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A Closer Look

A November 15 advertisement in the Wall Street Journal caught my attention – and then my ire. Rick Pollack, President and CEO of the American Hospital Association (AHA), a national organization that represents nearly 5,000 hospitals and health care networks – penned a piece titled, “Fighting for Fair Health Insurance Policies for Patients and Clinicians.”

The advertisement began with the following statement: “Hospitals and health systems put the health and welfare of their patients first. But for some of the nation’s largest commercial health insurance companies, that increasingly is not always the case.”

Pollack continues by asserting health insurance companies have policies that compromise patient care, access to that care and safety. “These include frequent changes to coverage, limited provider networks, delays in authorizing treatment and failure to pay providers in a timely manner.” I must admit, there is some truth to these assertions. Defending insurance companies on many of these issues will not come from me.

Pollack provides a few examples of the atrocities committed by insurance companies, which “blindsides” patients and “puts their health at risk.” Equally abhorrent, are the “billions of dollars in added costs to the health care system,” which “contribute to clinician burnout.” Again, I will not push back on such allegations.

Finally, Pollack goes for the jugular by writing that unjustified behavior by insurance companies is allowed because “commercial health insurance markets are increasingly concentrated and nearly every market is dominated by a single larger commercial insurer.” Yep, this too has some validity.

My ‘Ire’

So why am I incensed by this AHA advertisement? Quite simply, it amounts to the pot calling the kettle black. Finger pointing deflects blame from where it also belongs. Medicine has become more of a profit-incentive business than a public good that cares for patients. The large majority of clinicians serving patients are doing so for the ‘right’ reasons. Unfortunately, the business side of medicine tears away at the sanctity of patient care, leaving doubt in the care we once trusted. 

The AHA and its members are far from faultless on many of the criticisms it throws at health insurers. In fact, the atrocities they commit are swept under the rug and largely left ignored. When transgressions do surface, carefully polished responses are crafted by the AHA and its minions. Below are just a few of the many transgressions committed by the AHA and its powerful members:

  • Leveraged Local Power – Local hospitals infiltrate and hypnotize our communities, business associations and the state legislature to help soften or silence negative pushback on their business behaviors and practices. They often remind us of the “economic impact” they provide to our local economies and the ‘free’ care provided to those without health insurance. This is true, but nonprofit hospitals are exempt from paying most federal and state taxes, which may outweigh the charity care they provide. Because of this economic presence, they feel entitled to be treated with reverence to promote their own business interests. Yet contrary to arguments made by the medical establishment that bloated healthcare equates to more local jobs and serves as a multiplier-effect for local economies, growing our medical industrial complex just does not fit the true narrative of having thriving economies. Consolidation of hospitals, we are often led to believe, will broaden access to care and increase efficiency. As a result, the public will benefit by having “lower costs and improved care.” Yet, many of these mergers serve as a ploy to leverage bargaining prowess with third-party payers to ensure favorable, and more profitable prices. Studies have shown that hospital consolidation is more about enhancing bargaining power and less about integration aimed at reducing costs and providing better, safer care.
  • Opaque Pricing – The hospital price-transparency rule, which took effect this past Jan. 1, required hospitals for the first time to disclose the confidential prices negotiated with health insurers. Despite hospital opposition to this rule, it was implemented to help boost competition and control rising U.S. healthcare spending. According to a Wall Street Journal article in March, hospitals used various methods, including so-called blocking codes, to make it harder for people to search for and download pricing data. The Centers for Medicare and Medicaid Services then recently released a final rule to raise penalties if hospitals do not comply. Not surprisingly, the AHA and other hospital trade groups pushed back. Hospitals around the country are notorious for charging exorbitant and variable prices to patients. Keeping prices opaque is a huge benefit to hospitals, but not to those who pay the bills. Let’s be honest, it’s about the bottom line – healthcare is in the money business.
  • Billing Complexity Equals Medical Debt – Opaqueness in pricing also carries through to how hospitals bill for their services. Hospitals behave as if they are entitled to our money – even if the billing is unfair and inaccurate. Fortunately, we have a new law enacted to protect patients against surprise medical bills, a practice that hospitals have allowed to happen for decades. Medical debt continues to pile up for patients, causing bankruptcy to those with and without health insurance coverage. 
  • Harm to Patients – We have known for years that fatalities due to preventable mistakes made in U.S. hospitals are enormous. In fact, if medical errors were tabulated similarly to other diseases, it is estimated that medical errors would be the third-leading cause of death in this country, behind only heart disease and cancer. It is egregious that death certificates do not list the preventable complications that contribute to the death of patients. The AHA and hospital trade groups whitewash preventable medical mistakes and patient harm as if they don’t happen. Instead, more resources are spent to initiate state laws that implement and enforce tort reforms that protect their backside. Apparently lobbying for such legislation is much easier than actually mitigating the harm they are needlessly causing.
  • Lobbying Power – The hospital and medical community lobbies state legislatures, Congress and federal agencies to influence decisions that benefit themselves, not the public. According to OpenSecrets.org, a nonpartisan, nonprofit, and independent organization that tracks money in U.S. politics,health’ was the top lobbying sector in 2020, spending over $629 million. Since 1998, this sector has dished out over $9.5 billion, edging out ‘Misc. Business’ ($9.4 billion) and Finance/Insurance/Real Estate ($9.36 billion).  ‘Health’ lobbyists represent the American Medical Association, American Hospital Association, pharmaceuticals, and so on. In the $4+ trillion healthcare industry, lobbying efforts can pay off handsomely. The ‘investments’ mentioned above are merely a drop in the bucket for the eventual returns that will come sometime later. 

