Tuesday, March 18, 2014

HCR -- Patient-Centered or Profit-Centered?

Two recommended readings this morning were brought to my attention by a comment left at The Health Care Blog yesterday. What the Work of the Inspector General Tells Us about Patient Safety… by Dr. Ashish Jha is the first reading. 

The second is the comments thread, focuses on the connection between what professionals euphemistically call "sentinel events" (another way of referring to often preventable circumstances leading to often fatal results) and how they are paid for (or not).


A couple weeks ago while waiting for my wife to undergo a hospital procedure I read an unsettling link about (you guessed it) patient safety in hospitals. It was not a pretty picture and I urge others to check it out.
>> The OIG looked at care for a national sample of Medicare beneficiaries and what it found was unexpected: 13.5% of Medicare beneficiaries suffered an injury in the hospital that prolonged their hospital stay, caused permanent harm, or even death. 
An additional 13.5% of Medicare patients suffered “temporary” harm – such as an allergic reaction or hypoglycemia – things that are reversible and treatable, but quite problematic nonetheless. Taken together, these data suggest that 27% of older Americans suffer some sort of injury during their hospitalization – much higher than previous numbers. 
There are three more statistics from the OIG report that should give us all pause: First, they estimate that unsafe care contributes to 180,000 deaths of Medicare beneficiaries each year. This is a stunningly high number. Second, Medicare pays at least an additional $4.4 billion to cover the costs of caring for these injuries. And finally, about half of these events are preventable based on today’s technology and know-how. 
I suspect that if we actually make safety a priority, many more events would become preventable over time. And yet, although hospitals are supposed to identify, study, and track adverse events, the OIG says it mostly isn’t happening. At least not in any systematic way. <<
That should be enough to whet your appetite. But a comment left yesterday about the connection between the PRICE of medical care (I refuse to say "cost" which is quite different from "price") and outcome statistics reminded me of Dr. Jha's post, which I would rather forget.
>> What is really disgusting is that these errors, i.e. “adverse events” are NOT reimbursed by CMS or GAP and Advantage Insurers. Medicare/Medicaid patients (most prone to suffer from adverse events) who pay Medicare and Social Security taxes their whole working lives have NO IDEA that they are the victims of errors and “charity” patients for the hospitals —and that they may be hastened unto death for fiscal expediency and to hide the errors. 
Disgracefully, our Congress, HHS, CMS and Big Insurance, when they developed the policy to NOT reimburse hospitals/physicians for adverse events, made no law that protects the patients and that requires hospitals, physicians, or Medicare to notify patients that they are the victims of errors and “charity” patients for the hospital. Often, these elderly/disabled Medicare/Medicaid patients are hastened unto death with covert/overt (default DNR Code Status) for the fiscal expedience of Big Insurance and the hospitals. 
This is what happens when you have “profit-centered” health care and not patient-centered healthcare. The epidemic of unilateral covert/overt(default DNR Code Status) that is extrapolated into the hospital charts of elderly/disabled Medicare/Medicaid patients to limit/withhold life-saving and life-extending treatments that won’t be reimbursed is a national disgrace. <<
There is more at the link. Much more, including a raft of supportive outlinks as well. I trust the reader to follow the trail, drill into the links and in the end, as they say, follow the money. 


  1. Thanks, John, for posting this comment. I see your comment on my comment is now in the search for "Unilateral Covert and Overt(Default) Code Status hastening the death of elderly/disabled Medicare Patients."

    Strangely, "Patient Safety" is another disgrace that is swept under the radar of public scrutiny because the private "for profit" interests have had their way with the Public Medicare Purse and mistakes and errors to include non beneficial over treatment, exceeding the Diagnosis Related Group Cap for the disease/cancer being treated are NOT reimbursed by Medicare or the private GAP and Advantage Insurers. But! the patients do not have to be informed that they are victims of mistakes, errors, exceeding the DRG caps, and have no idea they are in a hostile situation as charity patients of the hospital.

    The covert/overt(default) DNR Code Status is a tool for the hospitals to use to CAP their costs when CMS and private insurance refuses reimbursement because they can then deny or withhold the life-saving/life-sustaining treatments that they KNOW are not going to be reimbursed by Medicare and the private insurers even as these treatments are indicated and are not medically futile. .

    The OIG knows of course that the Hospitals rarely report all of the errors and under most State laws, the errors that are reported and made public cannot be used in any private right of action for damages, etc..by the victims of the errors.

    The unilateral DNR, if discovered, is treated merely as an "ethics lapse" and the "free press" of the USA has ignored this disgraceful epidemic in our public hospitals.

