Wednesday, December 19, 2007

Medicare Cuts On Hold (for now!)

The U.S. Senate this evening passed legislation by unanimous consent that
replaces a 10.1% physician payment cut with a 0.5% increase for six
months,extends expiring rural physician payment provisions and the Medicare
physician quality reporting initiative and extends the SCHIP program
through March 31, 2009.
Sound like good news but its NOT.
Here is the rub: The President and the Republican Senators are NOT
willing to address MEANINGFUL Medicare reform
They rejected options to reduce or eliminate Medicare Advantage
subsidies to offset the increase physician reimbursement.
Therefore the current TEMPORARY compromise can only be characterized as
anemic. The 0.5% increase is essentially a DECREASE because it does not
even come close to cover for the increase in practice expenses and the
annual inflation rate.Furthermore, in six month we have to deal again
with the issue and the outcome maybe the same or even worse.
I suggest asking our Senators the question why they are willing to use
Medicare funds for corporate subsidies (i.e. Medicare Advantage plans)
and not for the designated Medicare beneficiaries and their doctors?
Happy Holidays.

Saturday, December 08, 2007

Rating Doctors

Dear Friends and Colleagues:

Attached you find an interesting editorial from todays New York Times
The editorial highlights a disputed issue: how shall doctors performance be assessed and ranked.
An investigation by New York's attorney general has concluded that existing doctor-rating systems are based solely on the cost of care NOT on its quality.
Under a negotiated agreements with several major insurers, including Aetna, Cigna, United Healthcare and Empire Blue Cross/Blue Shield, a more user-friendly rating system should be developed that includes quality as measured by national standards and guidelines.

"Insurance companies have to make public what factors are included in their ratings and reveal how much weight they gave to cost in any composite score. An independent monitoring organization, approved by the attorney general, must oversee the process.
From a consumer’s perspective, it would be much better if the insurance companies all turned over their data to an independent organization to combine the results. It would be even better if evaluations also included such information as whether a doctor has been disciplined by state medical boards or has paid a large number of malpractice settlements."

This agreement may serve as a model for other states and organized medicine should proactively participate and contribute to the development of a rating system that empowers healthcare consumers to make informed decisions regarding their doctors choice.
Looking forward to your comments and critique.

Happy Holidays,



December 8, 2007
Rating Your Doctor, Fairly

The drive to give consumers more information about the quality of their doctors has gotten an important shove forward by New York’s attorney general, Andrew Cuomo. That could be good for patients in dozens of states across the country that are served by some of the major health insurance companies.

An investigation by Mr. Cuomo’s office found that various doctor-rating systems currently used or planned by insurers are based primarily on the cost of care, not its quality. Doctors may be awarded a grade or stars, much like a restaurant or movie review, if they routinely treat sick patients for less than their competitors do. With that information, employers are able to steer their workers to lower-cost doctors by reducing deductibles or co-payments for those who patronize them.

Unfortunately, insurers seldom make clear just how they come up with their ratings, and there is no guarantee that the cheapest doctors are necessarily the best choice. Now the attorney general’s office has negotiated agreements with several major insurers, including Aetna, Cigna, United Healthcare and Empire Blue Cross/Blue Shield, that should make the ratings systems more useful to consumers and fairer to doctors.

Under the agreements, if insurers rate doctors, they cannot rely solely on cost but must also include quality as measured by national standards and guidelines. They have to make public what factors are included in their ratings and reveal how much weight they gave to cost in any composite score. An independent monitoring organization, approved by the attorney general, must oversee the process.

This approach has been endorsed by consumer advocacy groups, such as Consumers Union and the National Partnership for Women and Families, as well as the American Medical Association and the Medical Society of the State of New York.

Even with the improvements, ratings systems run by insurance companies may fail to provide consumers with the best possible information because they are based solely on the experience of that company’s subscribers. That may provide only limited insight into a doctor’s performance. Some doctors who participate in more than one insurance plan have received different ratings from different plans.

From a consumer’s perspective, it would be much better if the insurance companies all turned over their data to an independent organization to combine the results. It would be even better if evaluations also included such information as whether a doctor has been disciplined by state medical boards or has paid a large number of malpractice settlements.

Ideally, there should be a single Web site where consumers can get all the information they need to judge the quality of a doctor’s care and its cost-effectiveness.

Sunday, November 25, 2007

AMA Presidents Speech November 2007

hall We Dance?

61st Interim Meeting
American Medical Association House of Delegates
Hawaii Convention Center
Honolulu, Hawaii
Saturday, November 10, 2007

Ronald M. Davis, MD
American Medical Association

Aloha, and mahalo nui loa, thank you very much. I hope you’re all enjoying our location. I know I am. The beauty of these islands is simply unsurpassed. And the people are so warm and friendly. I think I feel healthier just breathing in the air here, or smelling the flowers. I wish we could write prescriptions for that.

Another reason why I have a deep affection for Hawaii is because my very first AMA meeting was here, back in December 1979. Also, my father was stationed here during World War II, from 1942 to 1945.
Hawaii is still a crucial strategic location in the world. Did you know that this is the only place with all five U.S. armed services on one small island? Soldiers at Schofield Barracks, sailors at Pearl Harbor, airmen at Hickam Air Force Base, Marines at Kaneohe Bay, and the Coast Guard patrolling the waters as well?
Wherever they are, and whenever they served, I want to acknowledge all those who put themselves in harm's way to protect our freedom, and this country, and a way of life that embraces peace and friendship among all people. And that includes the selfless physicians here with us from the Defense Department and the Veterans Administration.

My brother returned from Iraq two months ago, and like others returning from the front lines, he’s going through a challenging transition. As physicians, we’ll be dealing for years to come with highly visible physical injuries suffered by service members returning from Iraq and Afghanistan, and also post-traumatic stress disorders and other emotional wounds that afflict our returning troops. Let’s be ready for them. They deserve it.

Getting back to my father, who passed away in 1997 … he was in the 113th Radio Intelligence Corps, just a few miles from here. And in his free time, believe it or not, he taught ballroom dancing to his fellow GI’s.
Watching a film clip a few weeks ago of him teaching dancing in Hawaii got me thinking about the dancing we do at the AMA, and the partners with whom we dance. We engage in a very special form of dancing. It’s not the Hula. It’s not Tahitian dancing. It’s not nearly as pretty, or graceful, or enjoyable to watch. Sometimes it’s more like a limbo at a luau.
Thirty years ago, a Rhodes Scholar named Eric Redman wrote about “The Dance of Legislation.”

That was actually the title of his book, about the drafting and passage of legislation to establish the National Health Service Corps. The NHSC, through scholarship and loan repayment programs, has recruited more than 27,000 health professionals to deliver primary care in underserved communities.
Many of you have no doubt read “The Dance of Legislation.” Redman published an updated version of it a few years ago.
This dance is one of both triumph and frustration, and includes some strange moves and countermoves. But most of all, it involves one hell of a lot of work. And it’s a very slow dance. Legislative change usually occurs incrementally rather than revolutionarily.

Take a look at the State Children’s Heath Insurance Program, or SCHIP. The original legislation passes 10 years ago, but with a 10-year sunset. This year, Congress passes a bill to reauthorize the program, but it’s vetoed by President Bush, and the House fails to override his veto.
So now we have a new bill, stewing in the most partisan environment I’ve ever seen. Yet it’s over something that we, the members of the House of Delegates of the AMA, had no problem with last summer. We were virtually all on board when we adopted our position. It’s clearly in the best interests of everyone.

I’ve been disappointed in hearing a lot of uninformed criticisms of the SCHIP legislation. Let’s separate fact from fiction.
*Myth No. 1 is that the SCHIP compromise is a major step toward “government-run,” “socialized” health care. In fact, SCHIP is a public-private partnership, with 77 percent of kids in the program getting their coverage through private health plans. Let me ask you this: If the SCHIP legislation is socialized medicine, why is Senator Orrin Hatch supporting it?
* Myth No. 2 is that the SCHIP compromise vastly expands program eligibility. In fact, there is no provision in the bill to expand income eligibility for children, and the compromise will limit program eligibility more than current law.
* Myth No. 3 is that the SCHIP compromise bill will cover illegal immigrants. In fact, the SCHIP bill does not change current law prohibiting coverage for illegal immigrants. Health coverage is only available for U.S. citizens and legal immigrants who have been in the United States for at least five years.
*Myth No. 4 is that the SCHIP legislation will cover adults. In fact, the bill phases out non-pregnant adults from the program.
I don’t know about you, but I can no longer stomach rollercoaster rides. So let’s get SCHIP off Washington’s rollercoaster, so children from low-income families will have secure and reliable access to health care.

* * *

The first version of the SCHIP legislation in the House included Medicare physician payment reform. Unfortunately, the Medicare provisions were not included in legislation passed by the Senate, and did not make it into subsequent compromise bills. So now it’s likely we’ll be dancing with that one all the way to December, down to the wire, once again.
Recent Congresses seem to want to wait until a crisis occurs, or until the last possible moment before it would almost assuredly occur, before taking definitive action. And this pathetic yearly tourniquet approach to the SGR cuts is a perfect example of management by crisis.

We in medicine know a lot about crises through our work in disaster preparedness. We plan for, and respond to, terrorism, tsunamis, hurricanes, and many other mass-casualty events.
The latest are the fires in southern California, which were on everyone’s minds when I was at the California Medical Association’s annual meeting in Los Angeles a few weeks ago. Our hearts go out to our colleagues and their patients who have been affected by the fires, and we’ve offered assistance through our AMA Center for Public Health Preparedness and Disaster Response.

Speaking of fires, I share a birthday with the late Red Adair. You’ll remember that he was the world-famous oil field fire fighter, who successfully battled more than 2,000 fires in oil and natural gas wells.
Adair’s well control company, which continues its work today, divides its services into three categories: prevention, response, and restoration.
Let’s apply those approaches to the looming SGR disaster.
Let’s begin with prevention. Prevention involves safety inspections. We’ve already done safety inspections, and we already see weak points in our system of care for seniors. According to the Medicare Payment Advisory Commission, or MedPAC, about a quarter of seniors seeking a new primary care physician are already having difficulty in finding one to take care to them.
Prevention also includes conducting a risk assessment. We’ve done that too. And we see huge risks if Medicare cuts go through as projected.

According to our MemberConnect survey, if the 10 percent cut goes through in January, almost a third of physicians will reduce the number of new Medicare patients they accept, and almost 30 percent will stop accepting new Medicare patients altogether. Even more disturbing is that almost a third of physicians will reduce the number of established Medicare patients in their practice, if the 2008 cut goes through. And another eight percent will stop seeing any Medicare patients in their practice.
And ladies and gentlemen, 10 days after Halloween, this is not the type of scare I want. Before the U.S. Capitol becomes a haunted house, Congress needs to listen to MedPAC, its own advisory committee, and scrap the SGR. Listen to MedPAC, and tie physician payment to the Medicare Economic Index, the government’s own index for the costs of running a physician practice.

A few years ago, the Congressional Budget Office estimated that a permanent SGR fix would cost $90 billion. Now the CBO says that deep-sixing the SGR in favor of the MEI will cost us $262 billion. As Congress continues to kick the can down the road, effective remedies become more and more costly.
But Congress seems to ignore the benefits of preventing an SGR disaster. It seems willing to rely on disaster response and restoration.
Well, we need to tell Congress that if this imminent melt-down occurs, response and restoration will be slow in repairing the damage, will be expensive, and may ultimately fail. If physicians across the country are forced out of the Medicare program, and lose trust in the program, they may become wholly resistant to any last-ditch effort by the federal government to respond to the crisis, and to restore the program to “business as usual.”
Unless Congress has a “Medicare Red Adair” to put out brush fires in every one of the 3,066 counties in the United States, a lot of seniors are going to get burned.

I’m pleased that my own senator, Debbie Stabenow, is showing leadership on this issue. You’ll recall that she spoke at our National Advocacy Conference in February, wearing her AMA purple.
Two days ago, she spoke passionately about the SGR problem on the floor of the Senate. She called on Congress to “pass legislation this year that provides physicians with two years of positive Medicare payment updates … in a way that does not add to the cost of eliminating the SGR.”

Senator Stabenow endorsed a repeal of the SGR and the establishment of “a Medicare physician payment system that will provide stable, positive payment updates to preserve Medicare beneficiaries’ access to high-quality care for the long-term.”
She said, “It defies common sense to think that payment rates that are lower today than they were six years ago will be enough to maintain the access to care that our seniors need.”
Many physicians have told me that they doubt Congress will solve this problem unless a melt-down actually occurs. Thus, some have suggested that we acquiesce to the 10 percent cut for 2008 -- just let it go through, they say -- so Congress will see that our concerns and predictions are not a poker-style bluff.
A few have even suggested to me a physician boycott of the Medicare program. Well, boycotts raise serious legal and ethical issues. But I know where those suggestions come from. Many or most physicians are mad as hell and are in no mood to take it any longer. Lest you have any doubt, there’s as much anger on this stage as there is on the floor of this House and in physician offices across this country.

So let me highlight several courses of action that are available to physicians.

First, we can do what TV news anchor Howard Beale suggested in that 1976 movie “Network” -- get up out of your chairs, go to the window, open it, and stick your head out, and yell, “I’m as mad as hell, and I’m not going to take this anymore!”
Unfortunately we don’t have any windows in this room, so you’ll have to save your best Halloween scream for later.
For our second course of action, we must continue, and intensify, our advocacy efforts, talking to our Congressmen, and our patients, and the media, about the looming melt-down.
And third, we must remind physicians, in the face of these huge cuts, that they may wish to review their Medicare participation options.

As explained in the fact sheet that’s available on the tables at the back of this room, physicians who wish to change their current Medicare participation or non-participation status for next year, must do so between November 15th and December 31st.
They have three options:
One, they may sign a PAR agreement and accept Medicare’s allowed charge as payment in full for all of their Medicare patients.
Or, two, they may elect to be a non-PAR physician, which permits them to make assignment decisions on a case-by-case basis and to bill patients 9.25 percent above the PAR-approved payment rates.
Or, three, they may become private contracting physicians, agreeing to bill patients directly and to forego any payments from Medicare to their patients or themselves.

* * *

For folks who are fatigued by these endless machinations in policy, Eric Redman explains our current reality: “… the dance of legislation never really ends, and … a law may [even] intensify rather than terminate the perpetual struggle over policy.”
At the AMA, it’s our job to continue this dance until the music stops. Fortunately, we’ve had some nice recent victories in the smaller dance contests, such as getting the Department of Education to extend eligibility for deferring repayment of student loans, so that medical student and resident debt burdens don’t get worse than they already are. Yet that, too, is a short-term fix. We still need a long-term legislative solution to that problem.

Have you seen either of the current reality television shows, “So You Think You Can Dance” or “Dancing with the Stars”? To win these competitions, you need to be more than just the best dancer. There’s song selection. There’s how well you’re trained by a randomly chosen choreographer. And there’s your popularity with the viewers, who vote off the contestants. Thus, winning the dance contest involves talent, training, and a tendency to be liked.

Well, physicians have a lot of talent. Are we’re certainly well trained. And I’d like to think we’re popular among our patients. So we must show Congress that we’re in this for the long haul. We aim to win our dance marathon, and not get voted off.
Now, to accomplish this, I believe the key is to always keep patients as our main focus, and to ensure that their access to care is the basic harmonic running through everything we do.

Which is why we’ve been pushing so hard to be the Voice for the Uninsured.
I’m very proud of our campaign. We’ve joined forces with some of the most influential groups in America. And we’ve joined forces with our patients. What we’re doing, we’ve done before, but never with as much strategic and tactical focus.
So this is probably a good time to show you one of our 30-second spots. These will go national in January. And those of you in Iowa, South Carolina, and New Hampshire have most likely already seen it.

I’d really like to thank the Medical Societies of those states for their superb partnership with us on this campaign. When I was out on the road for four days last week in Iowa, I personally heard several sad stories about the devastating impact that lack of insurance can have on people who experience serious illness or injury.

I heard something else, too. Leaders of the Iowa Medical Society and I met with Gov. Chet Culver for an hour, to talk about covering the uninsured, Medicare physician payment reform, and a few other important issues. Moments after we walked into his office, the Governor mentioned that he had seen our AMA billboards about covering the uninsured all over the place.
I’m glad the Governor saw our signs. Because for two days before our meeting with him, I was out driving our mobile billboard around the state capitol in Des Moines.

So we need to do whatever it takes to get the message out in this campaign, to important decision-makers but also to our patients and to voters, to convince them to consider this issue when they decide which presidential candidate to support.
Politicians everywhere, but especially in Congress, need to be told by us that we’re going to do our damnedest to win these contests; that we’re going to lead the charge to provide the best health care for all Americans, but especially the most vulnerable: our children, the elderly, and the uninsured.

* * *

As we work toward covering all Americans, we need to remind our patients, and all citizens, that they play a critically important role in determining how healthy they are and how long they will live. More than one-third of all deaths in this country are due to four unhealthy lifestyles: tobacco use, alcohol abuse, poor diet, and physical inactivity.
That’s why I’m very pleased that earlier this week, our AMA and the American College of Sports Medicine launched a new initiative to assist physicians in helping their patients get more physical activity. The theme of the campaign is “Exercise is Medicine,” and we encourage you to prescribe exercise for all of your patients. Please check out the campaign website at
Incidentally, one way to get exercise is through dancing. In fact, the state of West Virginia is combating the epidemic of youth obesity by placing the videogame “Dance Dance Revolution” in all 765 public schools in the Mountain State.

* * *

I sometimes wish I had inherited my father’s dancing skills. I did not.
But when we do the “Dance of Legislation,” whether for SCHIP or Medicare or another important issue, it really doesn’t matter if we occasionally step on our partner’s toes. It might even prove a point. What matters is, when the music stops, who wins the dance?
I hope you get the chance to catch the evening show at the Hilton Hawaiian Village or out at the Polynesian Cultural Center. You’ll be amazed at all the dancing. And the climax is a dancer who juggles flaming torches. It’s like combining Red Adair with Fred Astaire.
Sometimes, we have to juggle a little fire in our dance. That just comes with the territory. And when we have partners, we’re not always going to be in sync. And we may have to switch partners when we find one who has better moves. And we may need to stay on the dance floor longer than we thought we should.
So bring your Dr. Scholl’s.
Because we need to fight for physicians everywhere.
We need to prevail for patients everywhere.
And we need to win, not to get a trophy, but because it’s the right thing to do.
There is no one in this country who has more expertise in health care than we do. So in this dance, we need to take the lead.


Saturday, November 24, 2007

AMA Efforts Not Appreciated?

"Your Senators are telling us that they are not hearing from physicians about the looming Medicare physician payment cuts.
So let’s make sure they get the message: now is the time to include positive Medicare physician payment updates in the Medicare bill that is being put together!"
AMA Grassroots Legislative Alert

Dear Friends and Colleagues;
In the last few days I have read several e-mails blaming our AMA for the looming Medicare cuts and and in one of those e-mails the author even suggest that
" the AMA likes to have this issue every year as it allows them to say they did something."
Lets examine the facts before we engage in self-destructive behaviors that will prevent us from achieving our goals.
A recent AMA News article reviews the current status of the Medicare physicians reimbursement battle. In this article American Medical Association Board of Trustees Chair Edward L. Langston, MD states that " Congress must step in to replace the cut with payment increases that keep up with medical practice costs. Next year's 10.1% physician payment cut is bad news for America's seniors as 60% of physicians say the cut will force them to limit the number of new Medicare patients they can treat."Dr. Langston suggested using $54 billion in what doctors view as excess payments to private Medicare health plans to offset the cut. These Medicare Advantage plans received 112% of the amount that traditional Medicare paid for each senior's care in 2006. The AMA News also published his opinion piece regarding the Medicare Advantage Plans. Congress needs to level the playing field between traditional and private Medicare plans by eliminating excess payments to Medicare Advantage plans in the amount of $54 billion! This money would be MORE than enough to offset eliminating the the two-year cut in physicians reimbursement.Cuts to Medicare Advantage health plans' payment would also have lowered Medicare's regional benchmark payments to insurance companies, ended a stabilization fund used to share risks with insurance companies and eliminated indirect medical education payments to teaching hospitals.
But what are the political REALITIES we are faced with:

* In the House, an Energy and Commerce Committee staff member said leaders are sticking with the Medicare physician pay provisions adopted as part of its State Children's Health Insurance Program reauthorization bill in early August. The measure would have increased reimbursement 0.5% in 2008 and 2009 each.But the provisions were removed in the House-Senate compromise SCHIP bill in an attempt to maintain a veto-proof Senate majority.
* Sen. Max Baucus (D, Mont.), chair of the Senate Finance Committee, would prefer to adopt a two-year payment fix by shifting some Medicare Advantage payments to fund physician reimbursement.But many Senate Republicans OPPOSE cutting private health plan payments therefore making it almost impossible to free additional funds to prevent the looming Medicare reimbursement cuts.
* Today, there are more than eight million seniors enrolled in the Medicare Advantage program that provides more services at a lower cost than traditional Medicare, but are often more limited in the health care providers available.An insurance industry sponsored survey revealed that more than 8 out of 10 survey respondents (84 percent) said they are happy with their healthcare coverage and 75 percent would recommend Medicare Advantage (MA) plans to their friends or family members.The survey also shows that beneficiaries believe sustained funding for the MA program is crucial, and nearly all survey respondents said it is important for Congress to work to maintain adequate funding for the program. Many worry that Medicare cuts could mean they could not afford to pay the bill for an unexpected illness (48 percent) or afford prescription drugs (45 percent). Our OPPOSITION to the MA program may backfire on us and we need to carefully navigate between reducing funding for the program and the popular support among seniors for the MA program. Any MA cuts will results in higher premiums for seniors who are already hit with a >20% premium increase for the Medicare part D program.

What can physicians do? TO SUPPORT OUR AMA in its effort to prevent the looming cuts by enrolling in the Grassroots network
We need to flood the offices of senators to impress upon them that the Medicare cuts will limit access to health care services for seniors. They need to understand that those seniors will vote in the upcoming elections and their vote may be influenced by the Senates inactivity and intransigence.


Our AMA is also vigorously lobbying for federal prompt-payment laws to close the loopholes of a system that resembles a swiss cheese.
See . Insurers have found loopholes to get around the state endorsed prompt-payment deadlines and are using federal law to slip out of state laws.
What is needed is a tough federal law penalizing insurance companies that delay payment.
One reason insurers can ignore prompt-payment laws is that they dominate the market in most communities, says Cecil B. Wilson, MD, immediate past chair of the AMA Board of Trustees. It gives them tremendous negotiating power and prevents physicians from addressing unfair payment practices. The situation, called an oligopsony, occurs when only a few buyers operate in a market with many sellers.
Another problem is that many health plans are not subject to state prompt-pay laws. The federal Employee Retirement Income Security Act exempts companies that self-insure from state insurance laws. About 55% of workers have such coverage, according to the 2007 Kaiser Family Foundation Employee Health Benefits Survey. The percentage rises with firm size: 77% of workers at businesses employing more than 200 people are in self-insured plans.
In addition, many health plans are not subject to state prompt-pay laws. The federal Employee Retirement Income Security Act exempts companies that self-insure from state insurance laws. About 55% of workers have such coverage, according to the 2007 Kaiser Family Foundation Employee Health Benefits Survey. The percentage rises with firm size: 77% of workers at businesses employing more than 200 people are in self-insured plans.

A federal law would fill the loopholes. Or very own Cecil Wilson,MD outlined the elements of a proposal when testifying to the House Small Business Committee's health panel in August:

* A strong federal standard. The AMA's policy is to support legislation that requires payment within 30 days for clean paper claims and 14 days for clean electronic claims.
* Stiffer fines than those in state laws to deter bad behavior. Interest should be assessed on the amount of payment outstanding and increase with the claim's delinquency. Physicians' attorney's fees and costs also should be provided when they win a claims dispute with an insurer.
* State law protections. Stronger state laws should be protected, and state requirements not covered by a federal standard should not be preempted.
* Application of state laws. Any federal law should clarify that state prompt-payment laws apply to all nongovernment health plans, denying insurers the argument that ERISA preempts state law.
* Time limits for notification. Federal law should set a statutorily defined time limit for insurers to notify physicians that additional information is needed to process a claim. The notice should specify all problems with the claim and give an opportunity to provide the information needed. Insurers also should be required to pay any portion of a claim that is complete and uncontested.

In these critical times it would be politically suicidal to divide organized medicine because some have "ideological differences" with AMA policies.
Political rigidity will hurt us. We need experienced leaders that can skillfully execute political decisions, are able and willing to reach reasonable compromises and achieve incremental change.
I hope that I am not alone stating that opinion and I call upon all of you to join our AMA in this struggle.


FMA AMA Delegate

Thursday, November 22, 2007

Working Harder or WorkingSmarter?

"The healthcare system has put physicians in a bad place... the options they have for escaping it aren't good; in our fee-for-service system,
they mainly consist of performing more services, even though they may not be needed.
We need to move away from fee for service and reward doctors for more efficient, higher-quality care."
Paul Ginsburg, Center for Studying Health System Change

The latest edition of "Medical Economics" contains an exclusive survey about physicians compensation and work hours
The key findings of the survey are not surprising:

* Most primary care physicians work harder to break even.
* Physician compensation in 2006 once again reflects economic forces that are eroding the cottage-industry model of medicine. If you want to earn more, join a group practice.
* While family physicians, internists, pediatricians, ob/gyns, and general practitioners as a whole earned a median of $165,000 last year, the soloists among them trailed the pack at $152,000, with doctors in two-partner practices second from last. Their peers in groups of 50 or more posted the highest earnings—$175,000.
* The percentage of internists, FPs, and pediatricians in solo practices and two-doctor groups slipped just a notch—from 37.5 percent in 1996-1997 to 35.6 percent in 2004-2005, according to the nonpartisan Center for Studying Health System Change (HSC). Those in groups of three to five also fell as a percentage, going from 10.3 percent to 7.3 percent during the same period.
* Medical and surgical specialists stand to earn far more by consolidating, and as a result, they're deserting solo and two-doctor practices at five to six times the rate in primary care.
* Suburban and rural doctors took home more than their urban and inner-city counterparts. The white coats of suburbia benefit from having the highest percentage of privately insured patients.

What can we learn from these facts:

1. The medical economic climate will remain cloudy in the foreseeable future and doctors need to adapt to the changing market place.
2. Declining reimbursement will force many doctors to work harder to keep their practices open, but working harder will cost MORE money (more staff hours, more overhead, more office utilization etc.)
3. Working SMARTER may include the following:
* Joining a group practice
* Rebalance the payer mix
* Renegotiate contracts and if necessary discontinue existing contractual relationships
* Hire midlevel providers (PA, NP
* Implement cutting -edge technologies (EHR, Electronic Prescribing etc.) to reduce the overhead, increase patient satisfaction, reduce waiting time, maximize billing options
o Comment: Many EHR systems provide quality reporting functions allowing you to demonstrate efficient, high-quality care to potential payers (employer groups, insurance companies). This puts the doctor in the position to negotiate higher reimbursement rates based on demonstrable quality care. I have had a meeting with an executive of a large employer group who offered to pay significantly MORE $$$ per visit if chronic disease management measures can be implemented that will reduce ER visits and hospitalizations. But doctors need to have tools in place to demonstrate that they can track patients adherence and disease management performance criteria. That is an untapped potential income source for doctors who are willing to take the leap into the 21st century medical practice.

The future for medicine is not that bleak if we learn to adapt to a changing market place.


Tuesday, November 20, 2007

AMA Interim Meeting: Disappointing Results?

I have received an e-mail from a valued colleague and friend criticizing several decisions made at the recent AMA Interim meeting in Hawaii. I have offered my attached perspective:

"As an AMA delegate I would like to offer you a different perspective of the issues outlined in your e-mail and the conclusions you have drawn.Please be advised that my comments are NOT necessarily reflecting the consensus opinion of our delegation. I will try to present the issues as accurate as possible but those comments are subject to addendum, correction or deletion by others delegates.

1. Balanced Billing: Two resolution were submitted for discussion (906, 925). Resolution 906 was submitted by our delegation.The Reference Committee made the following recommendation to the HOD,

Mr. Speaker, your Reference Committee recommends that the first resolve of Resolution 925 be amended by insertion and deletion on page 1, line 24 to read as follows:

RESOLVED, That our American Medical Association devote the necessary political and financial resources to introduce national legislation at the appropriate time to bring about implementation of Medicare balance billing by January 2009 and to end the budget neutral restrictions inherent in to the current Medicare physician payment structure that interferes with patient access to care. (Directive to Take Action)


Mr. Speaker, your Reference Committee recommends that the third resolve in Resolution 925 be deleted.


Mr. Speaker, your Reference Committee recommends that the fifth resolve in Resolution 925 be amended by insertion and deletion on page 2, line 1, to read as follows:

RESOLVED, That our AMA Board of Trustees report back to the our AMA House of Delegates, by e-mail or fax on a quarterly basis, electronically by March 15, 2008, and at other times as appropriate on their its progress toward the completion of all of these goals. (Directive to Take Action)


Mr. Speaker, your Reference Committee recommends that Resolution 925 be adopted as amended in lieu of Resolution 906.

Resolution 906 asks (1) that our American Medical Association devote the necessary political and financial resources to protect patient access to care by advocating for national legislation or litigation to unconditionally implement Medicare balance billing by January 2009 and to unconditionally end the budget neutral restrictions of the current Medicare Physician Payment structure; (2) that this national legislation or litigation be designed to pre-empt state laws that prohibit balance billing and prohibit inappropriate inclusion of balance billing bans in insurance-physician contracts; and (3) that our AMA develop model language for physicians to incorporate into any insurance contracts that attempt to restrict a physician’s right to balance bill any insured patient.

Resolution 925 asks (1) that our American Medical Association devote the necessary political and financial resources to introduce national legislation at the appropriate time to bring about implementation of Medicare balance billing by January 2009 and to end the budget neutral restrictions inherent to the current Medicare physician payment structure that interferes with patient access to care; (2) that this national legislation be designed to pre-empt state laws that prohibit balance billing and prohibit inappropriate inclusion of balance billing bans in insurance-physician contracts; (3) that our AMA work on federal legislation that would prohibit any law or regulation from interfering with the patient-doctor relationship including any and all fiduciary relationships that are deliberate and contractual; (4) that our AMA develop model language for physicians to incorporate into any insurance contracts that attempt to restrict a physician’s right to balance bill any insured patient; and (5) that our AMA Board of Trustees report back to the AMA House of Delegates, by e-mail or fax on a quarterly basis, their progress toward the completion of all of these goals.

Your Reference Committee heard strong testimony in support of Resolutions 906 and 925. Your Reference Committee appreciates and agrees with the sponsor of Resolution 925 that it is more prudent to advocate balance billing legislation at an appropriate time in contrast to a time certain, as this may hamper ongoing advocacy efforts with respect to other issues currently pending before Congress. Further, your Reference Committee believes that the third resolve in Resolution 925 is overly broad and confusing. Since Resolution 925 mirrors Resolution 906, your Reference Committee recommends adoption of Resolution 925, as amended, in lieu of Resolution 906. Comment: This does NOT imply that the AMA opposes balanced billing. At this point in time we MUST focus on THE ISSUE pending resolution: STOP THE MEDICARE CUTS. Even though, legislators may recognize the need to stop the cuts, they have done little to prevent them. Our AMA representatives including Dr. Cecil Wilson are working tiredlessly to convince House representatives and Senators to fix the SGR and to stop the Medicare once and forever. If we add balanced billing as an additional issue we may loose the battle. We all agree that balanced billing is our final goal but we need to prioritize our efforts and focus our advocacy on ONE and the MOST IMPORTANT issue now.
2. Opposing a single payor system: This resolution was introduced by the Georgia delegation and adopted as amended or substituted by the Reference Committee.

(1) Resolution 717 - Single Payer


Mr. Speaker, your Reference Committee recommends that the second resolve of Resolution 717 be amended by insertion and deletion on lines 24 -27 to read as follows:

RESOLVED, That our AMA distribute our policy positions in opposition to a single payer system on health system reform to all declared candidates for the presidency of the United States of America and formally request their public support of AMA policy positions on single payer system those positions (Directive to Take Action); and be it further


Mr. Speaker, your Reference Committee recommends that the third resolve of Resolution 717 be amended by insertion and deletion on lines 29 – 32 to read as follows.

RESOLVED, That our AMA immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the United States on health system reform, emphasizing pluralism. (Directive to Take Action)


Mr. Speaker, your Reference Committee recommends that Resolution 717 be adopted as amended.

Resolution 717 asks that our AMA (1) reaffirm AMA policy in support of pluralism, freedom of enterprise and its strong opposition to a single payer system; (2) distribute our policy positions in opposition to a single payer system to all declared candidates for the presidency of the United States of America and formally request their public support of AMA policy positions on single payer system; and (3) immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the US.

There was strong testimony in support of the sentiment expressed in the resolution, particularly the reaffirmation of policies referred to in the first resolve. However, compelling testimony cautioned against a negative campaign. Rather than criticizing the single payer approach, it was strongly suggested that the AMA should focus on clearly articulating AMA policies for health system reform to physicians and the public. There was some support for addressing AMA opposition to a single payer approach within the context of the Voice for the Uninsured Campaign.

Your Reference Committee concurs with testimony to keep the first resolve intact, and with testimony stating that any campaign should focus on a positive message promoting the AMA proposal for health system reform. There was testimony advocating linking the positive media campaign to the Voice for the Uninsured Campaign. Your Reference Committee believes that our AMA should have flexibility in implementing the two campaigns.
Comments: During the house debate the resolution was extracted from the consent calendar. Our delegation submitted additional language to be inserted after the following RESOLVED, That our AMA immediately undertake a media campaign designed to educate the American people about AMA policy in opposition to a single payer system and the negative impact such a system will have on the profession of medicine and the delivery of health care by physicians in the United States on health system reform, emphasizing pluralism, creation of a marketdriven system, and continued opposition to a single payor system.(Directive to Take Action). This language was not adopted. I personally do not support a single payor system as THE only modality to reform the US healthcare system. A comprehensive system reform requires the participation of all participants in the healthcare delivery process - government (county, state, federal), insurance companies, employers etc.- . Our AMA is offering a plan to expand health insurance and we should support a PR campaign emphasizing this POSITIVE` message. We should clearly express what we stand FOR and not only what we are AGAINST. This resolution does not imply that the AMA favors a single payor system but in favor of market based approaches utilizing the brain power of potential innovative thinkers to reform our fragmented healthcare system.
3. Presidential Candidates:

(1) Resolution 603 - Presidential Candidates' Views on Health System Reform


Mr. Speaker, your Reference Committee recommends that Resolution 603 be referred for decision.

Resolution 603 calls upon our American Medical Association (AMA) to host a US presidential candidate forum of all the candidates at the 2008 Annual Meeting.

Your Reference Committee received testimony that was uniformly positive of the resolution’s goal—making the views of presidential candidates on health reform available to physicians. There was some concern, however, about the method proposed by the resolution—using the next House meeting as the specific vehicle. Additional points raised included a potentially low fiscal note associated with this resolution, the questionable value of such a forum to presidential candidates because of a fairly small audience, the practicalities (audience questions, logistics, security concerns, etc.), and alternatives such as using our AMA web site as a way to share information with all member physicians, not just those in the House.

Your Reference Committee supports referral for decision to allow the Board to investigate the legal issues associated with an organization such as our AMA hosting a presidential candidate forum. There also would be major logistical concerns associated with using the House as a venue for a town hall meeting in June 2008. Referral will give the Board opportunity to study the feasibility of organizing the event as proposed, as well as to identify other ways to make physicians more informed voters and supporters of presidential candidates who espouse their preferred health care system. Referral for decision also will allow the Board to start planning the event, if feasible.

Comment: The recommended referral for decision was debated ad our delegation disagreed with that proposal. Nevertheless, that does NOT mean that our AMA will NOT support such a Forum but is seeking for an appropriate venue and suitable modality to maximize the desired effect of a such a forum. I trust the AMA Board to reach a decision on that matter.

I hope that the above information may help you to reach a balanced conclusion of the actions taken. Our AMA is the ONLY and MOST effective national physicians organization to represent our interest. Dissent and disagreement is inevitable but we all strive towards a compromise based on a common denominator: to represent the interests of the majority of all physicians. Your input is crucial and valuable and please continue sending me your e-mails. I am sure that other members of our delegation will provide you with their perspectives.
Please stay involved and do not drop your membership. Otherwise your voice cannot be heard!"

Monday, October 29, 2007

Health Care Professionals Gravitate Towards Democrats

Dear Friends and Colleagues:
Attached an intersting article from todays New York Times highlighting the increasing financial support of Democratic candidates by healthcare professionals and the healthcare industry at large.In all, the Democratic presidential candidates have raised about $6.5 million from the industry, compared with nearly $4.8 million for the Republican candidates. At this point in the 2004 presidential race, President Bush had $4.4 million in donations from the industry, or about $1 million more than the Democratic candidates seeking their party’s nomination to challenge him. And in the first nine months of the 2000 presidential campaign — when there was no incumbent in the White House running for re-election — the Republican presidential candidates took in $3.9 million from the health care industry, compared with $1.7 million raised by the Democrats, campaign finance records show.
That demonstrates that healthcare ( or the lack thereof) is and will be the central issue of the 2008 Presidential campaign.
October 29, 2007
As Democrats Criticize, Health Care Industry Donates

WASHINGTON, Oct.28 — In a reversal from past election cycles, Democratic candidates for president are outpacing Republicans in donations from the health care industry, even as the leading Democrats in the field offer proposals that have caused deep anxiety in some sectors of the industry, according to campaign finance records.

Hospitals, drug makers, doctors and insurers gave candidates in both parties more than $11 million in the first nine months of this year, according to an analysis done for The New York Times by the Center for Responsive Politics, an independent group that tracks campaign finance.

In all, the Democratic presidential candidates have raised about $6.5 million from the industry, compared with nearly $4.8 million for the Republican candidates. Senator Hillary Rodham Clinton of New York has amassed the most of any candidate, despite her calls for broad changes to the health care system that could pose serious financial challenges to private insurers, drug companies and other sectors.

Mrs. Clinton received $2.7 million through the end of September, far more than Mitt Romney, the Republican who raised the most from the health care industry, with $1.6 million. The industry’s drift in contributions toward Democratic candidates mirrors wider trends among donors, but the donations from this sector are particularly notable because of the party’s focus on overhauling the health care system.

People in the health care industry say the giving reflects a growing sense that the Democrats are in a strong position to win the White House next year. It also underscores the industry’s frantic effort to influence the candidates, as Democrats push their proposals to address what many polls show is a top concern among voters.

“Everybody in the industry knows that health care reform is on its way, and you have only two decisions: sit on the sidelines or get on the field,” said Kenneth E. Raske, president of the Greater New York Hospital Association and involved in a national coalition seeking a health-care overhaul.

But the donations could expose the candidates, particularly Mrs. Clinton, to accusations of being captive to special interests, a charge that one of Mrs. Clinton’s rivals, John Edwards, has leveled against her on the campaign trail, telling her during one debate that she would “negotiate and compromise your way to universal health care” with the insurance and drug industries.

The donations have nevertheless come as the health care industry has been in the cross hairs of the Democratic candidates. Mrs. Clinton, for instance, has proposed barring insurance companies from “cherry picking” only healthy customers and also wants to have Medicare negotiate lower drug prices with the pharmaceutical industry. And Senator Barack Obama has called for actually limiting the profits of the insurance industry.

Phillip J. Blando, a political strategist who advises insurance and biotechnology companies, said the health care contributions to Democratic candidates were “smart politics.”

