Can protecting patients be made recession-proof? (Patient Safety Congress annual meeting)
■ As hospitals cut back, doctors and patient safety officers are exploring the business case for quality initiatives.
By Kevin B. O’Reilly — Posted July 20, 2009
Protecting patients from harm is medicine's bedrock goal, but the resources required to do so have never come cheaply. With the recession taking its toll on the health sector, doctors and other medical professionals who have tackled problems ranging from hospital-acquired infections to patient falls find their efforts increasingly scrutinized on dollars-and-cents grounds.
Ninety percent of hospital CEOs have cut administrative expenses, staff and services amid the recession, according to a survey of more than 1,000 chief executives released in April by the American Hospital Assn. More than three-quarters said they cut capital spending and nearly half scaled back ongoing projects.
The moves come at a time when hospitals already are facing a changing payment landscape. For example, the Centers for Medicare & Medicaid Services and many private payers have cut or stopped paying for "never events," such as wrong-site surgeries.
President Obama has proposed bundling payments for hospitalization and care 30 days postdischarge, penalizing hospitals with high one-month readmission rates. The administration says the move would save $8.4 billion and give hospitals more financial incentive to reduce the 20% 30-day readmission rate among Medicare patients.
Given all that, it was no surprise to hear phrases not frequently uttered in patient-safety circles -- cost-benefit ratio, return on investment, cost effectiveness -- flutter about the 2009 Patient Safety Congress convened in May. The annual event, organized by the Boston-based National Patient Safety Foundation, brought more than 1,200 doctors, nurses, pharmacists, patient-safety officers, risk managers and hospital executives to National Harbor, Md., across the Potomac River from the nation's capital.
"Absolutely, there is increased pressure to make a business case for patient safety," said Gregg S. Meyer, MD, senior vice president for quality and safety at Massachusetts General Hospital/Massachusetts General Physicians Organization.
"We've laid enough of a groundwork that folks recognize that quality and safety aren't something you should look at on the expense side and say, 'Here's a way to close gaps by cutting these programs.' In fact, they may be the key to closing your gap, because I'm a firm believer that if we do many of these things right, the economics will work out.
"The economy, in some ways, ought to focus our lens on putting resources into quality and safety," added Dr. Meyer, who spoke at a conference session on nonpayment for never events. "You just can't afford not to do it."
He noted, as another example, that hospitals already faced "major red ink" of up to $30,000 on each instance of mediastinitis -- a rare, serious, but not always preventable heart-surgery-related chest infection -- before Medicare last year added it to the list of conditions for which the agency will no longer reimburse extra care costs.
Many at the conference sought the nitty-gritty on how to bolster their financial arguments for quality and safety initiatives. One breakout session, called "Making the Business Case for Patient Safety," featured intricate equations for quantifying the savings that projects could yield.
At the session, Erik Stalhandske, of the Dept. of Veterans Affairs' National Center for Patient Safety, told the audience to scour the literature for the best evidence on the effectiveness of the proposed safety intervention.
"Take the conservative estimate" on the effect of a project, Stalhandske said. "Retrospectively, you can talk about how effective you were, but prospectively you have to do a little guesswork. ... Give yourself a longer time frame for the intervention to work. Underpromise and overdeliver. You'll be more likely to surprise people with the results you achieve."
Yet, many times savings just do not materialize as money in the bank, said the conference's keynote speaker, New York City Health and Hospitals Corp. CEO Alan D. Aviles.
Aviles cited the public health system's progress on a number of hospital safety metrics that it began publicly reporting voluntarily in 2005.
HHC has 11 acute-care hospitals and 80 community-based clinics. From 2005 to 2008, it cut by 65% its central-line infection rate and reduced the number of ventilator-associated pneumonia cases by 90%. Multiplying the average national cost of such infections by the number of cases reduced yielded an estimated savings of $16.3 million over four years.
After his talk, Aviles told AMNews that determining such savings can be tricky. "The business case can be a pretty complex calculation because it's a combination of fixed costs and variable costs," Aviles said. "If you reduce the number of nosocomial infections in the ICU, you may reduce the patients' length of stay, but that's a fixed cost. You're probably not going to lay off staff based on that. Unless you have patients to admit to those beds and are diverting patients, then you might be able to turn that improvement into big savings. The theoretical calculations make assumptions about essentially being able to put a new patient in every bed as soon as you reduce the length of stay."
Hopes for transparency
Aviles said hospitals need better accounting software to "disaggregate all the costs at a very granular level, particular on variable costs."
It is precisely because the financials of patient safety can be maddeningly equivocal that Aviles pushed HHC to make its performance data public. He predicted that the nation's health system will follow, whether by choice or force.
"At some point we will find ourselves in a situation where a lot of this data will be made public by the federal government," Aviles said. "When that happens, then the effect is going to be felt on the competitive position of hospitals and physicians."
Other experts predicted that Obama's readmissions pay-bundling proposal, if enacted, would spur health systems to invest more in remote-patient monitoring and work more closely with office-based physicians to keep patients out of the hospital.
In the meantime, as often as meeting speakers and attendees grasped for evidence of their work's quantifiable savings, they were just as likely to return to a constant refrain: The business case may be muddy, but preventing patient harm is a righteous endeavor.
"It's wonderful if you get a cost advantage by improving patient safety," said conference attendee Donald J. Palmisano, MD, founder and president of Metairie, La.-based medical risk-management firm Intrepid Resources and a former American Medical Association president. "But, as physicians and other professionals who deliver care to patients and administrators who oversee hospitals, it's our ethical imperative to do the very best for the patient, regardless of whether it costs more."