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The Horns of our Hospital Dilemma

Posted by John McDonough  April 21, 2013 05:19 PM

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Two articles this past week, each written in whole or part by Harvard's Atul Gawande, put our health care and hospital dilemma into exquisite perspective.

First, one can only feel admiration and respect for the incredible job done by Greater Boston hospitals and hospital personnel in the wake of the Marathon bombing. Our hospital system, our physicians and nurses and emergency personnel from across the City and beyond rose to the challenge in a deeply impressive way. If there was ever a moment to take collective pride in the world's most concentrated academic teaching hospital environment, this was it.

Here's a good account from USA Today highlighting the extraordinary efforts of our local and regional medical system in the wake of the terror.

As usual, Atul Gawande, the prize winning author, surgeon, and Harvard faculty member, put a special spin on it in a brief report for The New Yorker explaining Why Boston Hospitals Were Ready:

"Talking to people about that day, I was struck by how ready and almost rehearsed they were for this event. A decade earlier, nothing approaching their level of collaboration and efficiency would have occurred. We have, as one colleague put it to me, replaced our pre-9/11 naďveté with post-9/11 sobriety. Where before we'd have been struck dumb with shock about such events, now we are almost calculating about them. When ball bearings and nails were found in the wounds of the victims, everyone understood the bombs had been packed with them as projectiles. At every hospital, clinicians considered the possibility of chemical or radiation contamination, a second wave of attacks, or a direct attack on a hospital.

"We've learned, and we've absorbed. This is not cause for either celebration or satisfaction. That we have come to this state of existence is a great sadness. But it is our great fortune. Last year, after the Aurora shooting, Ron Walls, the chief of emergency medicine at my hospital, gave a lecture titled 'Are We Ready?' In Boston, it turns out we all were."

After so much complaining about our hospitals for their high costs and other flaws (from yours truly, among others), it feels good to take a moment to say congratulations for a job so exceptionally well done.

But only for a moment, because someone always has another perspective to throw on the table. Who is it this time? You guessed it, Atul Gawande.

Granted, he was only part of a team, but these days when Atul talks, people notice. This past week, the Journal of the American Medical Association published an important new study by Sunil Eappen, Gawande and others titled the "Relationship Between Occurrence of Surgical Complications and Hospital Finances."

Briefly, the team found that post-surgical complications in one southern U.S. hospital system were associated with a $39,017 higher contribution margin per patient with private insurance and a $1749 higher contribution margin per patient with Medicare. Basically, "many hospitals have the potential for adverse near-term financial consequences for decreasing postsurgical complications." In other words, under our current prevailing fee-for-service system, improving hospital quality and safety is bad for business. "We found clear evidence that reducing harm and improving quality is perversely penalized in our current health care system," said lead author Eappen.

In a related New York Times article, one of the authors put the results into perspective:

"The authors said in an interview that they were not suggesting that hospitals were trying to make money by deliberately causing complications or refusing to address the problem. 'Absolutely not,' said David Sadoff, a managing director of the Boston Consulting Group. 'We don't believe that is happening at all.' But, he said, the current payment system makes it difficult for hospitals to perform better because improvements can wind up costing them money."

I fully agree. It's not about hospital leaders refusing to reduce complications because it's bad for business. It is about system loaded with perverse incentives that don't give the results we all want, and that make it harder to fix what's wrong with U.S. medical care.

So while we rightly applaud and praise our local hospitals and medical professionals for their performance and integrity when we need it the most, we've still got a lot to do to get this system right. I believe we are on the right road by rejecting fee for service and moving to global payments, accountable care organizations, bundled payment, and the other financing reforms included in the Affordable Care Act, Massachusetts payment reform, and more. We still have a long way to go.  

So congratulations and thanks to our medical care professionals for your extraordinary service.  And let's keep working to get this system right on all sides.

This blog is not written or edited by or the Boston Globe.
The author is solely responsible for the content.

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About the author

John E. McDonough is a professor of practice at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011 by More »


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