hemmelgarn, who lost her 9-year-old daughter to a hospital’s mistakes. Hemmelgarn was the lead author of an article by patient advocates entitled, “Who killed patient safety?” in the Journal of Patient Safety and Risk Management. The article alleges that government-affiliated bodies charged with protecting patients “prioritize revenue preservation and consulting opportunities and often acquiesce to hospitals as their ‘clients’ to make safety less of a priority.” Sanders should ask Hemmelgarn for specifics.

David L. Katz, a physician who lost a loved one to medical error, wrote that dangerous care persists due to “unwitting delusion” in “a system populated mostly by genuinely caring and often highly expert people that nonetheless devolves into routine and dangerous dysfunction.”

That’s why it’s crucial for Sanders to also invite the physician and hospital administrator heroes who’ve defied that dysfunction to describe how in their hospital they’ve deliberately built a culture of safe care. And it’s why Sanders should work closely with the ranking Republican on the committee, Sen. Bill Cassidy (R-La.), a gastroenterologist with years of first-hand experience working in hospitals and clinics.

Research that I and several colleagues conducted found significant differences in safety among individual hospitals nationwide, but no connection between whether a congressional district was Republican or Democratic and the safety of the local hospitals. “First, do no harm” is, indeed, a sacred obligation, and it is one that supersedes political divisions. The only acceptable calculation is how many lives can be saved by a commitment to do everything possible.

As then-Vice President Joe Biden told the Patient Safety Movement Foundation in 2015, “It’s not like we have to find a new cure for brain cancer. This is within our grasp.”

Michael L. Millenson is president of Health Quality Advisors LLC and an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine.