SUMMARY: Over the past year, UCSF Benioff Children’s Hospital has been pioneering a virtual reality technology that enables pediatric patients, and their parents, to “tour” their brains before surgery. Special correspondent Cat Wise reports on how this 3-D platform may help young patients with epilepsy and brain tumors reduce their fears and anxieties before surgery, and maybe even yield an "epiphany."
SUMMARY: The Senate GOP's health care bill would lead to 22 million more uninsured Americans by 2026, according to a Congressional Budget Office analysis released Monday. That's slightly better than the CBO score for the House version of the bill. But there's a rising tide of opposition that may make it difficult to get it passed. Lisa Desjardins and Julie Rovner of Kaiser Health News join John Yang.
SUMMARY: Every major hospital group has criticized the health care bill crafted by Senate Republicans, especially for deep reductions in Medicaid spending for the poor and those with disabilities. At the Spotlight Health Conference at the Aspen Institute, Judy Woodruff talked to Kenneth Davis, president and CEO of the Mount Sinai Health System, to get his take on the health care bill and more.
SUMMARY: With the July 4th recess hours away, Republican lawmakers are scrambling to draft a new version of their bill before leaving Washington. Judy Woodruff speaks with Sen. Roy Blunt (R-Mo) about the chances of reaching a compromise on the Senate bill, as well as his reaction to President Trump's tweet attacks.
SUMMARY: Efforts by the Trump administration and congressional Republicans to dismantle the Affordable Care Act are underway, unnerving to some hospital executives who see uncertainty for their bottom line. If large numbers of people lose their insurance under a replacement, hospital finances could be at risk. Special correspondent Sarah Varney reports.
JUDY WOODRUFF (NewsHour): Now what hospitals fear about the possible costs of repealing and replacing the health care law.
Efforts by President Trump and congressional Republicans to unravel the Affordable Care Act are unnerving many hospital executives. They say they're worried about big changes to their bottom line, particularly after they overhauled how care is delivered in response to the health law's rewards and penalties.
While Republicans try to figure out their game plan, special correspondent Sarah Varney reports on how hospitals are bracing for the unknown.
This story was produced in collaboration with our partner Kaiser Health News.
SARAH VARNEY, special correspondent: Driving to work amid the barren winter fields in Northern Illinois, Cathie Chapman is worried about the future. She lost her job after a nearby rural hospital closed.
CATHIE CHAPMAN, Perry Memorial Hospital: I was really lucky. I found another great hospital to work in with a wonderful group of people who deliver high-quality care. But not everyone was as lucky.
SARAH VARNEY: And as Republicans work to dismantle the Affordable Care Act, she wonders if it might happen again. Now she runs the pharmacy at Perry Memorial in Princeton, Illinois. And she's watching the Republicans' repeal efforts warily.
CATHIE CHAPMAN: I think everybody who works in health care now feels a little uneasy. Even if you're a large, profitable hospital, we don't know what's coming around the corner, and how it will affect us.
SARAH VARNEY: Rural hospitals have long struggled to stay open: They have far fewer patients and thin margins. Dozens have closed across the country in recent years, mostly in states that didn't expand Medicaid.
But, in Illinois, which did extend Medicaid to nearly all poor adults, patients at Perry Memorial have gained coverage under the Affordable Care Act and many hospitals have found firmer footing.
But Annette Schnabel, the hospital's CEO, says if large numbers of people lose their insurance under the Republicans' replacement, the hospital's finances and its patients would be at risk, especially after the hospital has invested so much money and time in complying with the health law.
ANNETTE SCHNABEL, CEO, Perry Memorial Hospital: We have spent the last six years gearing up towards everything that we were responsible for doing in the ACA. And the idea of we might have to totally go a different direction or how will we do that, it's going to take a lot of work. There's a lot of effort that is going into this.
SUMMARY: Last October, U.S. forces bombed an Afghan hospital in Kunduz, killing 42 people. An Army inquiry last month found that the attack was an accident, but Matthieu Aikins of the Nation Institute blames Afghan troops who told the Americans that the hospital was a Taliban stronghold. Hari Sreenivasan talks to Aikins, Gary Solis of Georgetown University and Jeffrey Addicott of St. Mary's University.
HARI SREENIVASAN (NewsHour): In October 2015 an American AC-130 Gunship pummeled the Doctors Without Borders hospital in Kunduz, Afghanistan, hitting what the crew believed to be a Taliban fighting position.
The plane rained artillery and other fire on the facility, killing 42 people, despite frantic calls from the group, known by its French acronym, MSF, to stop the attack.
Last month, an Army investigation found there was no intent by the Americans to destroy the hospital, either by the air crew or the American special forces on the ground who were calling in for fire. The probe found that it was a targeting error born of confusion and miscommunication in the fog of war.
Sixteen soldiers were reprimanded, but no criminal charges were filed.
But a new report in “The New York Times Magazine” by Matthieu Aikins of the Nation Institute casts doubt on the motivations of the Afghan troops who told the Americans that the hospital was a Taliban stronghold.
I spoke with Aikins yesterday and with two former military attorneys.
I began by asking the reporter what may have motivated this attack.
MATTHIEU AIKINS, The Nation Institute: From the extensive reporting that we did starting from November, as well as documents that are buried in the military's redacted report, there's evidence that Afghan forces may have provided an exact description that matched the hospital as a target, meaning that they intentionally targeted the hospital, leading to U.S. forces perhaps unintentionally striking the hospital as a result of that description.
HARI SREENIVASAN: So, why would Afghan forces want to strike a hospital?
MATTHIEU AIKINS: There's been a long-simmering tension between MSF and the Afghan government, basically a collision between two different world views, MSF, which sees itself as a neutral humanitarian medical organization that treats all sides to a conflict, regardless of who they are, and Afghan forces that have resented MSF treating what it views as its enemy.
HARI SREENIVASAN: So is there a widespread mistrust?
MATTHIEU AIKINS: What we found, you know, when I went to Kunduz, was a resentment and a mistrust of MSF on the part of the Afghan forces. They told me they thought that MSF was supporting the Taliban.
And this, you know, later led to what turned out to be false beliefs that MSF actually had been taken over and there were Taliban leadership inside the hospital at the time it was struck.
SUMMARY: The Pentagon revealed that the bombing of an Afghan hospital occurred when U.S. forces preemptively fired to clear the way for an Afghan offensive. U.S. and Afghan forces were not under fire when U.S. aircraft destroyed the hospital. Hari Sreenivasan takes an in-depth look at the series of errors with Jamie McIntyre of the Washington Examiner.
HARI SREENIVASAN (NewsHour): The Pentagon laid out the key findings of its full investigation today, as well as the fallout affecting 16 service members.
Head of U.S. Central Command, General Joseph Votel:
GEN. JOSEPH VOTEL, Commander, U.S. Central Command: The investigation concluded that certain personnel failed to comply with the rules of engagement in the law of armed conflict.
HARI SREENIVASAN: The bombing of the Doctors Without Borders hospital last October in Kunduz, Afghanistan killed 42 people. Of the 16 service members who were punished, one was a two-star general and some were specials ops forces. They face administrative actions, but Votel maintained their actions didn't constitute a war crime.
GEN. JOSEPH VOTEL: The label war crimes is typically reserved for intentional acts, intentionally targeting civilians or intentionally targeting protected objects or locations.
The investigation found that the incident resulted from a combination of unintentional human errors, process errors and equipment failures, and that none of the personnel knew they were striking a hospital.
HARI SREENIVASAN: Even though they didn't know they were hitting a hospital, the investigation found they made multiple fundamental and fatal errors.
For example, the AC-130 gunship's targeting system became misaligned after its crew attempted to avoid fire over Kunduz. That resulted in their target appearing as an empty field, instead of a building filled with Taliban fighters firing on Afghan troops. The crew then switched its focus to the hospital, thinking it was the original target, based on descriptions relayed from special forces on the ground.
GEN. JOSEPH VOTEL: So the aircraft is looking at one location. The ground force is thinking they're looking at another location. There's no way to visually confirm that back and forth between them, and their discussions, as you look at the transcripts, don't add clarity to that.
SUMMARY: In rural communities across the country, health care is becoming an increasingly scarce commodity. More than 50 rural hospitals have closed nationwide since 2010, and hundreds more teeter on the brink of bankruptcy. It’s a trend driven by falling revenues and decreased federal funding, and it could have dire implications for small-town America’s future. Sarah Varney of Kaiser Health News reports.
SYBIL AMMONS, Stewart County Coroner: It’s just sad. And the hospital, oh, my goodness.
SARAH VARNEY (NewsHour): Sybil Ammons is a fixture in the town of Lumpkin, Georgia, population 1,500. For years, she was the director of nursing at the county’s only hospital in nearby Richland. Now she’s the county coroner.
SYBIL AMMONS: Our people built this hospital, our ancestors. The hospital, when I ride by there, it just breaks my heart, because my mama worked over there before I did. My sister was born over there.
It’s just so sad, so sad.
SARAH VARNEY: The hospital closed in 2013. Since then, Ammons can count off the local residents she thinks have been harmed or died because they couldn’t reach medical care quickly enough.
SYBIL AMMONS: We have had a stroke, several heart attacks, several cardiac problems. We have had traumas out on the four-lane. I would say at least 10 to 15 people have had bad outcomes from the hospital closing.
SARAH VARNEY: Two hundred miles away in Folkston, Georgia, near the Okefenokee Swamp, Pam Renshaw had to bypass her town’s closed hospital when she needed it most. After a day of yard work, Renshaw overturned her four-wheeler, spilling into a fire pit used to burn trash.