Bottom Line

The business of medicine should be less about ‘private gain’ and more about ‘public good.’ The monetization of medicine has been designed for the benefit of those who stand to profit at the expense of those who are forced to blindly pay. To be fair, insurance companies are not without fault. However, I see this advertisement as yet another deflection from the real truth. We deserve greater transparency and accountability from those who provide our healthcare and the insurance companies that help pay for such care. Lastly, we must have honest and bold action from those we elect to protect the public’s interests. Unfortunately, patients are an afterthought in this perverse system that too often lacks appropriate accountability.

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Trusting Science – Who will be the next ‘Elvis’ in 2020-21?

Unfortunately, the race for a Covid-19 vaccine is sounding so political that it is proving to divide Americans by party voting preference. As we are now keenly aware, science and politics do not mix well.

Following the Democratic National Convention, V.P. Mike Pence told CNN: “We think there is a miracle around the corner. We believe it’s very likely that we’ll have one or more vaccines for the coronavirus before the end of this year.  All of that’s attributed to President Trump’s leadership.”

As of August 31, the number of confirmed Covid-19 infections in the U.S. has topped 6 million, while national fatalities approach 183,000. Based on state sources in Iowa, there have been 64,102 confirmed cases and 1,110 deaths.

Vaccine speed is desperately needed, but will it come at the expense of accuracy and safety? Should Americans be concerned? Yet, just as important as having an effective vaccine, is the trust that Americans have in believing that government officials will do what’s right, not just what is most expedient for political purposes.

Trusting science during this era of social media and partisan politics may be very difficult to overcome. But 64 years ago this coming October, Elvis Presley stepped up. The eventual King of Rock-and-Roll became an influencer for a segment of Americans. More on that later…

Herd Immunity

Having trust in our national infrastructure to develop and distribute effective and safe vaccines is paramount to reaching herd immunity, which is having enough people become immune to a disease to make its spread unlikely. Many experts estimate between 60% and 70% of the population need to be immune in order to achieve herd immunity.

Here’s the growing concern: We could have the most effective and safe vaccine available, but if few Americans take it, then it won’t matter.

During the past six months, Americans have seen highly-touted solutions fall short of the hype. The U.S. and the world are starving for good news concerning a Covid-19 vaccine. The haste for finding the silver bullet is causing both confusion and hesitation for Americans to feel comfortable enough to eventually obtain a vaccine when it does become available.

As intent as one political party is for news of a year-end vaccine that could help ‘save’ the presidential election, the opposing party is nervously hoping any promising news does not occur until AFTER the election. Both parties are in precarious and compromised positions. This tug of war competition uses science as the rope.

Polling on ‘Vaccine Hesitancy’

Vaccine hesitancy is showing up in national polling during August. The results indicate that about half of Americans are ‘highly likely’ to get vaccinated for Covid-19. An Associated Press/NORC Center for Public Affairs online poll in May indicated that half of Americans would hesitate to take or refuse a vaccine, while a King’s College London study found similar numbers in the United Kingdom. To make matters worse, a vaccine may likely need two doses, not just one. Convincing people to seek a vaccine twice will be quite challenging.

According to scientists and America’s own Dr. Anthony Fauci, a widespread uptake of a coronavirus vaccine is the most effective tool in combating infectious diseases. But so far, the type of information being shared with Americans is both inconsistent and, in many cases, inaccurate. This is not a good combination needed to build the necessary trust in achieving herd immunity.

Below is a short list of examples that will erode American public trust if and when a proven vaccine becomes available.

