Gambling on Health Care

by Kim Bellard, November 23, 2010

I heard a speech by Tom Daschle recently, and something he said really struck me: to paraphrase, he pointed out that we can get more performance statistics on virtually every athlete than we can on any physician.  He’s not entirely right, but he’s close enough for this statement to hit home.

My tablemate at the speech suggested to me that fantasy leagues in health care might help solve this problem, which I think is a great idea, but perhaps what we really need to motivate getting more information on health care providers would be to introduce gambling into the health care system.  Oh, wait, cynics might argue that we already have gambling; we call it health insurance, and the bookies are actuaries. 

I’d argue that we have a different and more insidious form of gambling: simply getting care.

The HHS Inspector General recently released a report indicating that 13.5% -- that’s one in seven -- of hospitalized Medicare beneficiaries suffered an adverse event that caused a lasting impact or even death during the month reviewed; some 134,000 patients just in one month.  Worse than that, 15,000 of those patients ended up dying due to their adverse event; just in one month, just for Medicare patients.  An additional 13.5% of the hospitalized beneficiaries suffered events that caused temporary harm.  The researchers determined that 44% of the various events were preventable, and that the adverse events cost Medicare some $4.4 billion annually.  I say again: these deaths, and those costs, are only for Medicare patients. 

Sad to say, but these statistics no longer come as a surprise.  It’s been over ten years since the Institute of Medicine produced their estimates that as many as 98,000 deaths annually are due to medical errors.  The IOM also estimated that medication errors injure 1.5 million people annually.  Various other studies, including Zhan and Miller (2003), come up with similar sorts of numbers for hospital deaths.  I previously blogged about a study reporting on adverse surgical events that should scare anyone facing surgery.  One could conclude that going into a hospital is a crap shoot as to if you’ll be walking out with both legs intact, or walking out at all.

And it’s worse than that.  A study by a study by McGlynn, et. al., indicated it’s also essentially a coin flip as to whether you’ll get the recommended care when going to the doctor’s office.  Similarly, a study by the Urban Institute cautioned that “…patients may be at greater risk of safety problems in the United States than they are elsewhere,” citing issues with surgical and medical errors, issues with safe medication practices, receiving delayed or incorrect test results as examples. 

Given all these problems, one could naively conclude that it is no wonder that medical malpractice costs are high; reimbursing patients harmed by all this problematic care would be expensive.  That would be naïve indeed.  It appears that our malpractice system doesn’t make either patients or health care providers very happy.  Studies suggest that only a very small number of patients suffering actual medical errors even filed claims (see Localio, et. al.), and that as much as 54% of every dollar spent on compensation go to administrative expenses, such as lawyers’ fees and court costs (Studdert, et. al.).  Then there is the shibboleth of defensive medicine, which everyone agrees exists but which is hard to quantify.  Mello, et. al. bravely estimates that defensive medicine accounts for about $46 billion of the estimated $55 billion spent on medical liability, while Jackson Healthcare concluded that the order of magnitude was between $650 billion and $850 billion.  Whatever the number is, we can all agree it is big.  Defensive medicine as a way to reduce malpractice risk is like trying to hit a piñata; not really sure where the target is or what will happen if you do hit it. 

Which leads me back to statistics.  Our current liability system is based on fear and blame.  Documenting and reporting on errors can indeed seem foolhardy in a system that seeks to find deep pockets, not to fix problems or improve care.  It’s no wonder better data doesn’t exist and available data is hard to find.  Reform efforts based around capping liability payments miss the point almost entirely.  We need an entirely different mindset.

We have to start with the data: what happened, what went right, and what went wrong.  We should be looking for patterns, trends, and opportunities – not for culprits. 

We have to recognize that not everything that goes wrong is malpractice.  The notion that we will ever have an error-free health care system is folly, but at least we can get a clearer idea of who is making which errors how often.  Errors need to be tracked, and used to identify processes that can be improved.  Only with that kind of data can true quality improvement efforts happen.

Just as there will always be errors, there will also always be some unexpected medical outcomes.  Those are unfortunate, but they may not be due to any errors and may not be anyone’s fault.  They should be treated and fixed, without recourse to litigation or blame.  However, expecting patients or their insurance to pay for this follow-up care can unduly reward providers in a fee-for-service system, and payment reform should address.

There will still be a small number of situations where a health care provider is practicing in a manner that is not consistent with available medical evidence or best practices, is treating patients while impaired, or otherwise not acting in the patient’s best interests.  These are the situations where liability comes into play, but one would hope in a more transparent environment there would be fewer opportunities for harm to occur.  In theory, the medical profession self-polices itself, disciplining wayward members, but it is hard to imagine how this could ever happen under the current system of haphazard and incomplete reporting. 

Collecting the necessary data, and making it public, should go a long way to ensuring that patients are getting the right kinds of care from the appropriately qualified providers.  If we’re going to gamble with our lives and our well-being, I want to know the odds and I want to make sure I’m getting care from someone who would be on my health care fantasy team.