Friday, July 29, 2011

The Cost of Safety

At a time where the nation is struggling with a debt crisis driven in large part by the cost of our health care entitlement programs Medicare and Medicaid, the press reports of larger hospitals with fewer beds continue:
A southwestern Indiana hospital expects to start work in the coming months on a $100 million construction project to replace much of its existing facility that has parts dating back more than a century.

The master plan for the project approved by Good Samaritan Hospital's board includes a new 120-bed, five-story inpatient tower.

The completed project will see the hospital's capacity drop by 67 beds to 165, but Good Samaritan President Rob McLin said it will allow for growth in areas such as oncology, orthopedics and cardiology care.
You can never be too safe. Infection control requires single rooms with big screen TVs that have internet and personalized meals. Really it does.

No matter what the cost, it's safety, safety, safety. Entire institutes full of safety experts have sprung up the help hospitals make sure they keep the message coming and to fufill the lofty goal of never having a readmission. Hopsitals pay these institutions hefty sums to make sure they comply with mandated safety classes for all of their employees. In fact, these lessons is so important that they even give their directors millions of dollars of safety-inspired compensation packages to make sure their family members have a lifetime of safe health care after they retire.

And then there's that not-so-little issue of medical equipment expiration dates. Imagine if one of those foam headrests in the operating room were to expire! "You can't use those any more, doctor, they're expired!"

So we throw them away and order more.

In every hospital across our land this happens. Tons and tons and tons of medical waste because of expiration dates for things that, practically, shouldn't have expiration dates. But because we have regulations regarding how long things can sit on shelves in hospitals, we label them with expiration dates. "Order more, please." After all, if the Joint Commission finds expired headrests, hospitals might lose their accreditation. Our medical supply industry, full of middlemen like group purchase organizations that exist to get a better deal on bulk orders (really), is only too happy to comply.

My point here is not to speak badly of the need for safety in hospitals, rather a need to gain some equipoise on the subject. It is true that we've done a pretty good job improving surgical infection rates in America with things like pre-procedure antibiotics, antibacterial drapes, and good technique. But I wonder what's more expensive for our system in the long run, hand washing with soap and water or foam alcohol dispensers that have cannisters that have to be refilled and repurchased time and time again. what about all those plastic gowns we wear because a nasal swab shows traces of the genetic makeup of a single methicillin-resistant bacillus in a patient's nose? Or might all that plastic we purchase ultimately become more expensive to our health care system and environment in the long run?

These are not convenient questions to ask. But, given our concerns about the costs of health care and its affect on our economy, it seems to me that doctors AND patients had better start looking for (and demanding) ways to save money with the little things we do every day that might not be viewed as perfectly safe but rather, perfectly acceptable.



rlbates said...

So very well said, Dr. Wes!

a longtime reader said...

the term debt crisis is very misleading. we are not in a debt crisis. we are in a crisis caused by politicians who refuse to raise the debt ceiling, so instead the us government may be forced to default on its obligations- this act- defaulting, would increase the debt owed by raising interest rates we pay. to say that the current debt issue is largely due to healthcare is not accurate. by using the phrase "driven in large part"- you are inferring that over 50% of the current debt is due to medicaid & medicare. this is simply not true.

i go back and forth between loving and hating your posts. i love them when they are about the current state of electrophysiology but do not care for the false and misleading statements about government policy. i will continue to read because of the wonderful information you present and write about but will just start skipping over the posts about politics.

Alert and Oriented said...

Equipoise cannot be reached in a centrally planned economy, which is what health care has become increasingly over the last several decades. Because consumers (patients) don't immediately bear the cost of safety so as to modify their consuming behavior, there is no way to tell how much safety is enough. For the bureaucrats who are making the decisions (and their advisers like the IOM), there is never enough safety. That's because a bureaucrat's main incentive is to keep his job and not have his name or the name of his agency reported in the press in relationship to an "avoidable tragedy." And for bureaucrats, funds are unlimited as they come for your pocket and mine...

Andrew_M_Garland said...

Safety is not an absolute good. People routinely trade off safety against cost and pleasure.

People ski, routinely endangering life and limb for a thrill, paying a good amount to do it. People drive to work, trading unsafe car travel for higher incomes and personal freedom. But, some people do not ski, and a few people avoid cars as much as possible because they are too unsafe for them.

What is the proper amount of safety in a hospital compared to the costs of acheiving it? No one can know in general, because individuals vary. The "right" outcome would deliver an optimal amount of safety vs cost for each individual. That is a tough problem, but the best compromise is a process of discovery. That process can only come out of "market" interactions. Those interactions are eliminated by the current highly regulated, top-down mandates of a central bureaucracy interested in its own importance.

I wouldn't pay more for an unexpired pillow, unless it smelled bad. I would pay more for a hospital with convenient hand-washing stations and a rule against shaking hands with patients.

If patients cannot benefit from the lower costs of safety equipoise, then the system will fix at too much safety at too high a cost. Vital care will be rationed, rather than delivered at slightly greater risk. Too little safety increases death. Too high a cost increases death.

Anonymous said...

Where to start? I guess I might start with two questions. Where would we be without the 2001 and 2003 tax cuts? Where would we be if we had PAID for Afghanistan and Iraq? Sorry - third question. How would you re-do the Medicare Meds program? Would you maybe include the ability to negotiate price? But back to your issue... The first thing we might try is to have transparency on in-patient costs. Is there a web site where I can see how much it is going to cost to have this heart valve replaced? You're not big on bureaucracy, but how many do get MRSA while hospitalized? What are the costs of those infections? Are those infections reduced with new regs? What are those savings?

Damn. You drive me crazy. You love the new medical technology and their marvels, but at heart I picture you happiest as the careworn doctor in that familar painting sitting in the lamplight by the bedside of a dying patient. Nothing is between you and that patient - except, of course, death. But no bureaucracy!

I fear your heart is in 1880 and your head is in 2015. Like the rest of us - you're doomed.

Tim Hulsey said...

The JCAHO people need to get a real job!! When you have an oragnization with a captive whipping boy and mandates from the government to "improve" the system, they will find things to lash out about, even if they have to make them up; even if they have no data to support their recommendations! Buy more instruments so you don't have to flash sterilize, since this shorter cycle, which has probably been in use for not quite a hundred years yet, might lead to more infections. Is there any data to support the pressure to stock up on expensive surgical instruments? NO!! Then, it must be cost effective? NO!!!! But JCAHO can't be seen to be finding everything adequately handled! They have to create a problem where no problem really exists just to justify their own existence! Asking an organization to find fault with a system is a self fulfilling prophecy.
Maybe we could swap the JCAHO for the NCAA!! I suppose we would then have to worry about recruiting practices, though!