Her then-boyfriend, Billy Chavis, pulled her from the fire and patted down the flames on her body with his bare hands.
PAM RENSHAW, Burn Victim: Whenever I got in the truck, my whole — everything right here just fell in my lap. And I just pulled it back up, and I’m like, oh, my gosh. It’s bad, isn’t it?
BILL CHAVIS: And I said, yes, we got to get you to a doctor. And I seriously thought we was going to lose her. And the whole time, I’m driving to town with the palms of my hands, where I burnt my hands. I said, where do I go? Where do I go?
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SARAH VARNEY: More than 50 rural hospitals across the country have closed since 2010, and hundreds more are in fragile financial condition. It’s a trend hastened by declining revenues and a restructuring of the health care industry that rewards scale and connectivity, difficult goals for hospitals that are small and remote. As rural hospitals have closed here in Georgia, hundreds of people have lost their jobs. And many small towns have been left reeling.
SUMMARY: In medical school, Dr. Damon Tweedy says he learned about health problems being more common in the black community, but he didn’t hear the reasons why. In “Black Man in a White Coat,” Tweedy examines racial disparities in medicine, for both patients and medical professionals.
JEFFREY BROWN (NewsHour): Being black can be bad for your health.
It’s a lesson Damon Tweedy writes in his new book, “Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine,” that he learned time and again in his own life and in his many years as a doctor. Tweedy is a psychiatrist at Duke University, where he also attended medical school.
And welcome to you.
DR. DAMON TWEEDY, Author, Black Man in a White Coat: Thank you.
JEFFREY BROWN: So, you start with this big subject. Is that what started it for you, that you wanted to write about?
DR. DAMON TWEEDY: Yes.
So, race is this really highly charged political subject that we have in our society, obviously, but, for me, this is a very personal story. This is really kind of about my experience and my journey.
All too often in medical school, you learn about health problems in the black community, you learn — you hear this disease is more common than this. It’s always more common in black people, but you didn’t really hear why. And so it wasn’t — and the question of why is a huge issue for me.
And there was also a big question about how my experience as a young black man was different than the experiences of other people in my class.
JEFFREY BROWN: Well, that comes through, because you’re also saying that, as a young doctor in training, you’re saying constantly hearing about the medical frailties of black people picked at the scab of your insecurity. You didn’t set out thinking about medicine and race.
DR. DAMON TWEEDY: No, I was actually attracted to medicine.
It was sort of like this — it was almost like a post-racial kind of mind-set I had. Medicine to me held it appeal to being objective, formulas, equations. And it was really — and that was appealing. So much of society is messy, and life is messy as a black person. So this — it was this appeal that it could be objective.
And then, when I got to medical school, I kind of got a rude awakening that it wasn’t.
SUMMARY: Since 1982, the Orbis Flying Eye Hospital has traveled from country to country, performing surgeries and training local medical staff. Special correspondent Fred de Sam Lazaro meets up with the flying hospital in Vietnam.
FRED DE SAM LAZARO (NewsHour): So, well before the plane arrives, Orbis has alerted local eye care providers, who in turn alert likely patients.
For 8-year-old Thuy, it’s a rare chance at surgery for her strabismus, or lazy eye.
WOMAN (through interpreter): We took her to see the doctor four years ago.
MAN (through interpreter): We were afraid to even ask how much it would cost.
FRED DE SAM LAZARO: Thuy’s father is disabled. Her mother earns less than $2 a day gathering and selling recyclables.
CHILD (through interpreter): I hope the doctors can help me. I don’t want to be cross-eyed anymore.
FRED DE SAM LAZARO: Strabismus is common, affecting perhaps 4 percent of all people. Patients can lose sight in the wayward eye, and depth perception. There also are painful psychosocial effects, says Dr. O’Hara.
DR. MARY O’HARA: We’re keyed to be attracted to symmetry and repulsed by asymmetry on a very subconscious level. And people who have crooked eyes tend to be down-rated in society.
FRED DE SAM LAZARO: Just because of the appearance of that person.
DR. MARY O’HARA: Right.
FRED DE SAM LAZARO: Six-year-old Van doesn’t seem affected by social stigma, at least not yet.
MAN (through interpreter): Her life is pretty normal. She gets teased a bit, but her life is pretty normal.
FRED DE SAM LAZARO: Van’s parents also struggle to make ends meet and cannot afford surgery.
MAN (through interpreter): We had been to a doctor three years ago. They said wait for a charity group to come.
FRED DE SAM LAZARO: The next day, they and others gathered at the local eye hospital for screening. About 75 patients are being screened here at the local hospital. Some 45 will be chosen for surgery or laser treatment, based on a variety of criteria. They need to be particularly good teachable cases. Young patients with good prognoses have priority, as do those in danger of losing their sight altogether.
Prompted by an investigation by ProPublica and NPR, Sen. Charles Grassley asks a Missouri nonprofit hospital to explain why it seizes the wages of thousands of its patients.
