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My Office in a Treehouse? Pandemic Reflections

Over the years, I have had the luxury of working from home when inclement weather or other circumstances dictated that I do so. Other than making sure that I had my laptop and a reliable internet connection, I was good to go.

This past February, my wife had her knee replaced, requiring us to make necessary changes within the living space at home to ensure a safe and convenient recovery. During this period, I worked remotely without any hiccups. A few days a week, I would stop by the office – just 12 minutes away from home – to pick up the mail and water a few plants.

On March 11, the World Health Organization declared the relatively little-known coronavirus outbreak to be a worldwide pandemic. Two days later, President Trump declared the pandemic a national emergency. Within days, our state and country ground to a halt, profoundly altering our personal and professional lives. ‘Social distancing’ became the new norm. Businesses shut down and our once-busy streets resembled something out of an old western movie, minus the tumbleweeds.

We all painfully know the story since March: Millions of Americans lost their jobs or were furloughed. Those employees fortunate to continue working were relegated to finding new ways to operate out of their homes. For many of us, working remotely continues to this day – and will likely continue into the foreseeable future.

During the last seven months, I have had ample time to reflect on whether or not working in an office – along with its’ associated costs – made economic sense. Much of the work I do revolves around research and analysis – some is outsourced to trusted partners. In short, my work requires a quiet workspace with internet access, a coffee maker and a phone for periodic conversations. Being tethered to a formal office space is optional.

Over time, I have found that phone calls were becoming about as frequent as using the fax (remember that relic?).  Prior to the pandemic, most in-person meetings were conducted over coffee or lunch. It really was that simple.

After weighing the pros and cons, the necessity of having a separate office suite became a very easy decision. Paying office rent and utilities, phone and internet, renter’s insurance and, to a minor extent, fuel to commute to and from the office, was a personal preference – but not a business necessity. All of this can be accomplished from home – or perhaps a slightly advanced treehouse.

In the not too distant past, I may have confused my work-based livelihood with where I worked rather than what I did at work. For me, I have sorted out this seemingly razor-thin difference and have reconciled what is most desirable. I can easily perform this same work in the confines of my home and not skip a beat on my output. The pandemic has proven to be a helpful audition, guiding me to feel more comfortable with this eventual change of converting to a full-time remote workplace.

I recently spoke with a local commercial realtor who told me that office space may become more plentiful because of the pandemic. This glut of office space, however, has not hit the commercial market quite yet, primarily due to the Paycheck Protection Program (PPP) helping offset payroll costs, rent, interest and utilities for small businesses. But with a prolonged pandemic, decisions similar to mine will likely follow. A Des Moines Register article on September 3 approached this topic, using some interesting national statistics.

My office conversion has already begun, and in about eight months when my lease expires, I will be sitting in my home den, lakeside or in other locations – performing the ‘what’ regardless of ‘where.’ I’m very comfortable knowing that making ‘sausage’ in the backroom will be no different from home versus an office suite some 12 minutes away. The treehouse idea, however, may need to wait.

Working remotely will be seamless, while wearing pajamas has yet to be decided!

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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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Five Myths about Expanding Tort Reform in Iowa

Five Myths about Expanding Tort Reform in IowaPublic discussion is gearing up on a very contentious healthcare topic: Medical tort reform. In a span of two days last week, there were two opposing viewpoints in the Des Moines Register opinion section on whether or not tort reform should expand in Iowa.  A Waterloo OB/Gyn wrote a piece supporting expansion, while I penned an opposing view one day earlier.

In Iowa, two bills are in the legislature, HSB 596 and SSB 3085. Both are being pushed by the healthcare provider community to ensure their medical-malpractice premiums are held in check by hard-capping ‘non-economic damages,’ at $250,000 – damages that “arise from pain, suffering, inconvenience, physical impairment, mental anguish, emotional pain and suffering, loss of chance, loss of consortium, or any other nonpecuniary damages.”

The specific argument being made by the Iowa Medical Society and others who support this legislation is that “Iowa’s health care crisis” has experienced five lawsuits since 2017 – whereby Iowa juries awarded plaintiffs more than $63 million for “non-economic damages.” The argument being made is that physician’s malpractice insurance policies have a $1 million – $2 million limit, while hospitals also have policy limits. Consequently, when juries award a large amount beyond these limits, the doctors and hospitals are forced to pay the rest out-of-pocket.