“For many people in the industry,” Mr. Blando said, “these contributions are a defensive measure. Health care is the No. 1 domestic policy issue, and they want access, a seat at the table.”

The major Democratic candidates have issued detailed proposals to expand coverage, rein in health costs and hold down insurance premiums and drug prices. Contributions from the health care industry have grown as the candidates talk more and more about these ideas.

Some people donate because they like a candidate’s platform. Others donate because they are terrified of what the candidate wants to do and hope to mitigate the damage. But the Democratic presidential candidates are collecting more than Republicans from virtually every sector of the industry — pharmaceuticals, insurers and health maintenance organizations, doctors, hospitals and nursing homes, according to the analysis.

The imbalance in contributions from the health care industry is yet another sign of how drastically the political climate has changed for Republicans. At this point in the 2004 presidential race, President Bush had $4.4 million in donations from the industry, or about $1 million more than the Democratic candidates seeking their party’s nomination to challenge him. And in the first nine months of the 2000 presidential campaign — when there was no incumbent in the White House running for re-election — the Republican presidential candidates took in $3.9 million from the health care industry, compared with $1.7 million raised by the Democrats, campaign finance records show.

Among all the candidates in both political parties, Senator Barack Obama of Illinois is the No. 2 recipient of donations from the health care industry, having raised about $2.2 million, according to campaign finance records.

Two Republicans trail him in third and fourth place, Mr. Romney, the former governor of Massachusetts, and Rudolph W. Giuliani, the former mayor of New York City, with $1.4 million.

Senator McCain has taken in nearly $880,000 from the industry this year, while John Edwards, the former Democratic senator from North Carolina, has collected nearly $600,000, the records show.

One of Mr. Obama’s fund-raisers, Kirk Dornbush, president of Iconic Therapeutics, a biotech company in Atlanta, said, “The contributions reflect the simple calculus of the health care industry, making a bet that Democrats will control the White House and both houses of Congress after the next election.”

Drug and device makers have donated about $275,000 to Mrs. Clinton’s campaign, making her the top recipient of money from that sector, followed by Mr. Obama, with $261,400, and Mr. Romney, with nearly $259,000.

The health care industry has not been monolithic in its support of candidates, and is spreading its money around the field.

Campaign finance records show that Jeffrey B. Kindler, the chief executive of Pfizer, has contributed $2,300 — the maximum for an individual — to Mrs. Clinton. His predecessor, Henry A. McKinnell Jr., was a major fund-raiser for President Bush.

Kevin W. Sharer, the chief executive of Amgen, the world’s largest biotechnology company, appears to be hedging his bets. He has made contributions to Mrs. Clinton, Mr. Romney and Senator John McCain, Republican of Arizona.

Health care providers disagree with many of the Democrats’ specific proposals. But many endorse the goal of universal coverage, and they appreciate the fact that the Democrats are giving a high priority to health care as a campaign issue.

“For Democrats, health care is a much more central issue,” said David L. Friedman, an Obama fund-raiser who created a chain of nursing homes in Maine.

Mrs. Clinton regularly assails insurance companies, saying they make money by denying coverage or charging exorbitant premiums to sick people. She says she would eliminate such discrimination by requiring insurers to offer coverage at reasonable rates to “anyone who applies.”

Insurers have grave doubts about such proposals. A major purpose of their campaign contributions to her and her rivals is to make sure their concerns will be heard.

Mary Nell Lehnhard, senior vice president of the Blue Cross and Blue Shield Association, said, “As long as the candidates are willing to talk to us, we can educate them.”

Drug makers detest two ideas favored by Mrs. Clinton, Mr. Edwards and Mr. Obama: allowing imports of lower-cost prescription drugs from Canada and authorizing Medicare to negotiate directly with drug companies to secure lower prices.

But drug makers are themselves divided on some issues. Democrats have often sided with generic drug companies, against the makers of brand-name medications.

Jake Hansen, a vice president of Barr Pharmaceuticals, a generic drug company, said that Senator Clinton had been “amazingly supportive” of legislation to give consumers access to less expensive copies of biotechnology drugs that cost tens of thousands of dollars a year. “Mrs. Clinton’s position on this issue would make a brand-name company a little uncomfortable,” Mr. Hansen said.

Aron Pilhofer contributed reporting from New York.

Thursday, October 18, 2007

SCHIP- The Facts versus the Distortions

“About 92 percent of the kids will be under 200 percent of the poverty level,” Senator Oren Hatch, Republican,Utah

"The White House claims are flatly incorrect," Senator Charles Grassley, Republican, Iowa

Dear Friends and Colleagues:

Today, Congress will try to override President Bush's veto of the SCHIP (State Children's Health Insurance Program).
Unfortunately, it appears that these efforts will falter as the White House and its allies continue to spread "distorted facts" about the program that include slogans such as "federalized healthcare " and " pushing children from high-income families from private insurance plans into a federal program."
Lets examine the facts:

* States establish income limits for the child health program. A recent survey by the Congressional Research Service found that 32 states had set limits at twice the poverty level or less, while 17 states had limits from 220 percent to 300 percent of the poverty level. Only one state, New Jersey, has a higher limit. It offers coverage to children with family incomes up to 350 percent of the poverty level, or $72,275 for a family of four.
* States that cover middle-income children often charge premiums and co-payments on a sliding scale, so the coverage is not free.

In general, after Oct. 1, 2010, a state could not receive any federal money to cover children above 300 percent of the poverty level unless a vast majority of its low-income children — those at or below 200 percent of the poverty level — were already covered. To meet this test, a state would have to show that the proportion of its low-income children with insurance was at least equal to the average for the 10 states with the highest rates of coverage of low-income children.

If a state was allowed to cover children over 300 percent of the poverty level, the federal payment for those children would, in most cases, be reduced. New Jersey and New York would be exempt from the cuts if they met the bill’s other requirements.
* In New Jersey only 3,000 of the 124,000 children in the state program — about 2.4 percent — had family incomes exceeding three times the poverty level.

I urge you to contact your Representative and Senator to urge them to support SCHIP.
Our children's health is precious and should not be subject to ideological motivated political rangling.
October 17, 2007
Children’s Health Bill Dispute Turns to Income Limits

WASHINGTON, Oct. 16 — It is the $83,000 question: Could children with that amount of family income qualify for subsidized health insurance under the bipartisan bill passed by Congress and vetoed by President Bush?

When the House votes Thursday on whether to override the veto, Republicans will insist that the answer is yes. They will express outrage that rich children could get coverage from the government while hundreds of thousands of poor children still go uninsured.

Democrats say it is a total distortion for Mr. Bush and his Republican allies to say that the bill allows coverage with family incomes up to $83,000 a year.

Who is right? Each side appears to overstate its case. The bill does not encourage or prohibit coverage of children with family incomes at that level.

Of the 6.6 million children now covered by the program, most come from families with incomes well below $83,000, and the bill would give states financial incentives to sign up low-income children who are eligible but not enrolled.

In general, children with family incomes below the poverty level ($20,650 for a family of four) are eligible for Medicaid. The State Children’s Health Insurance Program is meant for families with too much income to qualify for Medicaid, but not enough to afford private insurance.

Mr. Bush said Monday that the bill would expand eligibility for the program up to $83,000.

But Senator Orrin G. Hatch, Republican of Utah and an architect of the bill, said Tuesday that the president’s argument was specious. “About 92 percent of the kids will be under 200 percent of the poverty level,” Mr. Hatch said at a news conference with supporters of the bill, including the singer Paul Simon.

Another Republican author of the bill, Senator Charles E. Grassley of Iowa, said the White House claims were “flatly incorrect.”

States establish income limits for the child health program. A recent survey by the Congressional Research Service found that 32 states had set limits at twice the poverty level or less, while 17 states had limits from 220 percent to 300 percent of the poverty level. Only one state, New Jersey, has a higher limit. It offers coverage to children with family incomes up to 350 percent of the poverty level, or $72,275 for a family of four.

In New York, which covers children up to 250 percent of the poverty level, the Legislature this year passed a bill that would have raised the limit to 400 percent of the poverty level, or $82,600 for a family of four. The Bush administration rejected the proposal, saying it would have allowed the substitution of public coverage for private insurance.

States that cover middle-income children often charge premiums and co-payments on a sliding scale, so the coverage is not free.

While the bill passed by Congress would not prohibit states from setting the income limit at $82,600, it would set stringent new standards for such coverage.

In general, after Oct. 1, 2010, a state could not receive any federal money to cover children above 300 percent of the poverty level unless a vast majority of its low-income children — those at or below 200 percent of the poverty level — were already covered. To meet this test, a state would have to show that the proportion of its low-income children with insurance was at least equal to the average for the 10 states with the highest rates of coverage of low-income children.

Moreover, if a state was allowed to cover children over 300 percent of the poverty level, the federal payment for those children would, in most cases, be reduced. New Jersey and New York would be exempt from the cuts if they met the bill’s other requirements.

Citing that provision, the White House said Oct. 6 that the bill included a “grandfather clause” allowing higher payment rates for children above 300 percent of the poverty level in New Jersey and New York.

Jocelyn A. Guyer, a researcher at the Health Policy Institute of Georgetown University, said: “This is a wildly contentious political issue, but it’s largely a theoretical question. More than 99 percent of children in the program are below three times the poverty level, and New York is the only state that has expressed any interest in going to four times the poverty level.”

Suzanne Esterman, a spokeswoman for the New Jersey Department of Human Services, said that 3,000 of the 124,000 children in the state program — about 2.4 percent — had family incomes exceeding three times the poverty level.

Some of the current confusion can be traced back to a bill introduced in March by Senator Hillary Rodham Clinton of New York and Representative John D. Dingell of Michigan, both Democrats. They would have explicitly allowed all states to expand eligibility to families making four times the poverty level. But the bill passed by Congress did not go that far.

Sunday, October 14, 2007

Patient Safety

Dear Friends and Colleagues:
Attached a very enlightening and interesting interview with Lucian Leape, one of the leading figures in the Patient Safety movement.
A MUST read for anyone who wants to understand the progress we have made towards Patient Safety and the ongoing challenges we still face.