Sen. Charles Grassley said nonprofit hospitals could be breaking the law when they sue poor patients over unpaid bills and issued a stern warning to one Missouri hospital that he hopes reverberates nationwide.
Citing a ProPublica and NPR report, Grassley, R-Iowa, sent a letter Friday to Heartland Regional Medical Center, a nonprofit hospital in St. Joseph, Missouri, that has seized the wages of thousands of lower income workers who were unable to pay their medical bills.
Under federal law, tax-exempt hospitals are supposed to provide care to those who can't afford it, but the requirements are fairly vague. Even so, Grassley said the hospital, which recently rebranded as Mosaic Life Care, had, at a minimum, stretched the law to the breaking point. In his letter to Mosaic's CEO, Grassley wrote that the hospital "may not be meeting the requirements to be a nonprofit, tax exempt hospital." He also asked a battery of questions about the hospital's treatment of lower-income patients, its debt collection practices, and how it administers financial assistance.
"Reports detail a number of instances where Mosaic failed to identify patients who would qualify for financial assistance and who have since been subject to abusive billing and collection practices," Grassley wrote. "The practices appear to be extremely punitive and unfair to both low income patients and taxpayers who subsidize charitable hospitals' tax breaks."
As ProPublica and NPR reported, the hospital has its own for-profit debt collection subsidiary, Northwest Financial Services, which files thousands of lawsuits each year. From 2009 through 2013, the company garnished the pay of about 6,000 people and seized at least $12 million.
In response to the story, the hospital announced a review of its debt collection practices. Tama Wagner, chief brand officer for Mosaic, said the hospital expected that new recommendations would be presented to the hospital's board next month. "Our goal is to do the right thing," she said.
In an interview, Grassley said the issue of nonprofit hospitals dodging their charitable responsibilities is not a new one. About a decade ago, as the chair of the finance committee, he launched an investigation into just what these hospitals were doing to warrant their valuable tax exemptions.
Grassley, now chair of the judiciary committee, said he was "astounded" that, years later, some hospitals continued to aggressively pursue the debts of poor patients who should have qualified for financial assistance. He'd hoped that Congressional focus on the issue would have persuaded hospitals to fulfill their mandate, he said, but "some hospitals, you hit them over the head with a two-by-four, and they still don't get the message."
The 2010 Affordable Care Act contains a provision, co-authored by Grassley, which requires hospitals to make "reasonable efforts" to determine whether patients qualify for financial assistance before taking an aggressive step like filing a lawsuit. It didn't appear that Mosaic had made such efforts, said Grassley. As ProPublica and NPR reported, the hospital said it had publicized its financial assistance policy in a number of ways. But Mosaic put the onus on patients to actively seek assistance and said those that didn't, and had their wages garnished as a result, were truly at fault.
"It seems like Mosaic turned [the law] on its head," said Grassley. The primary responsibility for identifying patients who need assistance lies with the hospitals, he said.
The IRS recently issued new rules for nonprofit hospitals. They provide more specific guidance on what steps hospitals must take, at a minimum, to evaluate patients for financial assistance. But like all laws and rules governing nonprofit hospitals, they provide hospitals wide latitude in how to interpret the law.
Grassley acknowledged this, but said he hoped his focus on Mosaic's debt collection practices would remind other hospitals of "their humanitarian responsibilities" and "the responsibilities they have as a nonprofit."
If they don't change their behavior voluntarily, Grassley said, their responsibilities may have to be spelled out in law.
"If they don't get the message now," he said, "we'll have to work towards getting the ideal language in the legislation."
SUMMARY: In negotiating the creation of the Affordable Care Act, hospitals took a big gamble, with the expectation that they would soon have millions of new Medicaid customers. In states that expanded Medicaid, the bet paid off. Sarah Varney of Kaiser Health News reports on financial gains made by some hospitals as more patients are able to pay their bills, and the heavy price being paid by hospitals in states that opted against expansion.
JUDY WOODRUFF (NewsHour): The White House said this week that more than 6.4 million people have signed up for health insurance plans through the Affordable Care Act’s federal marketplace so far during this year’s open enrollment season.
But even more people, nine million-plus, have gotten covered by Medicaid in recent months. And the decision by states whether or not to expand that federal-state program for the poor and those with disabilities is having a serious effect on the financial health of hospitals.
Sarah Varney from our partner, Kaiser Health News, has that story.
SARAH VARNEY, Kaiser Health News: A steady drizzle hasn’t deterred Jason Whiten from coming to this clinic in South Seattle to see if he qualified for Apple Health, Washington’s popular Medicaid program.
ISRAEL RUBINOS, Neighborcare Health: You don’t have any medical insurance, right?
JASON WHITEN: No.
ISRAEL RUBINOS: No? OK. And how about dental?
JASON WHITEN: No.
