When we’re going in for surgery, we want to feel comfortable that the surgeon is more than competent. That’s a big reason many people seek second opinions, pursue recommendations from friends, and read online reviews of providers. We have to put a lot of trust into the surgeons that are responsible for us in our most vulnerable moments. We want to know that our faith is in the hands of an expert – and a hospital system – that is putting our interests far ahead of its own. This may come as a surprise, or not, but sometimes our best efforts and our faith end up in the wrong hands.
It turns out that medicine in the United States is a business, and some of the incentives behind institutional decisions are not based solely on improving patient outcomes. And sometimes these decisions are made to protect individual careers, to protect reputations, and to keep a steady stream of paying patients coming in the door. In an era of increasing efforts (and, hopefully momentum) to improve transparency throughout healthcare, some hospital systems take efforts to obscure their own substandard mortality rates.
A specific example was laid out this week by Ellen Gabler at the New York Times, who has published a lengthy investigation into the machinations behind the University of North Carolina Hospital system. The article reveals several truths in American Health Care: that “competition” does not always mean superior patient care; that positive surgical outcomes are tied to frequency of surgeries, and that patients = $.
While in theory competition in a market economy should be promoting an improved product, that is not necessarily the case for specialized care. A saturation of the market may lead to a dispersal of talent and resources, when the way to improve outcomes comes from doing the opposite: focus the talent, resources, and experience in fewer locales. The Times article noted that Swedish and UK efforts to consolidate cardiac surgery hospitals resulted in cutting mortality rates by 80% and greater than 50%, respectively. A substantial driver against consolidation is that surgical patients are major revenue drivers for hospitals.
Next, it only makes sense that “practice makes perfect,” right? While we know nothing is perfect, particularly in medicine, a lot of empirical evidence demonstrates that surgeons who do more of a particular type or types of surgery are going to be better at it. The Times article shows that the mortality rate at the University of North Carolina Hospitals in pediatric cardiac surgery was unusually high, while the number of surgeries performed was substantially lower than a majority of their peer hospitals. This disproportion could be due to quality of individual surgeons, or communication among surgical teams, or a number of other reasons.
Finally, surgical patients are substantial revenue drivers for any hospital. The Seattle Times covered this extensively two years ago in their “Quantity of Care” series. This can create perverse incentives to keep surgical staff, and keep accepting patients more complex than the hospital is equipped to handle in the interest of driving revenue.
The New York Times investigation has the benefit of secret audio recordings of meetings held by surgical staff surrounding efforts to manage the hospital’s crisis of pediatric cardiac surgical mortalities. It is a revealing look at the conversations that go on behind closed doors at these institutions. The article further details the efforts by the hospital system to obscure their mortality rates, then obfuscate when the numbers are occasionally revealed.
As representatives of patients who have suffered horrible losses due to medical negligence, these types of stories reflect many of the realities that patients have to endure but have no idea about. That is, their exposure is to the minute world of their individual experience; but it may very well represent a part of a larger whole. We represent each client on a case by case basis, and it is through these individual cases that we strive to cause institutional improvements.
