Court rulings, cost cutting and culling hospital inspections: More of the best health stories of 2013

I wrote about five of my favorite health stories for 2013 on Monday. Here are the rest of my 10 favorites for the year.

1. Not so random: patient complaints and ‘frequent flier’ doctors, Ron Paterson, Quality and Safety in Health Care

I have spent a considerable amount of time writing about doctors who have abused patients, defrauded taxpayers, and generally left a black mark on the medical profession. At times, though, I have wondered whether focusing on one doctor behaving badly was really worth it given the large, systemic problems that cause so much harm. Now here comes Ron Paterson, a law professor at the University of Auckland, writing about a series of studies in Australia that show how really bad doctors can do a hell of a lot of damage. This piece should be a must read for anyone interested in patient safety. Paterson wrote:

For safety and quality researchers, complaints may be ‘canaries in the coal mine’, sounding an alert to deeper problems. Complaints also provide undiluted feedback on a patient’s experience, an important measure of quality. …

No one with a passing familiarity with the world of patient complaints will be surprised by the fact there is a group of ‘frequent flier’ doctors who attract a disproportionate share of complaints. What is surprising is the extent of the problem. A small minority of doctors accounts for around half of all complaints to official agencies. …

The public is used to being told, in the wake of inquiries into adverse events in healthcare, that the underlying problem is systemic and will not be fixed by person-centric solutions that focus on individuals. Undoubtedly a systems approach (examining all the factors that contribute to shortcomings in care and communication) offers the greatest potential for improving the quality of healthcare. But the existence of a small group of complaint-prone doctors who loom so large in the corpus of complaints made to external agencies is sobering. However unfashionable it may be to focus on individuals (‘bad apples’), there is clearly a need to do so in this context. Indeed, the fact repeat offenders can continue unchecked indicates a failure of colleagues, employers and regulators to respond satisfactorily — a different kind of ‘system’ problem.

2. Supreme Court ruling has chilled fraud probes of state institutions, Miles Moffeit, Dallas Morning News

Reporters run into road blocks all the time. Unanswered phone calls. Redacted records. Steep fees for providing information that should be easy to acquire. Yet few reporters ever stop to ask, “Why?” Fewer still report the answer and publish it. For this, Miles Moffeit should win a special award this year. He did journalists – and the public – a great service by exploring the far reaching ramifications of a now 13-year-old Supreme Court ruling. He wrote:

State institutions possess a powerful legal shield against federal civil fraud cases, particularly those triggered by whistle-blower lawsuits.

In 2000, the U.S. Supreme Court gave state entities the ability to claim immunity against suits filed under the U.S. False Claims Act. That landmark ruling in Vermont vs. Stevens has since chilled efforts by whistle-blowers and the federal government to expose fraud inside state institutions or hold them accountable for wrongdoing, legal experts say. …

The Stevens ruling had a quick impact on whistle-blower suits against state entities.

Cases under investigation by private attorneys were dropped. Cases winding through the courts were tossed. And the pipeline to the government for exposing potential fraud inside state governments was virtually choked off, attorneys say. …

Prior to the 2000 decision, however, whistle-blower suits against at least nine state academic medical centers during the 1990s led to $74 million in settlements with the Justice Department.

3. Should NC limit secret court settlements? Steve Daniels, WTVD

Similarly, Steve Daniels at the ABC station in Raleigh, North Carolina, decided to question something that most medical malpractice plaintiffs and most of the public assumes is normal: secret legal settlements. One of the biggest inducements to get a health care entity to settle a lawsuit is the promise that no one will ever hear about what happened that led to a patient being injured or killed. That’s unfortunate because this culture of silence prevents shared wisdom from improving health care over time. Daniels wrote:

Legal experts say the majority of lawsuits end with the injured plaintiff signing a secret settlement for an undisclosed amount of money. That means we may never hear all the details of the case, and we may not have the information we need to keep our families safe.

"The plaintiff's right to speak, their First Amendment right, is something that they can give up," explained Duke law professor Don Beskind. "In effect, they're getting paid to give up that right."

"If you take a defective product, somebody who's been injured by a product, if all those cases are settled with confidentiality agreements, the public won't be aware that a particular product is dangerous," Beskind continued.

Legal experts point to the Firestone tire case more than a decade ago as an example. Years before Firestone decided to recall its tires, the company used confidentiality agreements when it settled lawsuits that claimed injuries and deaths caused by failing tires on Ford SUVs.

Those secret settlements prevented people who claimed they were impacted by the tires from disclosing the dangers to other consumers - dangers a federal investigation linked to more than 270 deaths.

4. The Kindest Cut: How One Hospital Lowered Costs by Making Doctors More Budget Conscious, Dr. Toby Cosgrove, Time’s Healthland

Both Steven Brill writing for Time and Elisabeth Rosenthal at The New York Times dove into health care costs this year, and their pieces are well worth your time. My favorite part of these examinations, though, was a short piece by the CEO for the Cleveland Clinic. He wrote about how his health system asked its physicians to look at the procedures they performed the most and to examine all of the underlying costs, as he put it, “to record the price of sutures, count how many instruments were on the table, tag the devices on the shelf and record how long patients spent in post-anesthesia care.”

Take, for example, nitric oxide, a drug commonly used in heart, lung and chest surgeries to keep tissues well-supplied with oxygen during the operation. When it’s effective, it’s very effective, but it doesn’t help all patients. When we realized we were spending $2 million a year on the drug, we drilled down to see who was using it and why. We found that doctors and OR staff did not have a standard protocol to guide them on when and how much to rely on nitric oxide; we had to educate them that if the drug didn’t work within a half hour of being administered, it won’t work at all, so repeated doses were wasteful. The result: nitric oxide use dropped by half, saving $1 million without any adverse effect on patient care.

That was one of the modifications made in the OR. But each hospital department is different. In some, price lists are taped to supply cabinets. In others, posters remind everyone to choose supplies carefully, stressing this message: “Without compromising quality, consider cost-effective alternatives.” With these interventions, within a year and a half, we had already topped our $100 million goal; after three years we saved $155 million.

This isn't soley about price, though.  It can't be.  If nitric oxide is needed, doctors use it.  In any of the discussions, the first determination is what is best for the patient, not the price of a product.  And it's the doctors who are making these decisions.

5. AHCJ unveils hospitalinspections.org, Association of Health Care Journalists

The Association of Health Care Journalists handed reporters a gift in March. The organization had pushed the federal government repeatedly to release electronic copies of its hospital inspection records. Instead, the Centers for Medicare and Medicaid Services required reporters to submit Freedom of Information Act requests and then would comply with those requests by mailing hard copy documents that could not be searched quickly or compiled in any uniform way. AHCJ persuaded CMS to release the records from January 2011 to present. Then AHCJ made the records searchable by keyword, city, state, and hospital name. So, for example, I can search for “overdoses” in Illinois and find seven different inspections that are relevant. The database already has become a great resource for local reporters.

Ken Stone at the Coronado Patch in California wrote Wrong Box Pulled from Shelf Sparked U.S. Probe of Hospital Implant Flub.

David Wahlberg at the Wisconsin State Journal wrote Health Sense: New meningitis vaccine and other updates.

James Ritchie at the Cincinnati Business Courier wrote New data reveals Cincinnati hospital safety violations.

Dan Tilkin at KATU in Portland wrote Medical errors underreported. Why? System voluntary.

And Aaron Boyd at the Brookfield Patch in Connecticut wrote View Detailed Complaint, Violation Records for Danbury Hospital.

Did I miss your favorite? Nominate your own on Twitter using @wheisel and the tag #besthealthstories.

Image by shorts and longs via Flickr