ISRAEL RUBINOS: No dental, no medical?
JASON WHITEN: No.
ISRAEL RUBINOS: OK.
SARAH VARNEY: Whiten, who is 34 years old, has gone without health insurance for 16 years.
ISRAEL RUBINOS: So you got approved for the Washington Apple health program…
JASON WHITEN: OK.
SARAH VARNEY: He can come here to this Neighborcare Health clinic, instead of the (much more expensive) emergency room, to see a physician. It’s his first insured primary care checkup since becoming an adult.
JUDY WOODRUFF (NewsHour): Even as top administration officials were answering questions at the White House about the federal response to Ebola, much of this day’s attention was focused on the latest developments in Texas.
Hari Sreenivasan has the story.
HARI SREENIVASAN (NewsHour): A hazardous materials team arrived this morning at the Dallas apartment complex where Thomas Duncan stayed before being hospitalized on Sunday. They collected anything contaminated, including a car that they covered with a giant plastic bag.
The Dallas fire marshal said four of Duncan’s relatives are being moved from the apartment complex to new accommodations. They have been quarantined under armed guard after they refused to remain inside voluntarily.
SALLY NURAN, Property Manager: Nobody is supposed to go inside the apartment. They are in their apartment. They cannot come out. They are not even allowed to come on the porch.
HARI SREENIVASAN: Dallas County Judge Clay Jenkins, the county’s top administrator, voiced concern for the family’s plight and apologized for the delay in removing the soiled items. Meanwhile, Texas health officials said they have narrowed the group being monitored to 50 people who had direct or indirect contact with Duncan.
Crews have also cleaned schools attended by five students who were exposed to Duncan. But some parents say they’re far from reassured.
CANDIS HOLT, Parent: And then we just got letters in the kids’ backpack yesterday saying that they had it basically under control. But I feel otherwise, because if you really had it under control, the kids wouldn’t have came to school in the first place, but you will never know.
HARI SREENIVASAN: As for Duncan himself, questions continue to swirl over the handling his case. He managed to fly out of Liberia last month after having contact with an Ebola patient. He showed no symptoms at the time. But after falling ill in Dallas, he was initially turned away by Texas Health Presbyterian Hospital. The hospital blames a flaw in its electronic records system. Duncan was admitted on Sunday, but even then, his nephew complained that Duncan was mishandled.
At the National Institute of Allergy and Infectious Diseases, Dr. Anthony Fauci says he agrees.
DR. ANTHONY FAUCI, Director, National Institute of Allergy and Infectious Diseases: The idea that this person went to an emergency room and they didn’t flag that he had recently been in Liberia and thus immediately put him in isolation was unfortunate that that missed. That happens. I think the important thing is to have that as a lesson learned to look forward.
HARI SREENIVASAN: Infected hospital waste has also become an issue. Dallas officials announced today a disposal company is now in place.
This was a day when even one of the government’s top health officials said there were things that didn’t go the way they should have.
SUMMARY: Why was Ebola patient Thomas Eric Duncan initially turned away from the hospital even though he had symptoms of the disease? Hari Sreenivasan speaks with Stephan Morris of the Center for Strategic and International Studies about lessons from the handling of the first case of the disease in the U.S.
SUMMARY: How can the spread of the Ebola virus be stopped? Dr. Anthony Fauci, the Director of the National Institute of Allergy and Infectious Diseases, joins Hari Sreenivasan to discuss lessons learned in the missteps made in treating Ebola patient Thomas Eric Duncan, who is now in critical condition at Texas Health Presbyterian Hospital.
HARI SREENIVASAN (NewsHour): A story published a few days ago caught our attention. It described how hospitals buy information about you to determine how likely you are to get sick and what it would cost to treat you. For more we’re joined by one of the co-authors, Shannon Pettypiece of Bloomberg News. So what are they buying and who are they buying it from?
SHANNON PETTYPIECE, Bloomberg News: Well they are buying the same type of data that retailers have been using for years to target products at you and what we’re talking about here is that information that’s collected by companies called data brokers, which can track every transaction a consumer can make, every purchase they make, with a drug store or a grocery store loyalty card.
They can find out how much your home is worth, what type of car you own. Even things like your interests, whether you like hiking or rock climbing based off of public databases or even your web browsing history. And for years, retailers have used this to send you a coupon or to figure out who might want to subscribe to their certain list or product.
Now hospitals are saying, can we use this data this information to try to predict who’s going to get sick and who is going to end up at the emergency room.
HARI SREENIVASAN: So why are hospitals interested in having this kind of information?
SHANNON PETTYPIECE: Well under Obamacare they have an increased incentive to keep patients healthy because the law changes the way they are paid.
So under the law, hospitals now get penalized if you come back to the emergency room too frequently and if a hospital isn’t meeting certain patient quality and health outcomes and insurers are following the same mold too.