According to an article written by the Iowa Clinic in the February 14 edition of the Des Moines Business Record, the ‘simple solution’ is for the Iowa legislature to place a firm dollar hard cap of $250,000 on “non-economic damages,” but patients could still receive unlimited “economic damages” to cover treatment costs and lost wages. By placing a “reasonable” limit on “non-economic” damages, lawmakers, not juries, can ensure “fair awards” for plaintiffs, providers and hospitals “while keeping costs down for all Iowans.”

There you have it. Can we assume that hard-capping “non-economic” damages will miraculously eliminate “Iowa’s health care crisis” as we know it?  The quick answer is “NO.” But to better understand why Iowa’s on-going healthcare crisis will not be remotely solved by these bills, it is helpful to know the pertinent facts conveniently left unshared by the Iowa medical establishment.

There are five myths that the medical establishment would like for lawmakers (and key health payers) to believe. I will summarily refute each myth with some verifiable facts.

1. Iowa malpractice premiums are greatly increasing

Overall, insurance is a risk tool that is predicated on the experience of those being insured. If claims go up, the premiums will also move up. As is often the case, insureds are encouraged to mitigate the inherent risks within their organizations to keep the premiums affordable. The same principle applies to physicians and hospitals. If ‘safety’ and ‘best practices’ that help avoid preventable medical errors are widely pursued, adopted and implemented as the new culture of a medical organization, claims and, consequently, med-mal premiums would indeed go down.

For some Iowa physicians and hospitals, it is true that med-mal premiums are increasing. Much of this will depend on the actual claims experience for each physician practice and hospital. Here is what we currently know about med-mal premiums in Iowa:

  • Over the last 10 years, the medical liability insurance industry has taken in $709 million in premiums from the Iowa medical profession, and paid out just $308 million in combined losses and expenses. Stated another way, the med-mal insurance industry has $401 million in surplus premiums. (Source: NAIC Countrywide Summary of Medical Professional Liability Insurance – Calendar Years 2009 – 2018)
  • The average Iowa medical malpractice insurance premiums have increased 0% for Iowa doctors over the last 10 years. (Source: Annual Rate Survey, Medical Liability Monitor, October 2009-2018)
  • Over a 20-year period (1990 – 2010)*, only 1.73 percent of Iowa physicians were responsible for one-half of all the money paid out for medical malpractice in Iowa. Most of these physicians had multiple malpractice payments. If this small proportion of physicians were either ‘re-trained’ or ‘restricted’ from practicing in this same pattern of behavior, the claims could be cut in half. But only 16 percent of these doctors had reportable action – not even a slap on the wrist reprimand – by the Iowa Board of Medicine. About 10 percent had any reportable action taken against their clinical privileges by an Iowa hospital. Consequently, only about one-sixth of the 1.73 percent of physicians have had any action taken against their licenses – and only one-tenth of them have had any action taken against their clinical privileges. (Source: Robert E. Oshel, Ph.D., retired Associate Director for Research and Disputes for the National Practitioner Data Bank at the U.S. Dept. of Health and Human Services.)

*This calculation was made by Dr. Oshel in 2010 for each state, but has only been repeated since then on a national level only. The calculation is Dr. Oshel’s own independent, unpublished research using the NPDB Public Use File for reports information from www.statehealthfacts.org for the number of physicians in the state. This data was last updated using June 2019 data. According to Dr. Oshel, “the results for this almost 30-year period were very similar to what they have been for the 20-year period using the 2010 data. I would expect 30-year Iowa data also to be very similar.”

2. Tort reform reduces medical errors

The tort reform push in Iowa does nothing to address the root causes of why preventable medical errors occur in the first place. The medical establishment wishes to use hard caps to mitigate their claims and hold down their insurance premiums, but hard caps do not address or incent physicians and hospitals to provide safe care more effectively, through best practices.

After Texas implemented a hard-cap tort reform (passed in 2003), a University of Texas School of Law report years later (authored by Silver, Hyman and Black) stated that “Using standard patient safety measures, we find evidence that hospitals made more avoidable errors after the adoption of HB4 (name of reform).” This report, by the way, does an excellent job of detailing the actual subsequent outcomes of malpractice claims, healthcare costs, influx or exodus of physicians due to tort reform, and other issues that refute many of the arguments made by hard cap supporters.