    The Association of Hospital Journalists (strangely) seems to control the only safety "inspection" mechanism that might become public but, of course, they have never acknowledged or written about the unilateral covert/overt DNR code status in hospitals that has become epidemic as Medicare (CMS) and private insurance refuse reimbursement to hospitals/physicians for mistakes, errors, non beneficial over treatment, exceeding DRG costs, etc...

    Really a MESS and corporate journalism doesn't produce the whole truth to the public if it in any way impacts the $$$$ for the special interests.

    The Congress knows this is going on and does nothing. Both political parties are complicit and won't tell on each other.

    You are so right! Just follow the money! .

  2. Thanks for your comment and followup. Dr. Jha is shining a light into a dark corner of American health care but for reasons we already know (negative PR, liability and financial) it's a subject not likely to be trending any time soon. You are on an important mission and I encourage you to keep up the good work. In my case, I'm just an old guy in retirement stirring the pot, but I do what I can to keep the heat up. My post-retirement work in the senior care environment has taught me a lot about that segment of health care. I'm a non-medical person by definition, but so are the families and patients involved with medical errors and the built-in flaws in the system.

    One of my hobby horses is the incestuous connection between many officially "not for profit" segments of health care -- typically the large local hospital campus -- surrounded by a host of for-profit ancillary providers. The non-profit entity becomes a money-laundering engine for the ancillary services and a complicated matrix of local, state and national revenue streams coupled with byzantine tax codes and accounting tricks become the main contributing factors in what has become the world's most expensive health care system.

    (As an afterthought, I am curious if your pseudonym at THCB has any special significance?)

    1. No! John! The pseudonym was a "typo." --- I blog under my maiden name of Carol Cross and my married name of Carol Eblen, .and only rarely use a pseudonym.

      I am ancient ---even before the IBM technology ---I am of Royal Typewriter vintage --- and have a heavy touch on the keyboard that is attached to my lap- top computer and often goof when I am typing. I am the widow of a regular army officer who served in combat zones in three wars and who was the victim of cruel over treatment and a unilateral DNR in our local hospital that bears a Christian name.

      The recent nation-wide trend of Hospitals buying up the practices of physicians, who then become employees of the hospitals, must really be of concern to you. It appears that it will be Big Insurance and Big Hospital who will be negotiating the reimbursement protocols for Medicare/Medicaid patients. Original Medicare, the junior partner, will just stand by as Medicare/Medicaid patients are managed as "product" for the "profit" of Big Insurance and Big Hospital. Boutique services in hospitals will increase and increase profits and the Medicare Purse will still be wide open to ensure the viability and profits for Big Insuance and Big Hospital, Big Pharmacy, and Big Medical Equipment" Suppliers. The individual physicians are forced to run for cover to survive in this new "Accountable Care Organization" world. .

      At least this will stop the long-standing rampant and often cruel over treatment of Medicare patients driven by the quest for profits of the for-profit specialist clinics and practices. The lawsuits filed by HHS and Department of Justice in 2013 that charge over treatment for profit as a felony violation of the federal false claims law will also put the fear of God into many greedy physicians who sucked Medicare dry as long as they could.

      Under Obama Care, the autonomy of the individual physician and the individual Medicare patient will be removed as IPAB becomes law and elderly/disabled Medicare patients will have to "qualify" for expensive life-saving and life-extending treatments.in the OUTPATIENT and the INPATIENT setting in terms of whether or not these treatments will be statistically beneficial to them. The science of "prognostics" is greatly advanced and "Big Data" will at least, be neutral and fairer and will save money and Medicare.

      Of course, we need "single pay" as Public Citizen advertises to eliminate BIG Insurance and their profits in order to have effective Medicare coverage for all Americans. However, it is the banks and the insurance companies who have all of the money and, unfortunately, our Congress is beholden to the "money" and not to the "public good."

      The physicians, of course, asked for this because they were unwilling to cooperate with the public policy goals of the 1991 PSDA and SEEK informed consent for Curative Care as opposed to palliative care, i.e. doing nothing and transitioning to Hospice in the last six months of life.

      If Congress or The Executive had mandated in 1991 or would now mandate that treating physicians SEEK informed consent from all Medicare patients for either Curative Care or Palliative Care/transition to Hospice from all of their elderly patients with serious diseases and cancers, we would perhaps have avoided the disgrace and mess of the unilateral covert/overt(default) DNR code status that is hastening the death of elderly Medicare patients without their knowledge and consent. .

  3. Thanks for the response and clarification. You and I are almost the same vintage so I understand typos well. The invention of electric keyboards and spellchecker have been my ticket to blogging and Web activity.

    Regarding ACA and the sea changes it is bringing about I am more sanguine than you. Unfortunately, I also don't think either of us will be around when the dust finally settles (if it ever does) but here are some things I thought about as I read your comment.

