The Medicare program is betting on a new course of action to curb what one medical journal has dubbed an "epidemic" of uncontrolled patient harm.
The effort is pegged to the success of a little-known entity called a "hospital engagement network" (HEN). In December, the government selected 26 HENs and charged them with preventing more than 60,000 deaths and 1.8 million injuries from so-called "hospital-acquired conditions" over the next three years. That would be the equivalent of eliminating all deaths from HIV/AIDS or homicide over the same period.
Despite those big numbers, and an initial price tag of $218 million, it's unclear whether the HENs are adequately ambitious or still only pecking away at the patient safety problem. While this is by far the most comprehensive public or private patient safety effort ever attempted in this country, it still aims to eliminate less than half the documented, preventable patient harm.
The inspiration for these networks comes from similar collaborative projects run by the Institute for Healthcare Improvement and other groups. Dr. Donald Berwick, IHI's founder and president, headed up the Centers for Medicare & Medicaid Services for two years and launched a larger Partnership for Patients that includes the HENs.
In December, the government chose a mix of national and local groups -- primarily health systems and hospital organizations -- to run individual HENs. Each HEN is charged with spreading safety-improvement innovations that have been proven to work in leading hospitals to others through intensive training programs and technical assistance. Although the program lasts three years, initial HEN contracts are for two years, with an "option year" dependent upon performance.
This bottom-line accountability is what sets the HENs apart from past voluntary efforts. Program co-directors Dr. Paul McGann and Dennis Wagner give weekly briefings to Health and Human Services Secretary Kathleen Sebelius. "This is a full-court press unlike anything I've seen in my 10 years in government," McGann says.
Although the HENs' total cost is slated to rise to $500 million by its third year, that's still chicken feed compared to what the government says will be savings of up to $35 billion from safer care, including up to $10 billion in savings for Medicare. In addition to preventing injuries and deaths, the program plans to eliminate 1.6 million preventable hospital readmissions.
Still, there remains the question of whether the program's goals should be even more sweeping. And one might wonder why the chance to not harm patients is not reason enough for hospitals to change without being paid by the government.
For context, it helps to understand that the most widely quoted estimate of preventable patient harm – 44,000 to 98,000 deaths and one million injuries annually – was probably low. That estimate caused an uproar in a 1999 Institute of Medicine (IOM) report. Today, it seems conservative. The IOM total was based on studies conducted in hospitals in the mid-1980s. Recent research by the HHS Office of the Inspector General (OIG) and others has found a much higher rate of harm. A Medicare patient today has a one-in-seven chance of suffering harm in the hospital, a risk about four-to-seven times greater than in the IOM report.
Moreover, nearly 9 out of 10 incidents are never reported, the OIG concluded, even including incidents that led to patient deaths. "If you measure all-cause harm, you find it in about one-third of patients," says the University of Utah's Dr. David Classen, lead author of a 2011 study that appeared in Health Affairs. That lack of progress testifies to very modest pressure to show results.
Enter the HENs, prodded by a stick.
In 2008, Medicare began denying payments to hospitals for eight complications of treatment, the program's first major use of negative incentives. The number of conditions has since increased, along with efforts to pressure hospitals through public quality report cards. Meanwhile, the 2010 health reform law includes financial penalties that go into effect later this year to discourage preventable readmissions.
Put differently, hospitals now have a significant financial as well as ethical incentive to participate in a hospital engagement network. Even so, just 3,800 of the nation’s 5,000 acute-care hospitals have done so.
Federal officials stress they are paying the HENs, which both guide and oversee hospitals, not individual institutions. For instance, a HEN run by a national consortium of academic medical centers is building a data analytics infrastructure which it will share with another HEN run by a national public hospitals group. State and local HENs have said they will form "learning communities," providing technical expertise and one-on-one coaching reporting and tracking databases. Each HEN will monitor member hospitals' progress and, in turn, be monitored by HHS.
Meanwhile, two groups that are operating HENs and are national leaders in patient safety say that the program will be helpful even in light of the care improvements they have already made. Executives at the Ascension Health system and the Premier hospital alliance say that the resources, cooperation and infrastructure assistance from the federal program will enable even their groups to reach a level of performance improvement unattainable on their own. One reason is that participants in the HEN must reduce hospital-acquired conditions by 40 percent from their starting point, not from a potentially laxer national average.
That still leaves the question of how much harm could truly be eliminated. HHS hopes to save 20,000 lives and roughly $12 billion each year. (The harm avoided will be to all patients, but only the financial savings from avoiding harm to Medicare patients will accrue to the program.) By way of context Premier says that if all U.S. hospitals achieved similar results to its QUEST collaborative, whose results were announced in January, it would save more than 87,250 lives and $34 billion in health care costs in just one year. Ascension has had similar success, although the two organizations are measuring a somewhat different set of indicators from each other and from the HEN program.
Consumer advocates such as Martin Hatlie, a co-founder of Consumers Advancing Patient Safety, and Helen Haskell, head of Mothers Against Medical Error, believe the program's target is too low. Still, both Hatlie and Haskell support the program's approach -- and the Medicare decision not to pay for some medical problems caused by hospital mistakes.
Says Haskell, "I do think federal dollars – whether offered or withheld – are the key to getting hospitals to pay attention to safety."
Michael L. Millenson is a Highland Park, Illinois-based consultant, a visiting scholar at the Kellogg School of Management and the author of Demanding Medical Excellence: Doctors and Accountability in the Information Age.