Insurers no longer want to pay for hospitals who are just doing more and more test and procedures over and over again and they want to be paying for quality so hospitals are going to be held accountable if patients are too sick if patients are coming to the emergency room too frequently.
It seems that every time researchers estimate how often a medical mistake contributes to a hospital patient’s death, the numbers come out worse.
In 1999, the Institute of Medicine published the famous “To Err Is Human” report, which dropped a bombshell on the medical community by reporting that up to 98,000 people a year die because of mistakes in hospitals. The number was initially disputed, but is now widely accepted by doctors and hospital officials — and quoted ubiquitously in the media.
In 2010, the Office of Inspector General for Health and Human Services said that bad hospital care contributed to the deaths of 180,000 patients in Medicare alone in a given year.
Now comes a study in the current issue of the Journal of Patient Safety that says the numbers may be much higher — between 210,000 and 440,000 patients each year who go to the hospital for care suffer some type of preventable harm that contributes to their death, the study says.
That would make medical errors the third-leading cause of death in America, behind heart disease, which is the first, and cancer, which is second.
The new estimates were developed by John T. James, a toxicologist at NASA’s space center in Houston who runs an advocacy organization called Patient Safety America. James has also written a book about the death of his 19-year-old son after what James maintains was negligent hospital care.
Asked about the higher estimates, a spokesman for the American Hospital Association said the group has more confidence in the IOM’s estimate of 98,000 deaths. ProPublica asked three prominent patient safety researchers to review James’ study, however, and all said his methods and findings were credible.
What’s the right number? Nobody knows for sure. There’s never been an actual count of how many patients experience preventable harm. So we’re left with approximations, which are imperfect in part because of inaccuracies in medical records and the reluctance of some providers to report mistakes.
Patient safety experts say measuring the problem is nonetheless important because estimates bring awareness and research dollars to a major public health problem that persists despite decades of improvement efforts.
“We need to get a sense of the magnitude of this,” James said in an interview.
James based his estimates on the findings of four recent studies that identified preventable harm suffered by patients – known as “adverse events” in the medical vernacular – using use a screening method called the Global Trigger Tool, which guides reviewers through medical records, searching for signs of infection, injury or error. Medical records flagged during the initial screening are reviewed by a doctor, who determines the extent of the harm.
In the four studies, which examined records of more than 4,200 patients hospitalized between 2002 and 2008, researchers found serious adverse events in as many as 21 percent of cases reviewed and rates of lethal adverse events as high as 1.4 percent of cases.
By combining the findings and extrapolating across 34 million hospitalizations in 2007, James concluded that preventable errors contribute to the deaths of 210,000 hospital patients annually.
That is the baseline. The actual number more than doubles, James reasoned, because the trigger tool doesn’t catch errors in which treatment should have been provided but wasn’t, because it’s known that medical records are missing some evidence of harm, and because diagnostic errors aren’t captured.
An estimate of 440,000 deaths from care in hospitals “is roughly one-sixth of all deaths that occur in the United States each year,” James wrote in his study. He also cited other research that’s shown hospital reporting systems and peer-review capture only a fraction of patient harm or negligent care.
“Perhaps it is time for a national patient bill of rights for hospitalized patients,” James wrote. “All evidence points to the need for much more patient involvement in identifying harmful events and participating in rigorous follow-up investigations to identify root causes.”
Dr. Lucian Leape, a Harvard pediatrician who is referred to the “father of patient safety,” was on the committee that wrote the “To Err Is Human” report. He told ProPublica that he has confidence in the four studies and the estimate by James.
Members of the Institute of Medicine committee knew at the time that their estimate of medical errors was low, he said. “It was based on a rather crude method compared to what we do now,” Leape said. Plus, medicine has become much more complex in recent decades, which leads to more mistakes, he said.
Dr. David Classen, one of the leading developers of the Global Trigger Tool, said the James study is a sound use of the tool and a “great contribution.” He said it’s important to update the numbers from the “To Err Is Human” report because in addition to the obvious suffering, preventable harm leads to enormous financial costs.
Dr. Marty Makary, a surgeon at The Johns Hopkins Hospital whose book “Unaccountable” calls for greater transparency in health care, said the James estimate shows that eliminating medical errors must become a national priority. He said it’s also important to increase the awareness of the potential of unintended consequences when doctors perform procedure and tests. The risk of harm needs to be factored into conversations with patients, he said.
Leape, Classen, and Makary all said it’s time to stop citing the 98,000 number.
Still, hospital association spokesman Akin Demehin said the group is sticking with the Institute of Medicine’s estimate. Demehin said the IOM figure is based on a larger sampling of medical charts and that there’s no consensus the Global Trigger Tool can be used to make a nationwide estimate. He said the tool is better suited for use in individual hospitals.
The AHA is not attempting to come up with its own estimate, Demehin said.