A study by Black & Zabinski examined five states that enacted caps during 2003-2005 used standard Patient Safety Indicators (PSIs) that were available for at least two years prior to caps being implemented in each state allowing for comparisons later. When comparing data in the five states (Florida, Georgia, Illinois, South Carolina and Texas) to PSIs from previous years, and with other ‘control’ states, the authors determined:

  • “Consistent evidence that patient safety generally falls” after caps are passed.
  • “We find a gradual rise in rates for most PSIs after [caps were passed], consistent with a gradual relaxation of care, or failure to reinforce care standards over time.”
  • “We find evidence that reduced risk of med mal litigation, due to state adoption of damage caps, leads to higher rates of preventable adverse events in hospitals.”

(Source: Bernard S. Black and Zenon Zabinski, “The Deterrent Effect of Tort Law: Evidence from Medical Malpractice Reform,” Northwestern University Law & Economics Research Paper No. 13-09 (July 2014). http://ssrn.com/abstract=2161362.).

The ultimate question that Iowa lawmakers must answer is whether hard caps will reduce medical errors. Unfortunately, rehabilitation of health providers to provide better and safer care is not baked into this tort reform, and other states consistently prove this point. Eliminating financial deterrents for medical providers will only shield them from having accountability to their patients.

3. Tort reform will reduce healthcare costs

The Texas report does confirm one key initiative that physicians and hospitals supporters wish to have:  Hard caps through tort reform greatly reduces the frequency of paid med mal claims, in addition to sharply reducing total payouts.

But implementing hard caps will do little-to-nothing toward curtailing healthcare costs. Various national sources indicate that between 21 – 47 percent of healthcare costs are considered to be waste. This waste, which represents about $1 trillion in the U.S., comes from six categories:

  1. Administrative Complexity
  2. Overtreatment – includes excessive and inappropriate care
  3. Fraud and Abuse
  4. Pricing Failures
  5. Care Delivery Failures
  6. Care Coordination Failures

Many of the above problems exist due to inefficiencies in a poorly-functioning healthcare system. Tort caps are nothing but a small band aid to a much larger systemic problem that the medical establishment fails to meaningfully address. When using this information, the estimated annual waste in Iowa employer health premiums is $2,400 for single and $6,600 for family coverages.

A 2014 study by Black, Hyman and Paik, examined healthcare spending trends in nine states that enacted caps during the period, 2002-2005, and compared this with data from other ‘control’ states. The authors found:

  • “Damage caps have no significant impact on Medicare Part A (hospital) spending, but lead to 4-5 percent higher Medicare Part B (physician) spending.”
  • “[O]ne policy conclusion is straightforward: There is no evidence that limiting med mal lawsuits will bend the healthcare cost curve, except perhaps in the wrong direction. Policymakers seeking a way to address rising healthcare spending should look elsewhere.”

(Source: Bernard S. Black, David A. Hyman and Myungho Paik, “Do Doctors Practice Defensive Medicine, Revisited,” Northwestern University Law & Economics Research Paper No. 13-20; Illinois Program in Law, Behavior and Social Science Paper No. LBSS14-21 (October 2014), http://ssrn.com/abstract=2110656.)

The Texas study mentioned earlier found that “tort reform is unlikely to reduce overall healthcare spending, and could even lead to higher spending…that overall (healthcare) growth is driven primarily by rapidly rising costs for prescription drugs, and by healthcare providers, especially hospitals, charging ever-higher prices for doing much the same things as before.” The report found that “Doctors who fear liability may sometimes do more (conduct more defensive tests and procedures) but they may also sometimes do less (avoid risky procedures). Texas was among the higher spending states per capita before (tort) reform, and is among the higher spending states today.”

4. Tort reform will increase physicians in our state

If tort reform in Iowa is the solution to attract and retain physicians, we can learn from Texas and other states that have already implemented these reforms. A major finding from the Texas study revealed that “neither an exodus of physicians before the passage of HB4 nor an influx thereafter…Texas had a lower ratio of physicians to population than most other states before reform, and has a lower ratio today.”