Hospital Patient Care Becoming Safer?
A Conversation With Lucian Leape

Insights into how the health care system is changing in response
to the growing emphasis on patient safety.

by Peter I. Buerhaus


According to Lucian Leape,patient safety in hospitals is improving, and it is now possible to get to a level of zero defects.Growing recognition of the need for team training, use of trigger tools, improving the competency of physicians, and full disclosure and compensation to injured patients exemplify positive developments. Yet formidable barriers remain, including separatism in how doctors, nurses, and pharmacists learn; inadequate instruction in communication and team-building skills; poorly developed quality and safety curricula; lack of leadership among CEOs and hospital boards; physician apathy; absence of effective systems for accountability; and failure to believe in the possibility of eliminating medical errors and injuries. [Health Affairs 26, no. 6 (2007): w687-w696 (published online 9 October 2007; 10.1377/hlthaff.26.6.w687)]

Peter Buerhaus: You were among the first to suggest that the way our health care delivery system is designed accounts for almost all of the problems that lead to errors, poor quality, and unsafe care. Are patients treated in hospitals safer today than when you wrote your 1991 landmark article, "The Nature of Adverse Events in Hospitalized Patients," published in the New England Journal of Medicine?1

Lucian Leape: Fortunately, patients hospitalized today really are safer than they were in 1991. The pace of improvement in patient safety has accelerated greatly. When we published the findings from the medical practice study in 1991, we had no idea what to do about the problem. We merely found that there was a big problem, that a lot of people were being injured, and that there were many preventable deaths, but there was not much in the literature or in any of our personal experiences about what could be done about it. A few years later we recognized that cognitive psychology and human-factors engineering could teach health care a lot about analyzing errors and injuries that result from systems failures. We began to do work in that area to see if these approaches would work in health care. They did. But these lessons did not begin to catch on for most people until the Institute of Medicine (IOM) advocated these ideas in 1999 and declared that we could make a significant reduction in accidental injuries by changing systems. The IOM committee and all those who worked in patient safety had no doubt that what we needed to do was change our systems. But because we had no experience in doing that, we were asking people to do something that was untried except in other industries.

Today we have a very large armamentarium of tested and proven safe practices. The Agency for Healthcare Research and Quality [AHRQ] has funded research, and the National Quality Forum [NQF] has done an outstanding job of identifying, validating, and certifying, if you will, safe practices that all health care organizations should implement. And the Institute for Healthcare Improvement [IHI] has been a major driver for systems change for ten years.

In December 2004, the IHI launched its 100,000 Lives Campaign, which ultimately involved the participation of more than 3,000 hospitals to implement six safe practices. This was a hugely successful experiment. At the end of eighteen months, the IHI reported that the hospitals had reduced hospital deaths by 122,000. Some have challenged the numbers, and even the IHI acknowledges that it is unable to attribute all of those lives saved to its interventions. However, if only half of them resulted from this effort, it is impressive. And, to answer the question, is health care safer, all 122,000 lives saved are evidence for that.

What was so striking with the 100,000 Lives Campaign is that more than half of the hospitals in the country committed to the campaign and are continuing their involvement. The IHI is now transforming the 100,000 Lives Campaign into a 5,000,000 Lives Campaign in which they are going beyond preventing deaths to focus on all preventable injuries. The IHI estimates that there are fifteen million preventable injuries per year, and this initiative is an attempt to cut that by one-third over the next two years.

Other impressive results--some included in the 100,000 Lives Campaign--are those achieved by Ascension Health, which has reported impressive reductions systemwide in birth trauma, pressure ulcers, and nosocomial infections, with an estimated 1,953 lives saved over two years.2 And, in Michigan, 100 hospitals in the Keystone project reported that they succeeded in reducing their central-line infections to zero.3

There is no question that we are seeing progress. We have a much clearer idea of what we need to do, and the momentum is increasing. It is a very exciting time. We have worked through a lot of skepticism, denial, fear, and confusion, which always attend new ideas, particularly if you are asked to change your behavior. While I was not too surprised that there was a lot of sputtering when we began, what is exciting is that these reactions have largely settled down.

Government And Media Efforts

How would you grade both federal and state governments in providing incentives to get providers to focus on reducing errors and improving safety?

Leape: I would give them an F, at best a D-, as they have done very little. Although there was some increase in funding for research early on after the 1999 IOM report, since then the federal government has not done much to provide incentives, financial or other, to improve safety. Some states have established reporting systems, but most of us do not think that those are very effective as incentives. It is a good idea to collect information and learn from it, but this is not a very powerful factor for change. There is a movement in a number of states to require hospitals and health care organizations to publicly report data. This is going to turn out to be fairly powerful, I believe--not so much in that it will help the public shop for their health care, as the economists always want to do. I don't think that happens very often. But public reporting makes hospitals realize they are not doing as good a job as they could, and that makes them do something to improve. I believe that every hospital in this country should be required to report its nosocomial infection rate. The public ought to know what percentage of patients developed an infection as a result of coming into the hospital, particularly infections with resistant organisms, and this information should be reported regularly in newspapers. If we did that, we would begin to see hospitals take more action to reduce infections. If there is one area where there is clearly a great deal of room for improvement, as well as the know-how about how to do it, it is decreasing nosocomial infections. We need to get on with it.

How would you characterize the media's portrayal of the quality and safety of the health care system?

Leape: The media have treated us very well. From time to time there are sensationalized reports, but nothing like they have experienced in Great Britain. The media have increasingly become more sophisticated; certainly the elite media--the New York Times, Wall Street Journal, Washington Post, Boston Globe--which do an excellent job. I was very heartened recently when Newsweek published a special issue containing eighteen stories about patient safety, all focused positively on improvements. Ten hospitals were profiled to show what changes they had made and what safe practices they were implementing. The emphasis was all on how things are getting better, and the results were awesome. It is a delight to see the media accentuating the positive. I think they have done pretty well by us.

"Hot Topics" In Patient Safety

What are the hot topics today? What is new in improving safety?

Leape: The most exciting thing that has happened recently in patient safety--something that has truly changed our agenda--is that it is now apparent that we can use perfection as a benchmark. This means that we can stop talking about reducing medication errors by 50 percent or improving hand washing by 30 percent, and so forth. We now have convincing demonstrations that when the effort is made and new practices are implemented, we can actually eliminate certain adverse events. There is no reason to think that this cannot be expanded to the whole universe of adverse events. The IHI led this effort five or six years ago by teaching hospital teams how to reduce central-line infections and ventilator-associated pneumonia. Not a large number, but several hospitals had very impressive results.

Peter Pronovost,
a physician at Johns Hopkins, demonstrated in his own intensive care unit [ICU] the ability to totally eliminate central-line infections. Let's put this in perspective. Thirty-six million people are hospitalized in the United States every year. Approximately 11 percent receive care in an ICU, so the total number of ICU days is eighteen million or so. Approximately half of the patients in ICUs have a central venous catheter, so the best estimate is that there are 9.7 million catheter days per year and 48,600 central-line bloodstream infections. Approximately one-third of those patients die because of those infections. The figures for ventilator-associated pneumonia--another major cause of morbidity and mortality--are similar. Pronovost's team at Hopkins was able to eliminate both of these types of infections by implementing protocols and rigidly enforcing them: ensuring that the five or six things that needed to be done every time were done and done right. The secret was a major team effort and commitment.

But the exciting thing is that Pronovost took the protocols to hospitals in Michigan, with support from Blue Cross and Blue Shield, and recently reported that 100 of those hospitals have reduced central-line infections to zero.4 For more than six months, sixty-eight hospitals had no central-line infections and no ventilator-associated pneumonia. I call this "getting to zero." What Pronovost has shown is that this is not just something that one or two "safety nuts" can do, but, rather, anybody can do it if they put their mind to it. If sixty-eight hospitals in Michigan can achieve these results, then so can all 5,000 hospitals in the United States. We have a new ballgame and a new benchmark, and it is a very exciting development.

A major part of what Pronovost did was to make teamwork a reality and show that it makes a huge difference. Indeed, my second hot topic is team training, an idea that has finally caught on and has been greatly facilitated by simulation. Although simulation is expensive, it is a very powerful teaching tool. Everyone likes the idea of doctors, nurses, and anesthetists experiencing their first crisis on a plastic patient as they learn how to put a tube in, tap a chest, or give a medication. Simulation is sweeping the country and with it a new emphasis on and increased sophistication in team training. Many of us think that this is second only to implementing new practices in terms of its power to create a culture of safety and reduce accidental injuries.

The third important new development, in my opinion, is the use of more sophisticated ways to identify adverse events. The IHI trigger tool has proved very effective. This is a list of approximately fifty elements that can be found in the patient record, many of them laboratory tests or simple clinical observations. One searches for these, either in the electronic record or by going through a paper record, reviewing lab tests and so forth. You identify abnormal findings and investigate whether a patient has suffered an adverse event. We are moving away from looking at deaths (which is a rather crude measure)--in fact, even away from errors, because injuries are what count. It does not make any difference if we are preventing errors if we can't prevent the injury.

The frightening thing is that when hospitals have used this trigger tool--and now there are dozens that have--they find that not 4 percent of injuries, which is what we found in the medical practice study in 1991, but 40 percent of patients admitted will experience some sort of injury. Some are rather mild, such as when a patient suffers nausea after taking a drug, a slight rash erupts and dissipates, blood pressure drops, or some other minor occurrence happens that we did not count in our studies in the 1990s, which looked only at disabling injuries and deaths. But the fact that so many patients have untoward events is very sobering. I firmly believe that every hospital should be actively employing the trigger tool. All they have to do is review twenty charts per month, and they will find that probably eight or ten will contain something that makes them realize that there is a problem, and they can then go to work on it. Let me finish talking about the trigger tool by saying that this kind of proactive searching for problems is much more effective than responding to reports of injuries and accidents after they happen. Indeed, we are finding that people who are aggressive at improving safety and quality use these prospective real-time tools rather than just responding to reports after they get them.