1. Operation Warp Speed (OWS)

Introduced in early April 2020, Operation Warp Speed was initiated by the Trump Administration to facilitate and accelerate the development, manufacturing, and distribution of Covid-19 vaccines, therapeutics, and diagnostics. As a public-private partnership consisting of federal agencies and private pharmaceutical firms, OWS promotes mass production of multiple vaccines based on preliminary evidence allowing for faster distribution if clinical trials confirm one of the vaccines is safe and effective. Congress has directed nearly $10 billion to fund OWS so that any vaccine or therapeutic doses purchased with U.S. taxpayer money will be given to Americans at little or no cost.

Four coronavirus candidate vaccines are expected to be in large-scale clinical trials by the middle of September – a remarkable timeline since the SARS-CoV-2 virus was discovered in December. However, the marketing of “Warp Speed” causes concerns for critics and some science experts that the government and its research partners may cut corners that would increase the likelihood that chosen vaccines are not really safe and effective.

2. Convalescent Blood Plasma Treatments

On the eve of the Republican National Convention, the FDA Commissioner, Dr. Stephen Hahn, reiterated President Trump’s proclamation that 35 people out of 100 (35 percent) would survive the coronavirus if they were treated with convalescent plasma. This “historic breakthrough” was based on preliminary findings of Mayo Clinic observations.

However, medical experts and scientists – including former FDA officials – pushed back saying the treatment’s value has not been established, and the claims vastly overstated preliminary findings of the Mayo Clinic.  One day later, Hahn backtracked from his comments, stating, “…The criticism is entirely justified. What I should have said better is that the data show a relative risk reduction not an absolute risk reduction.”

The FDA is under intense pressure from the White House to move the approval process along when deciding whether upcoming vaccines are safe and effective for Covid-19.

3. CDC Using Yesterday’s Technology to Fight Covid-19

The Centers for Disease Control and Prevention (CDC) is the federal agency that has primary responsibility for handling infectious diseases, which is a huge lift during this pandemic. Yet, according to authors Joel White and Doug Badger in a recent Op-Ed in the Chattanooga Times Free Press, “the CDC uses an antiquated system to collect information essential to fighting the coronavirus.” The CDC, since 2006, has ignored four separate laws requiring it to build a modern, efficient system for collecting information to combat disease. Currently, they argue that “medical workers literally phone or fax in their data. And when they do, it’s not the data we need.” Fax???

During the week of August 24, the CDC quietly released controversial new guidelines that caused an outcry from various medical groups and allegations of political intervention. The agency dropped its previous recommendation to test everyone who’s come into close contact with a person infected with Covid-19 – even those who don’t have symptoms. Confusion reigns on what one should do if they become recently exposed but have no symptoms.  In fact, several large states and providers rebuke this latest testing plan.

4. Hydroxychloroquine

On May 18, President Trump claimed that he has been taking doses of hydroxychloroquine, a drug he has highly touted as a potential coronavirus cure despite concerns from medical experts and the FDA, specifically regarding its efficacy and potential harmful side effects.

Initial data from observational studies have shown this drug has limited or unproven benefits for Covid-19 patients, and could be harmful when used in certain combinations.

5. Reporting Glitches from the Iowa Department of Public Health

Not to be outdone by the CDC, according to an August 28 Des Moines Register article authored by Lee Rood, the state health department has drawn widespread criticism from other Iowa county authorities because of data collection and reporting problems, resulting in thousands of coronavirus infections being misreported. The accuracy of underreported new infections has plagued the state for months.

6. U.S. Postal Service Delivery Problems

This summer, U.S. Postmaster General Louis DeJoy, a Republican, has been slashing budgets and services due to poor finances, causing concern on whether the USPS can handle mailed-in ballots of three-quarters of the voting population this coming November. In fact, the Postal Service informed 46 states and the District of Columbia that it did not have service capacity to meet the deadlines for voters to request and send in ballots, prompting almost two dozen states to sue DeJoy and the Postal Service. The fundamental infrastructure for voting now becomes highly questionable because the mail service has become politicized.

Who will be the next ‘Elvis Presley’?

The first half of the 20th century saw a series of polio epidemics affect hundreds of thousands of children across the world. As a result, many were left seriously incapacitated, with one victim being Franklin D. Roosevelt, the future U.S. president.  Major research was launched to combat polio, and in 1955, Dr. Jonas Salk announced that he developed a vaccine, that provided more than 90 percent protection after three shots.

At that time in America, the American public was somewhat indifferent towards the importance of vaccinations, in fact, there were organizations that lobbied against vaccinations in general, including polio.

Initiatives were launched for children to take the vaccine, but few U.S. teenagers and adults sought to be immunized, most believing they were not at risk. To boost teenager take-up of the polio vaccine, Elvis Presley was recruited, receiving massive media coverage while receiving the shot prior to his appearing on the Ed Sullivan Show 64 years ago this coming October 28. Newspapers all over the country published photos of the Presley vaccination. This publicity ‘stunt’ suggested that the vaccine was safe and helped promote public confidence. Presley, it should be mentioned, continued to work on behalf of the National Foundation for Infantile Paralysis and the vaccination became one of his advocacies.