Dr. David Mayer, the vice president of quality and safety at Maryland-based MedStar Health, said people can make arguments about how many patient deaths are hastened by poor hospital care, but that’s not really the point. All the estimates, even on the low end, expose a crisis, he said.
“Way too many people are being harmed by unintentional medical error,” Mayer said, “and it needs to be corrected.”
A dozen Southern California doctors are accusing the leadership of a Prime Healthcare Services hospital of refusing to notify them about their patients because they won’t engage in profit-driven practices, according to a request for a restraining order filed this week.
The San Bernardino County physician group suing Chino Valley Medical Center and its director say it has been asked to needlessly admit patients from the emergency room into hospital beds, according to the lawsuit filed Wednesday in San Bernardino County Superior Court. The group’s doctors also have been urged to document patient conditions as more complex or severe than they are, the filing says.
The doctors suing the hospital maintain that both practices are meant to drive up hospital bills. The result of their refusal to go along, they say, is that they’re not receiving what they characterize as legally mandated notifications when their patients land in the hospital.
The physicians have asked the judge to lift the alleged freeze in communication, saying it puts fragile patients in danger. A hearing is set for April 19 on the temporary restraining order.
Prime spokesman Edward Barrera released a statement Thursday saying Chino Valley expects to prevail and the lawsuit “has no merit and is a regurgitation of unproven allegations voiced by critics over the past three years.”
The statement says Chino Valley routinely contacts primary care doctors when their patients come to the ER, and it calls the plaintiff doctors “upon request of patients themselves.” It also says Prime complies with state law and notifies health plans when their patients arrive in the ER and their medical conditions are stabilized.
“Plaintiff’s lawsuit attempts to rewrite (the law) so as to require a hospital to contact a HMO and the HMO’s contracted physician,” Prime’s statement says. “There is no requirement to contact the HMO’s contracted physicians.”
California’s largest health plan is locked in a legal battle with Prime, accusing the hospital chain of shirking the same notification requirement. Kaiser Permanente has accused the hospital chain in Los Angeles County Superior Court of “trapping” Kaiser patients in Prime hospitals, failing to notify Kaiser doctors and upcoding patient diagnoses for profit.
The suit by the Inland Pulmonary Medical Group marks the first time that a small group of doctors has stepped forward in court to criticize a Prime hospital’s practices.
“It’s interfering with the care of the patient,” said Michael Amir, a Los Angeles attorney representing the doctors. “Patients go to the hospital – a lot of times they want to talk to the doctor who’s been treating them for years, and they’re being prevented from seeing their doctors, from doctors even knowing they’re in the ER.”
The seven physician plaintiffs in the Inland group say that together they’ve lost $150,000 in income as a result of Chino Valley’s actions. Five other area doctors filed declarations in support of the case but are not plaintiffs.
One of the supporters, Dr. Gerardo General, said his patients routinely are admitted to Chino Valley without his knowledge and given batteries of tests and drug prescriptions.
“They go upstairs (into the hospital), and they expect to see my face. They don’t see me,” General said. “This is abuse; we can’t take it anymore.”
The lawsuit alleges that the communication cutoff endangers patients. It claims one patient with a serious breathing condition was admitted without her doctor’s knowledge. During her stay, Chino Valley staff operated to remove her gallbladder.
“Because (Inland) was not contacted, no doctor gave the required pulmonary clearance nor did the patient receive proper respiratory treatment prior to surgery,” the lawsuit says.
The suit alleges that such practices put patients “at serious risk of injury and even death.”
A yearlong California Watch series documented high rates of lucrative and severe medical conditions at Prime hospitals, as well as an aggressive approach to admitting ER patients into hospitals, rather than treating them in the ER and sending them home.
State hospital data analyzed by California Watch showed that Prime hospitals admitted about 63 percent of Medicare-funded ER patients into hospitals in 2009, compared with 39 percent at the state’s other leading for-profit chain, Tenet Healthcare Corp. In response, Prime said the analysis “utterly fails to consider the medical basis for admissions.”
The U.S. Justice Department is investigating Prime’s billing practices, according to a document the chain filed as part of a hospital purchase plan. Dr. Prem Reddy, founder of the Ontario, Calif.-based chain, has overseen rapid growth since Prime’s 2001 start as the company expanded into a coast-to-coast 21-hospital chain.
Chino Valley was among the first hospitals the chain bought. It is bound by state laws that say hospitals must notify health plans to discuss post-emergency hospital care decisions for their patients. Federal regulations also say patients have the right to have their doctor “notified promptly of his or her admission to the hospital.”
The physician group suing Chino Valley holds contracts with about a dozen managed care firms that expect group doctors to handle local members’ care in the case of a hospitalization.
The Inland doctors say that instead, they’ve been stonewalled. In their lawsuit, they say the silence is a result of their refusal to follow the direction of the hospital’s president and chief medical officer, Dr. James Lally, a defendant in the case.