A fourth hot topic is the national-level effort to ensure the competency of physicians. The Federation of State Medical Boards has spearheaded a joint effort that involves all the national stakeholders: the AHA [American Hospital Association], AMA [American Medical Association], AAMC [Association of American Medical Colleges], and the Board of Medical Examiners, as well as the ABMS [American Board of Medical Specialties] and ACGME [Accreditation Counsel for Graduate Medical Education]. All of the participants are developing more effective methods for measuring physician competency and ensuring that it happens on a continuing basis. The ABMS has moved toward continuing assessment of competency, which they call maintenance of certification, rather than merely having a physician take a board examination on one occasion. The licensing boards are very interested in learning how to link this with licensure. We are going to see actual progress in that area, and it is long overdue. Many doctors have deficiencies that need to be identified and corrected.

The final hot topic is that the need for full disclosure and compensation is finally on the patient safety agenda. Acknowledging mistakes when they occur, fully explaining what happened, apologizing for errors, and providing compensation for the cost of the injuries we cause are things that we have to do. For too long, too many doctors and nurses have not been forthcoming and honest with patients when things go wrong. Just as patients sometimes accuse, there has sometimes been a conspiracy of silence. Patients too often do not get the truth, the whole truth, and nothing but the truth, and it is time to stop that.

There are many reasons why physicians have been reluctant to be open and apologize after accidental injury, but a major factor has been bad advice from liability insurance carriers and hospital counsels, who have perpetuated the myth that informing the patient will increase the likelihood of being sued. There is not a shred of evidence to support this assertion--not a single study--yet the myth dies hard. Fortunately, evidence is now coming forth to prove just the opposite--first from the Lexington Veterans Affairs [VA] Hospital eight years ago, and more recently from COPIC [a liability insurer] in Colorado and the University of Michigan.5 The facts are that full disclosure and early compensation have led to substantial reductions in the number of suits filed and in the total payouts.

Although fear of litigation is very real, and understandable, I believe that a more powerful reason that doctors sometimes do not communicate fully with patients after a serious error is their sense of shame and guilt. Physicians hold themselves to high standards of performance. As a result, they find it difficult to deal with failure. And they get very little support, either from their colleagues or from risk management personnel. It turns out that full disclosure and apology when there has been an error are important for the physician as well as for the patient. We need to provide them with support to help make it happen.

We recently issued a consensus statement from all Harvard-affiliated hospitals in which we attempted to lay out the rationale and evidence for a more open, honest, and forthright approach.6 The response has been gratifyingly positive. Doctors and hospitals have always wanted to do the right thing but have been afraid of the consequences. Those fears are subsiding, and there is at last a growing interest in disclosure that is very encouraging and long overdue. Health care organizations also need to provide the training and support needed to turn aspiration into reality.

P4P And Patient Safety

What are the implications of pay-for-performance (P4P) initiatives for improving safety?

Leape: I think that the implications are rather provocative. Essentially, it suggests that you can get quality by paying for it. The idea seems sound, but whether the results will confirm it remains to be seen. It certainly is a concept worth trying, given that our current system of paying for health care is rife with perverse incentives. As some wag observed, health care is the only industry where you get paid more for a defective product! But, it's true: Hospitals and doctors receive more income when things go wrong than when they go right. And it works both ways: You get paid less for good care. That is clearly not what we want. Here is a classic example: A doctor does a good job treating patients with asthma, teaching them to manage themselves, and the end result is exactly what we want--patients have fewer attacks. They are not going to the doctor's office as often, they are not going to the emergency room, and they are not being admitted to the intensive care unit and being intubated. But the net result is that both the doctor and the hospital lose money. That does not make any sense, and we need to change that. Our fee-for-service system also emphasizes providing services rather than providing care, and that also needs to be changed. We should pay for good-quality care.

On the flip side, I am one of those people who support another new idea. Some payers have said they are no longer going to pay for so-called never events, those twenty-seven events that should never happen according to the NQF, such as a surgeon removing the wrong leg, a mother dying during normal childbirth, that sort of thing. First in Minnesota and now in other places, some payers are no longer going to pay for never events because they are so egregious that the hospital has a responsibility to make sure they do not happen. This policy will not have much financial impact on a hospital because these events are fortunately very rare. Nevertheless, it sends an important message to hospitals.

Pay-for-performance, though, has some major problems that we have to sort out. I do not know how they are going to be resolved, but let me at least briefly mention a few. The first is whether you should pay for process or for outcomes. Second, how do you pay: Do you pay a bonus for good care, or do you punish people who fail? Let us say you pay a bonus for somebody who does a better job of making sure that all patients who have a heart attack get beta-blockers afterward. We have pretty good data that this makes a difference in outcomes, so one thing to do is say, "If you achieve a high level--say, over 90 percent of your patients get beta blockers--we will pay a premium." Or do you not worry about that and focus on outcomes? Going back to the asthma example, "If you are able to keep your asthmatics out of the hospital, we will give you a bonus." I much prefer the outcome approach, but it is often easier to measure processes than outcomes, if for no other reason than you have many processes for each outcome. For example, you have to give beta-blockers to hundreds of people to be able to show that you reduced mortality. It is not a simple issue.

Another concern with pay-for-performance involves whether we are paying for the right performance--that is, do we have good enough data that establish that the treatment we want to see happen actually makes a difference? A treatment gets challenged quickly if there is any debate over its effectiveness, and rightly so. We have to be very careful that we link compensation to a specific performance that we know makes a difference.

I am also concerned about the possibility of perverse effects. Any time you change payment, you change behavior, and that often has unintended consequences. If we concentrate on paying for outcomes, will we in effect devalue and direct attention away from the "soft stuff" that means so much to patients: time spent listening to them, caring about them, communicating with them? If we do not pay for that, then is it going to be diminished? I would hope not, but one must be aware of that possibility. And there is always a concern that people will game the system and figure out a way to make pay-for-performance work to their financial advantage. You can only do so much in terms of clever design. The bottom line is that pay-for-performance is today's "new thing," it is the current fad, and it has some appeal on the surface. We have a lot to learn about it and how effectively it can help improve quality and safety.

When people have studied progress in quality and safety, two approaches have been shown to be most effective in driving change. One of them is a Joint Commission [on Accreditation of Healthcare Organizations] requirement. If the Joint Commission requires you to implement a practice, you will implement it. The second approach, which is even more powerful, is data and feedback. When you show people they are not doing well, they improve. Everybody in medicine, perhaps everybody in health care, thinks they are from Lake Wobegon--that they are "above average." It is very hard for any doctor, for example, to be called average. When you are average, that means that 50 percent of the people are performing better than you. But nobody thinks they are average; they think they are above average. And when they find out from the data that they are below average, they begin to do something about it. We saw this years ago in Pennsylvania and New York with the publishing of results of coronary artery bypass graft surgery. Invariably, hospitals at the bottom of the list in one year moved up the next year, some of them to very near the top of the list. Nobody wants to be at the bottom.

An even more impressive example is the National Surgical Quality Improvement Project run by the VA, which is now being rolled out in the civilian sector. This consists of collecting a large amount of data on every patient who undergoes surgery, and then using that information to determine risk-adjusted death and complication rates. The results are then fed back, not by individual doctor, but by medical specialty, to each hospital. Each VA hospital's surgical specialty department receives observed versus expected mortality and complications scores, which allow them to see how they compare with everybody else. When they discover that they are in the bottom quartile, they do something about it. The end result has been a significant and sustained reduction in deaths and complications in VA hospitals over the past decade. The collection of meaningful data and feedback, as well as making that data publicly available, have been very powerful. We are going to see more of this, which I believe is a positive development.

Consumer Involvement

Buerhaus: The consumer has become more involved in health care, particularly as market forces have begun to influence the system and the portion consumers pay for health insurance premiums have increased. In addition, we seem to be placing greater emphasis on transparency and public accountability. How do you see these developments affecting error reduction and quality improvement?

I'm all for it. Patients are becoming increasingly sophisticated in understanding, demanding, and actually looking at data. More and more people use the Web to obtain information and advice, and that is good. A well-informed patient is a safer and happier patient. However, I believe that the economists are wrong in one respect, in that until now, patients have not seemed interested in a big way in shopping for quality. That is, most people do not want to pick their doctor or hospital by a set of scores posted on the Web. Some do, but it is a very small number, and my guess is that it will always be that way. Most people prefer to get their advice from their doctor whom they trust, or their friends. Thus, I do not think that the data on hospital and physician performance have had as much effect on patient choice as some people think they should. However, they have had an effect on patients' sophistication and understanding, and that is certainly positive.

As premiums increase, one hopes that this will create consumer pressure for health care systems to become more efficient. I would like to see this evolve into the development of a new form of managed care. It is almost impossible to provide safe care as an individual, as a doctor in solo practice, or even in a two- or three-physician practice. You need to have groups. Safety is much more the property of organizations than it is of individuals. Individual vigilance and competence are clearly important, but safety is tied mostly to systems, and it is organizations that have systems. We need to move more into an organizational approach to health care and manage our care accordingly. The increasing costs of health care as well as increasing consumer sophistication are already pushing us that way.

One of the surprises for those of us who work in safety--something we did not see coming--was the rise of patient advocacy groups. We now have at least a half-dozen of these groups in the United States, in addition to others around the world. These organizations were developed by aggrieved patients--CAPS [Consumers Advancing Patient Safety], PULSE [Persons United Limiting Substandards and Errors in Health Care], MITSS [Medically Induced Trauma Support Services], and others. Each of them developed not because of someone's desire to improve safety but in reaction to how they were treated when something went wrong. These groups are saying, "When something goes wrong, you need to be honest and open with us and treat us like human beings, give us support, and apologize." They are shaking the medical profession by the shoulders and saying, "Listen to us and treat us the way you want to be treated yourself." That has been a very effective and important development. That part of the consumer movement has been very helpful.

More Effective Health Care Professions

What barriers exist in the way in which nurses and doctors are educated and interact clinically that need to be overcome before either profession can be more effective in reducing errors?

One of the encouraging developments of the safety movement is the growing recognition in both the professions of nursing and medicine that their relationship needs to improve if we are to make major strides in improving patient safety. James Reason says that in one sense, safety is all about relationships, and I agree. The nurse-doctor relationship is crucial to providing safe care, and too often it doesn't work smoothly.