Moving Forward

Even in ‘better’ times, there is a segment of the American population that believe vaccinations are not safe and can cause dangerous health problems, such as autism. In 2015, a Pew Research Center study found that about one in 10 Americans believe vaccines for diseases such as measles, mumps and rubella are not safe for healthy children.

By this November, the U.S. Department of Health and Human Services plans to launch a public-awareness campaign across television, radio and social media, with the intent of focusing on vaccine safety and efficacy. Medical experts will be paired with celebrities to help these messages resonate with the public. Based on the confusion, doubts and concerns mentioned earlier, this will be a formidable challenge to overcome.

Several health policy experts envision vaccine ‘mandates’ coming from the government, much like the current vaccine requirements for school-age children, military personnel, and hospital workers. Imagine restaurants and bars having signs at the entrance saying, “No Shirt, Not Shoes, No Inoculation, No Service.” Providing proof of inoculation (and booster shots) could be mandatory before entering the establishment. In essence, being inoculated becomes your reward for doing the right thing.

It’s time to put science ahead of politics. Trust, as we all know, must be diligently earned.

Will the next ‘Elvis’ be able to restore our sagging confidence?

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Research on ‘Medical Errors’ Published in Journal of Patient Safety

NOTE:  Our peer-reviewed article concerning the prevalence of medical errors experienced by Iowans has been published in the September 2020 issue of the international publication, Journal of Patient Safety (JPS).  The article summarizes the experiences and opinions of a statistically representative sample of 1,010 Iowans, and provides new insights on approaches Iowa can take to determine the extent of the problem and develop solutions to obtain safer care for patients. 

The article, “Medical Errors in Iowa: Prevalence and Patients’ Perspectives,” was co-authored by myself and two others: David R. Andresen, PhD and Andrew Williams, MA. The article reports that medical errors, also known as preventable adverse events, are seldom voluntarily reported by healthcare providers in Iowa and the U.S.

Quantifying the magnitude of the medical error problem is an essential first-step toward solving these safety issues. The hope is that vulnerabilities in the healthcare delivery process will be exposed so that solutions can be found. However, the U.S. does not have a bona fide national strategy to assess medical errors, and, as a result, hospitals and clinicians around the country do not report medical errors accurately and consistently.

The JPS article suggests there is no single method for healthcare providers to promote full, transparent reporting of medical errors. However, the approaches described can serve as a counter-balance to lax provider reporting that includes the patient experience and perspective:

  • Implement mandatory provider reporting and appropriate compliance enforcement. From this, reported errors can help medical organizations more clearly understand exactly what happened, regardless of the outcome of the error, and identify the combination of factors that caused the error or near-miss to occur.
  • Create a central state repository for patients to report medical errors, making sure the reporting process is uncomplicated.
  • Develop an on-going, independent, random-sampling process to survey patients (and family members) who recently received care to document the prevalence and nature of medical errors. This is the most disruptive approach. From this collection process, state authorities, medical providers and the public will gain critical insight on the prevalence of medical errors, allowing for improvements. When errors are not reported and discussed, providers miss crucial feedback and learning opportunities.

The survey process can originate from claims data available through Medicare, Medicaid and private insurance companies. Patient experiences with medical errors can be collected and monitored for each medical provider, who would then receive systematic feedback about these errors to facilitate improvement processes. Through this data collection, results of medical errors would eventually be publicly reported for each institutional provider (e.g. hospital, surgery center, etc.).

A vast majority of Iowans have positive experiences with the healthcare system in Iowa. However, nearly one-in-five Iowa adults (18.8 percent) report having experienced a medical error either personally or with someone close to them during the past five years. Of those, 60 percent say they were not told by the responsible healthcare provider that an error had occurred. The survey found that hospitals were the most frequent site of medical errors (59 percent), while 30 percent of errors occurred in a doctor’s office or clinic, four percent in nursing homes and seven percent at some other location.

Among many important findings, the Iowa survey found that nearly 90 percent of Iowans “strongly agree” that healthcare providers should be required to tell patients about any medical errors. Additionally, 93 percent of Iowans “somewhat agree” (30 percent) or “strongly agree” (63 percent) the public should have access to medical-error information for each hospital and doctor.

Iowans feel strongly that medical errors must not be hidden from the public and should be reported, both to the patient and to an appropriate regulatory agency. Quality of healthcare will only improve when leadership, organizational culture and patient engagement are fully aligned. When seeking healthcare, patients deserve truthful, timely and transparent information about medical errors. Additionally, insurance companies can also contribute by embracing the safety of care their members receive from the medical providers included within their networks.

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