Another study by Black, Hyman and Paik, examined physician supply in nine states that enacted caps during 2002-2005, and compared this data to other “control” states. The authors found:

  • “No evidence that cap adoption predicts an increase in total patient care physicians, in specialties that face high med mal risk (except plastic surgeons), or in rural physicians.”
  • “[W]e find no evidence that the adoption of damage caps increased physician supply in nine new-cap states, relative to twenty no-cap states.”
  • “Physician supply does not seem elastic to med mal risk. Thus, the states that want to attract more physicians should look elsewhere.”

(Source: Bernard S. Black, David A. Hyman and Myungho Paik, “Does Medical Malpractice Reform Increase Physician Supply? Evidence from the Third Reform Wave,” Northwestern University Law & Economics Research Paper No. 14-11; University of Illinois Program in Law, Behavior and Social Science Research Paper No. LBSS 14-36 (July 2014) http://ssrn.com/abstract=2470370.)

A suggestion to Iowa lawmakers would be to find new approaches to support effective strategies ensuring the Iowa Board of Medicine has all the resources it needs to take action when confronted with physicians who repeatedly have malpractice claims and payments brought against them. Self-policing of doctors can be effective when appropriate culture allows for this to happen. Additionally, Iowa hospitals should be encouraged to ensure that peer reviewers take needed actions. As mentioned earlier by Dr. Oshel, restricting or retraining this small proportion of physicians would be most beneficial to patients and other doctors practicing within Iowa.

Another issue that was raised by the OB/Gyn physician who wrote the DMR Op-Ed is rural communities and their hospitals. It is true that rural hospitals are financially struggling. Rural providers are not seeing as many patients as they have in the past, and because of an older patient mix, they are increasingly being paid at reduced amounts by public payers, such as Medicaid and Medicare. This requires a host of other difficult decisions and solutions, but this discussion and any subsequent solutions goes well beyond med mal issues. This is not only an Iowa problem, it is a national concern.

5. Tort reform reduces defensive medicine

It is true that defensive medicine – a practice by which physicians and hospitals perform additional tests to help mitigate potential lawsuits – is a problem. But as mentioned earlier, there are six primary categories that are extremely wasteful in our healthcare system that require major reform.

A 2010 paper by Mello et al. attempted to determine the cost of defensive medicine in the U.S. The authors took great effort to review other reports on this topic, but conveyed language from the U.S. Congress Office of Technology Assessement, stating, “that defensive medicine is highly prevalent, [but] reliable estimates of its cost are notoriously difficult to obtain.” Mello et al. ventured to estimate that the overall health system cost of defensive medicine to be $55.6 billion in 2008 dollars, approximately 2.4 percent of total national healthcare spending in 2008.

The argument that defensive medicine is expensive has merit, but we must not be led to believe that it makes up a large component of high healthcare costs – it does not. It is important to keep our eye on the true drivers of healthcare costs and the associated waste.

Summary

I do not support unwarranted lawsuits that result in large payouts. But I will say, especially with this particular issue, there are two sides to this story. Much too often, the lobbyists who represent the medical establishment are powerful, vocal – and extremely well-financed – to promote their own self-interests at the public’s expense. They will use this particular issue to leverage the argument about why we have skyrocketing health costs in our state and country. I wish it were that easy.

Iowa and the U.S. does indeed have a “health care crisis.” But it is not because of malpractice costs…which is merely a symptom of a much larger issue. Medical errors are the third-leading cause of death in the U.S.  Based on my analysis in 2016, “Silently Harmed’ in Iowa,” using Iowa and national hospital data, an estimated 2,400 Iowans die and 85,000 are harmed in Iowa hospitals by preventable medical errors each year. Even if the actual numbers were a quarter of these estimates, we would still have an absolute crisis on how care is performed in our state and country. It must be said that estimates are necessary because medical providers often fail to report medical errors, which would be a useful process to gauge future improvement initiatives.

True reform should not come in the form of med mal caps, but rather, how Iowa medical organizations practice and behave in the delivery of medical care. Additionally, the small proportion of Iowa physicians who make up about half of malpractice costs must be held accountable, primarily through the authority and appropriate action of the Iowa Board of Medicine.

Former Senator Daniel Patrick Moynihan said it quite well, “Everyone is entitled to his own opinion, but not to his own facts.” This discussion represents the other side of what we are being led to believe as truth.

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