One of the sources of tension relevant to error prevention stems from different approaches in their education. Much of the emphasis in nursing education is on learning practices and following rules. Physicians are taught analytic thinking and individual responsibility; rules are much less important and are sometimes regarded as subject to individual veto. Not surprisingly, these different approaches can produce conflicts.

A more serious problem is that some physicians don't treat nurses as valued colleagues. For decades nurses have legitimately chafed at not being respected by physicians for the high level of professionalism and expertise they bring to patient care. Even worse, surveys show that a majority of nurses have experienced disrespectful conduct from physicians.7 Although a small minority of physicians are responsible for these episodes, effects on morale and doctor-nurse relationships can be substantial. So, I would frame the question as, What barriers in our educational systems perpetuate these cultural differences that are so detrimental to patient safety?

One of the obvious barriers is separation. Nurses and doctors should be learning together--obviously, not everything, but they should be having experiences in which they learn together by actually working together. We have done a pilot program where nursing students and medical students got together for clinical problem-solving exercises focused around a case. They talked about how to manage the case--technical issues as well as psychosocial aspects. It was very successful; both medical students and nursing students were very positive about it. One of the nursing leaders made the comment that it was important for doctors to understand how nurses think about the problem and vice versa. I agree, but I think it is even more important for all of them to have the experience of working together to solve a problem. The best way to learn teamwork and how to respect and collaborate with your colleagues is by doing it. What we were providing was a hands-on experience, not didactic material. Sadly, our experiments, while successful, still face the problem of getting woven into the curriculum. I believe that the time is long past that medicine, nursing, and pharmacy--the health care professions for whom training is long and who will work with each other all the time--should have significant joint exercises. Hopefully, we will see much greater expansion in this area over the next several years.

The second barrier is that we are still very much prisoners of science. Most people think of medical education as learning the science of medicine--basic anatomy, physiology, pathology, medications, problem solving, technology, and technical proficiency. There is no question that this is absolutely critical, but too often the other half of the practice of medicine, which is how you apply that knowledge to the care of a human being, gets short shrift. We do not give our medical students enough experience in how one actually carries out a treatment plan, communicates effectively with a patient and manages their care, and works well and communicates effectively with the other team members. In other words, we don't do a very good job with the "soft stuff"--the absolutely critical aspects of how we work together to make health care happen. Medical education is still very much caught up in the romance of medical science and continues to ignore the practical aspects of application.

The third barrier is that students in medicine, nursing, and pharmacy receive insufficient basic education in quality and safety. At a minimum, in the first year of school, all of them should learn the basics of error theory, why people make mistakes, and how to prevent them. Later, they should learn how to analyze systems, how to identify systems' failures, and how to redesign systems. As we mentioned, they need to learn how to work in teams by doing it, and doctors especially need to learn the basics of leadership. They need to learn much more about how to communicate more effectively, how to handle their own feelings and concerns, and how to handle the shame and guilt they will feel when things go wrong, so that they can still be effective caregivers. They need to learn how to apologize. These are things that are currently not being taught to our budding doctors. In most schools, we have not provided students in any of these disciplines even the rudiments of what they need in basic knowledge in safety, what is known scientifically; nor have we given them the instruction and the experiences they need to develop communication, managerial, and team skills. That has to change.

Role Of Hospital Executives

How significantly have hospital executives changed their attitudes and behavior toward improving patient safety? How much progress have you seen in the creation of a nonpunitive environment in hospitals?

Leape: I certainly hope they have changed more than I see! This is the single most disappointing aspect of the safety movement for me: the difficulty in getting CEOs of hospitals and health care systems to make safety a priority. On the other hand, we have begun to make some progress in reducing the punitive environment: It certainly is not acceptable anymore to admit that you punish people for errors. Every hospital says, "Oh, yes, we have a nonpunitive environment." In reality, that is often far from being true, but at least they are paying lip service to it, so that's a start.

Lack of inspired, consistent, and forceful leadership is a major drag on progress. CEOs are a "sea anchor" on progress, and that has to change. To be sure, there have been a few exceptions, organizations that have made a great deal of progress. However, no organization can make the significant changes that are necessary to develop a culture of safety without vigorous leadership at the top. I think of the Dana Farber Cancer Institute in Boston, the Virginia Mason Clinic in Seattle, Ascension Health, and others, and characteristically it is the passion from the CEO that makes change happen. It must happen at this level because middle managers and people at the grassroots of the organization who are eager to make changes cannot do so without support. Getting CEO leadership remains a major unsolved problem in moving patient safety forward.

Barriers Remaining

Buerhaus: Finally, what are the most important problems or barriers that still must be overcome to make health care safe for everyone?

We can pick up on what we were just talking about, including leadership. We need to reach higher in the organization and get boards of trustees of hospitals and health care organizations involved. If boards have patient safety as a concern, then so will CEOs. Perhaps what we need to do is develop more significant negative consequences for organizations when they provide unsafe care, in terms of either fines, reduced payments, publication of safety data, or sanctions. Clearly lack of leadership is a barrier.

Other barriers I see are ones that do not seem to be much related to safety, but in reality are: namely, our perverse financing system and the perverse incentives it provides, which I mentioned earlier. I believe that we need to have universal coverage. It has now gotten to the point that several states (I am proud to live in one of them, Massachusetts) are trying to achieve this, but it should be a national effort, and it ought to occur tomorrow. I hope that universal coverage will be a major theme in the 2008 presidential election. I mentioned before that we need to facilitate, encourage, and fund managed, comprehensive, patient-centered care, not services. There is no way to do that unless we retire the fee-for-service system. The lack of appropriate financing is one of the major barriers to progress in health care, but particularly to improving quality and safety.

Another barrier is persistent physician apathy. In spite of everything that has occurred, the majority of doctors today are still not very involved in the promotion of patient safety. There is less resistance--certainly less complaining and carping--but there is not the active participation that is needed. Safety is not a daily concern of most doctors, and it should be. Nursing is way ahead of us on this, but even there things can be improved. Physician apathy continues to be a real drag.

An even more important barrier to achieving safe health care is the absence of effective systems for accountability at every level. Physicians and nurses are not held accountable for safe practices. Why are nosocomial infections such a scourge in this country? We have the highest resistant infection rates in the Western world, and yet we tolerate the fact that in most hospitals fewer than 50 percent of doctors routinely disinfect their hands. It is absolutely incredible that hospitals tolerate deliberate deviation from a known safe practice, and equally incredible that state health departments do nothing about it.

What we are talking about is accountability at every level. While no individual should be punished for making an error, which by definition is an unintended act, willful disregard of safe practices or knowingly engaging in unjustified hazardous conduct must not be tolerated. We call this a "just" culture: no blaming for errors, but no tolerance for misconduct. By the same token, organizations that permit unsafe conduct or perpetuate known hazards should be held responsible. Until those who are responsible are willing to get tough and make sure that we all do what we know we should do, both as individuals and as organizations, lack of accountability will continue to be formidable barrier to making progress.

The final barrier is psychological. Most people do not believe that truly safe care is possible, that it is possible to eliminate medical injuries. They do not believe that we have the knowledge or the methods. Clearly, we are not going to give improving patient safety the effort, the enthusiasm, or the money that is needed unless we believe it is possible to really make health care safe.

The experience with eliminating central-line infections and ventilator-associated pneumonia in Michigan and the great strides at Ascension Health have changed all that. We now see that it is possible to totally eliminate certain adverse events. A health care system that is almost entirely injury free no longer seems impossible. What we need now is the will to make it happen. Yes, the last barrier is the psychological one, of not believing that we can all do what is now clearly possible.

Buerhaus: Thank you, Lucian, and best wishes.

Leape: Thank you; it has been good to talk with you again.

The author thanks Brenda Compton for her assistance transcribing and editing the manuscript.


1. L.L. Leape et al., "The Nature of Adverse Events in Hospitalized Patients: Results from the Harvard Medical Practice Study II," New England Journal of Medicine 324, no. 6 (1991): 377-384.
2. D.B. Prior, "Case Study: The Clinical Transformation of Ascension Health" (Presented at the Agency for Healthcare Research and Quality and Institute for Healthcare Improvement Symposium on Large Scale Change in the Quality of American Health Care: Key Challenges and Lessons Learned about Spreading and Sustaining National Improvement, Rockville, Maryland, 16 March 2007).
3. P. Pronovost et al., "An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU," New England Journal of Medicine 355, no. 26 (2006): 2725-2732.
4. Ibid.
5. S.S. Kraman and G. Hamm, "Risk Management: Extreme Honesty May Be the Best Policy," Annals of Internal Medicine 131, no. 12 (1999): 963-967; R.E. Quinn, "The Insurance Industry's Role in Supporting Apology and Disclosure Policies" (Presented at the Joint Commission Conference on Seeing Your Way Clear to Apology and Disclosure, Rosemont, Illinois, 6 June 2007); and S. Hall, "U-M Docs Say Sorry, Avert Suits," Detroit News, 12 May 2004.
6. Massachusetts Coalition for the Prevention of Medical Errors, "When Things Go Wrong, a Consensus Statement of the Harvard Hospitals" (Boston: Massachusetts Coalition, 2006).
7. A. Rosenstein and M. O'Daniel, "Disruptive Behavior and Clinical Outcomes: Perceptions of Nurses and Physicians," American Journal of Nursing 105, no. 1 (2005): 54-64.
Peter Buerhaus ( is the Valere Potter Distinguished Professor of Nursing and director of the Center for Interdisciplinary Health Workforce Studies, Vanderbilt University Medical Center, in Nashville, Tennessee. Lucian Leape is an adjunct professor of health policy in the Department of Health Policy and Management, Harvard School of Public Health, in Boston, Massachusetts. He is well known for his path-breaking research and thinking about patient safety, particularly on the need to focus on systems of care to prevent injury to patients, and, more recently on the need for full, open disclosure and apology when things go wrong.

DOI: 10.1377/hlthaff.26.6.w687
©2007 Project HOPE–The People-to-People Health Foundation, Inc.