Getting The Bugs Out Of Health Reform

Nov 23, 2009

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This column is a collaboration between KHN and The New Republic.

Health professionals spend many thousands of hours training to cure disease. But they can learn how to stop the spread of deadly hospital infections in just a few minutes, by learning five steps for putting lines (that is, tubes) into patients’ bodies.

Wash your hands. Clean the patient’s skin with chlorhexidine, a special antiseptic. Cover the patient fully in sterile drapes. Don full protective gear, including mask and gown. Add a sterile covering to the site afterwards.

In a now-famous study of Michigan hospitals, a physician named Peter Pronovost was able to reduce the rate of in-hospital infection nearly to zero, simply by creating a checklist with these steps and then having hospitals empower nurses to enforce it. The reduction took place in big hospitals and small ones, urban and rural, famous teaching institutions and obscure community establishments. In short, the strategy worked everywhere, which means it ought to work anywhere.

These sort of hospital infections kill as many as 20,000 people a year. And they cost a lot of money to treat. Each episode requires about $45,000 a year in overall spending, which adds up to more than $2 billion a year by some estimates. Getting doctors and hospitals to adopt the anti-infection strategy should be, as Atul Gawande has observed in the New Yorker, a “no-brainer.”

Listening to the health care debate, you might think that Congress agrees. The proponents of reform talk all the time about improving the quality of care, both to save lives and make it less expensive, and frequently cite hospital infections to make their point. (Even opponents of reform have been known to agree on this front.) And the bills they’ve moved through the legislative process supposedly follow through on this.

But if you look closely at the legislation, you’ll see that the proposals fall a bit short on that promise. The bill that passed the House of Representatives last month does have a section on reducing infections--and, smartly, it applies not only to hospitals but also to out-patient clinics, which are prone to the same problems. But the House bill requires only that hospitals and clinics report the incidence of disease. The bill doesn’t attach financial rewards or penalties to the results.

The Senate bill Majority Leader Harry Reid just introduced is a bit better on that front. It establishes a monetary penalty designed to prod hospitals in the right direction: Medicare would reduce payments to hospitals whose infection rates put them in the worst quartile nationwide. But the penalty is tiny: Just one percent. And, unlike the House, the Senate chose not to extend the penalty to outpatient clinics.

Who stood in the way of doing more? Depending on who you ask, it was hospital lobbyists, career bureaucrats reluctant to tinker with Medicare, ideological opposition to aggressive regulation of medical care, or--most likely--some combination of all three. And, sadly, the same set of forces seem to have successfully undermined other, similarly inspired efforts at what’s come to be known as “delivery reform.” Remember the proposal to reduce preventable re-admissions? The policy applies only to a handful of conditions. And the commission to recommend Medicare payment changes? By law, the commission couldn’t touch doctors, hospitals, or hospices until 2019.

It’s important to keep these shortcomings in perspective. They don’t, for example, affect the Congressional Budget Office estimates of the bills’ costs, since CBO never gave them much credit anyway. (CBO has predicted reform will pay for itself largely because of tax increases and separate Medicare changes.) And if the measures in the law don’t go as far as they should, they would move our health care system in the right direction -- ideally, making possible more sweeping changes in the future.

But when it comes to making medical care not only cheaper but also better, reducing hospital infections is among the easiest changes to make--something reform really should be able to do, even in this political universe of such limited possibility. It’s an almost perfect test case of whether reform can, in fact, change medical care for the better. “If we can’t eliminate [hospital infections], we will never have a system that works for people,” says Harvard economist David Cutler. But if reform does eliminate (or even reduce sharply) the infections, Cutler goes on to explain, “it shows the government, providers, and taxpayers that we can do this.” No doubt something on this front is better than nothing. But we can still do a lot better than something.

Jonathan Cohn is a Senior Editor of The New Republic