    >> The consolidation of hospitals and health care systems morphing into the ACO universe is, as you note, an identifiable trend. I don't think, though, that as many individual practices are being gobbled up as you might think. The rise of the "hospitalist" is a mixture of specialists and generalists with years of practice, but the number is also growing as newly minted younger doctors as well as those coming from other countries are choosing the hospital route rather than the more expensive (and risky) private practice route. I had a couple of assignment at one of the local metro hospitals staffed by hospitalists (my post-retirement job is working as a non-medical caregiver through an agency) and was impressed with the youth and flexibility of the doctors on duty -- around the clock, incidentally. But I had the impression that they did have a more perfunctory manner than the few family practice doctors that came around for specific patients.

    >> The ACO model is nothing really new. It is in some ways the old HMO in a new form, this time with the handful of systems that have for years been able to deliver good outcomes at realistic costs. Names like Mayo, Geisinger, Kaiser, Cleveland and a few others come to mind. The articles of Atul Gawande and Maggie Mahar's book (and documentary) Money Driven Medicine have been my source material, and I am more optimistic about the ACO experiment than you seem to be.

    >> What I see happening with Medicare is that Medicare Advantage (a misleading name if there ever was one) is kidnapping eligible seniors from original Medicare so fast that upwards of a third of all beneficiaries are now in the hands of those plans, and most of them have no idea that they are in the hands of private insurance -- NOT Medicare.

  4. [My comment was too long, so this is the rest...]

    I don't know what the formula for MA reimbursement is from CMS but it is at least everybody's Part B charge plus some other amount to enable those private carriers to pay for hospital care (Part A) which they otherwise would not be able to absorb otherwise. I have read that the amount being awarded to MA is being reduced but I have no idea how much it is or what formula is applied. But my feeling is that CMS together with IPAB are still holding back until ACA is well out of the woods, but there will be a time in the future when all hose ACA's will be competing for a shrinking revenue stream. And the metric for who gets the most will be "outcomes" however that is determined. I feel certain that preventable errors will definitely be a part of that formula. CMS began penalizing hospitals several years ago (prior to ACA) for having too many readmissions, the thinking being that dismissing patients too soon or with inadequate aftercare was a problem that needed correcting.

    >> My work in the senior care world has made me an evangelist for advance directives, which properly and widely used would significantly reduce the number of what you refer to as default DNR status. Forms vary from state to state, but they become more specific every year. I 'm of the opinion that everyone should have an advance directive, together with no less than three appointed agents for medical decision making who know who they are and have agreed to the responsibility, the documents should be updated no less than every three to five years and anyone who does not have them as part of their medical records should pay a surcharge for every medical service and prescription until they have them.

    I have seen far too many instances of families and individuals in denial of the need for palliative care and too many doctors reluctant to broach the subject. There is nothing about palliative cae (a more agreeable term than "hospice") which precludes curative care. In fact, I have seen hospice cases that have been de-certified and taken off the protocol when the person got well enough no longer to merit the six-months-to-mortality prognosis.

    If you key in "HCR" to the search field in the sidebar above you will get a list of the health care reform posts I have put together thus far.
    Here are a couple of links you may find useful:



    1. You are so right, John, when you indicate that elderly/disabled Medicare patients don't understand that their Advantage Policies are really "private contracts" that deliver their original Medicare benefits because of the Insurance Companies' rights given to them by the Congress to contract with the government to deliver Medicare benefits to these individual patients --for profit, of course.

      The American public who pay SS taxes and Medicare taxes all of their working lives don't understand that they are "product" to be managed for the profits of Big Insurance and Big Medicine.who have access to the people's Medicare Purse.

      Do you know that Sy Mukherjee of Think Progress, a health reporter, disclosed in an Article on April 19, 2013, entitled "After Making 2 Billion in Profits, Insurer Complains It Doesn't Get Enough Government Money." He reports that United Health Group, " which is the largest heath insurer in America and the biggest manager of private Medicare Advantage plans ------"that despite a 14 percent decline in earnings, it had still made a profit of 2.1 billion, and that was just in the last fiscal quarter."

      Aren't we, the American people, stupid or something that we don't understand that the benefits of original Medicare had to be reduced in order to guarantee these kind of profits to the private sector?

      What about the big ads in the newspapers from Advantage Insurers who then can advertise that "we will give you more than original Medicare" ,because, of course, they have influenced original Medicare Administrative Law to deliver less!

      Follow the money!.

  5. Carol Cross, I have no way to contact you other than this comments thread, so here is nother link (non sequitur to this post) that you may find interesting,


    I had completely forgotten about it but somebody left a comment there tonight which triggered a notice to me since I had a comment in the same thread.