Patients blamed for medical errors

Dorothy Guellec

The American Medical Association believes it may have discovered a root cause for the many medical errors - patients themselves. Isn't that cute. Rather than focus on the incredible complexity of the system and processes at work and everything needed to reduce errors, let's pick on someone to blame. This is not a coincidence, not by a long shot. The Institute of Medicine is preparing to release a second report on healthcare quality (early February 2001) at a time when many providers and lawmakers are still trying to digest the impact of the institute's 1999 medical errors study "To Err is Human." To prepare the way the AMA Foundation, the philanthropic arm of the AMA, said late last week (Jan. 2001) that " the problem of patients not being able to understand, interpret or act on basic health information results in $73 billion in unnecessary health expenses nationwide." It is developing a program to address the phenomenon.

This sizeable expenditure, the AMAF (American Medical Association Foundation) notes, is the result of something called "low health literacy." This means that patients cannot understand, interpret, or act on basic health information, such as instructions on prescriptions. Rather than fulfill the basic doctor-patient covenant within the implied, if not explicit, community of trust, the Foundation representing the American Medical Association blames the patient. This analysis ignores all the realities of the market driven share-holding system. It is downright nasty to attribute the 44,000 to 98,000 mistakes in all parts of the giant healthcare industry to "low health literacy " whatever that means. This is grasping for straws. Low health literacy is not the answer, and life is not that simple, and the patient for one is never at fault. The AMA goes on to define low health literacy as "the inability to act on basic health information such as appointment slips, informed consent documents, insurance forms, or other health educational materials. With more than 90 million Americans or 46% of the adult population today considered functionally illiterate, low health literacy is becoming a dangerous and alarming public health issue" Maybe they think that a naïve, incorrect and damaging analysis such as this will cover their tracks, and more importantly, serve as a buffer when the second Institute of Medicine's Report is released in February, if it isn't stopped by certain parties. The impending release is already generating a buzz in healthcare circles.

Lucian Leape, M.D. an adjunct professor at the Harvard University School of Public Health who worked on both Institute of Medicine's reports, promises that the new report will be "equally radical" to its predecessor. Kenneth Kizer, M.D., president and chief executive officer of the National Quality Forum, has read the report and said it makes "some very poignant recommendations." I am sure that patient error, or blaming the patient, does not figure except very briefly, in this new report. Dr. Kizer's forum is a Washington-based-not-for-profit membership organization whose goal is to improve quality measurement and reporting in healthcare. It's working on three patient-safety projects for HHS.

"Basically, it's about the need that healthcare has to focus on quality, which has to be an essential business strategy for the healthcare industry," Kizer said. As healthcare inflation continues to rise, no easy places to cut costs are left, he said. "You have to improve the processes of care." Note how quality has to be a business decision and not a humanitarian one. Then, if all else fails, the entire industry can blame the patient and his or her lack of health literacy skills.

The AMA's call to action comes only days after an article in the mainstream revealed, and HCFA confirmed, a change in federal policy that will require Medicare peer review organizations to tell patients whether their hospital and physician care met "professionally recognized standards." Tens of thousands of Medicare patients file complaints each year about the quality of care they receive from doctors and hospitals. But in many cases, patients get no useful information because doctors can block the release of assessments of their performance. No more. Under a new policy, officials said, doctors will no longer be able to veto disclosure of the findings of investigations.

The new policy came in response to a lawsuit against the government by the son of a Medicare patient who was admitted to a hospital in Jacksonville, Fla., on Dec 8, 1998, after an asthma attack and after experiencing high blood pressure. The patient died from a stroke six days later, while still a patient at the hospital. The plaintiff (the patient's son) had concerns about his mother's care. He filed a complaint, which was investigated by a group of medical quality experts known as a peer review organization. Mr.Levine (plaintiff) and his lawyer, Amanda Frost of the Public Citizen Litigation Group, a nonprofit law firm, filed a lawsuit, in which they argued that the old Medicare policy violated federal law. The suit is pending in Federal District Court in D.C.

The AMA finger pointing at patients comes right after the Joint Commission on Accreditation of Healthcare Organizations adopted new accreditation standards that will require physicians to tell hospital patients when their clinical outcomes deviated from acceptable norms. The sweeping requirements for accredited hospitals include six new standards, such as mandating that hospitals implement organization wide safety programs and revise 29 existing standards.

Just to make us all feel secure across the nation, 933,687 elderly and disabled have been dropped as of Jan 1st by HMO's pulling out of the Medicare program according to the US government. These Medicare recipients - a sixth of those enrolled in HMO's - are "likely to be poorer, less educated and in worse health than others in the program." Terminations in 2000 affected a disproportionately vulnerable subgroup of beneficiaries, many of whom were confused about options and worried about the future. I can't wait to see what 2001 brings.

"I think it's a dirty trick," Mr. Castle, 73, said as he thumbed nervously through the thick stack of papers he had brought to the Elderly United Downtown Center in Springfield, Ohio in search of advice from Lynn Heskett, the center's medical claims coordinator. As they spoke, Ms. Heskett's phone rang incessantly with calls from other elderly people in the same predicament.

Although everyone dropped from a Medicare HMO can return to the basic fee-for-service Medicare, it does not pay for drugs. Neither do the supplemental Medicare policies, the so-called Medigap plans, in which enrollment is guaranteed to those who are dropped. The costs of these policies, which pay doctor and hospital charges not paid by Medicare, vary among the private companies, and state to state. In Ohio, they cost from $40 to $143 a month. The few that cover drugs cost as much as $418 a month and acceptance is not guaranteed.

The HMO industry shakeout started 3 years ago and continues due to mergers, acquisitions and outright failures. I personally think the system will eventually self-destruct, but so-called experts in the healthcare industry do not agree. We can expect that the number of HMO players - now about 568 - and the number of enrollees will continue to drop and the sector will reshape itself. Meanwhile the nation's largest hospital company (for profit of course) which awed Wall St. for more than a decade agreed to $95 million in criminal penalties and pleaded guilty to charges that "it obtained some of its money by cheating government health care programs." The settlement with HCA, the Healthcare Company amounts to the largest fraud settlement in American history. HCA has agreed to pay a total of $840 million in criminal and civil penalties.

Dorothy Guellec
guellec@purvid.purchase.edu