Lally suggested that the physicians document serious medical conditions, such as a certain type of pneumonia that Medicare pays hospitals a premium to treat, the suit says.
Lally also discouraged doctors from putting patients on “observation” status, according to the suit. That means a doctor will monitor a patient’s condition, rather than sending him or her home or admitting the patient to a hospital bed.
The lawsuit alleges that Lally prefers doctors to admit patients into the hospital so the hospital can receive “significantly higher Medicare reimbursements.”
Lally did not return a call for comment. Chino Emergency Medical Associates also is named in the case, accused of failing to call patients’ doctors. Dr. Val Warhaft, chief risk officer of Chino EMA, declined to comment.
Prime Healthcare has been criticized for aggressively admitting paying patients since its founding. Reddy once referred to an ER as a “gold mine,” according to court testimony from the medical director of the first hospital taken over by the Prime founder. The reference, which the medical director said during a 2005 trial, was to numerous Kaiser and Medicare patients who could be admitted for further care.
Another doctor told the Orange County Board of Supervisors in 2006 that when Prime took over Huntington Beach Hospital, doctors were urged to admit insured patients with maladies as minor as a headache.
Prime also has been accused previously of stonewalling managed care doctors.
In early 2012, a Kaiser physician testified before a California legislative hearing into Prime Healthcare’s practices. Dr. John Shohfi told lawmakers that after Prime took over a number of hospitals, they stopped contacting a 24-hour call center where Kaiser doctors coordinate care for members who land in out-of-network hospitals.
He said the practice means doctors are treating patients with little knowledge of their medical history or prior and ongoing care.
In turn, lawmakers drafted a bill that would have limited the number of out-of-network patients a hospital can admit before health plans can pay the hospital lower rates.
Gov. Jerry Brown vetoed the bill in September, acknowledging the problem but saying he was not convinced that the rate setting prescribed in the bill “has it right.”
“Extraordinary hospital billings are harmful to the health care system as a whole, including patients,” the veto message said. “If found to be as widespread and as excessive as some claim, such practices will invite an appropriate regulatory response.”
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| Naval Medical Center San Diego |
A huge section of Balboa Park, sandwiched between the golf course and the pipe organ, belongs to a giant, drab U.S. Navy hospital complex and parking lots.
How did a park, originally set aside in 1868 as a 1,400-acre natural preserve, wind up housing a federal military complex? It’s one of the major chapters in the history of big land use changes and controversies in Balboa Park. We’ve been unraveling highlights from that history in a series of posts the last few weeks as the park prepares to undergo a major remodeling.
The Navy first stuck its foot in Balboa Park’s door when it took over a few mostly empty buildings during World War I, after the park’s first exposition in 1915. (This delighted the city, which was trying to woo the giant employer.)
A few years later, the city gave to the Navy land at Inspiration Point for a hospital — the first of several land transfers for Navy expansions. By 1941, the Navy had in its control the whole 93-acre Inspiration Point, according to Richard Amero’s history of the naval hospital.
But in the 1970s, the Navy felt growing pains. It needed to upgrade the buildings to better care for patients and prepare for possible earthquakes. And being in the airplane flight path was a noisy hassle. Balboa Park wasn’t ideal for the Navy’s hospital plans.
The Navy began to talk about moving the hospital out of the park. Officials mulled a few different sites — land near the Veterans Affairs hospital in Torrey Pines, or Murphy Canyon in Tierrasanta.
City leaders, including Mayor Pete Wilson, celebrated — the acres dedicated to the hospital could be returned to park land.
But when the Navy asked for the money to buy the larger Murphy Canyon site and build its hospital, Congress scrutinized the request, questioning whether the size of the hospital was really necessary, after all.
So the Navy — not wanting to risk shrinking its operation and staff — stuck its head back down and took the Murphy Canyon plan off the table. One of the city’s congressmen, Rep. Bob Wilson, came out in support of the hospital staying in Balboa Park. Now the road leading up to the hospital is named for him.
The Navy asked the city to swap land. The Navy would surrender 37 acres of Inspiration Point land and old buildings in exchange for a larger chunk in Florida Canyon — previously intended to remain as a nature trail and preserve.
The city balked. The city charter required the land swap be put to a vote of the people, and a bitter battle began to woo voters.
Voters weren’t having it.
In 1979, only 61 percent — not the 67 percent needed to turn parkland over — voted to allow the Navy’s desired land swap.
The feds planned to just take the land anyway, over the protests of the city.
The city tried one last-ditch plan to dislodge the Navy from its central park. A parcel came available at the 11th hour near the intersection of the 94, 15 and 805 freeways. “It had plenty of room to grow, no airplanes overhead, good freeway access from all directions and no controversy,” wrote Welton Jones in the San Diego Union-Tribune in 1994.
Pete Wilson was especially excited.
But top Navy officials dug their heels in — the plan to keep the hospital in the park was final. The Navy broke ground on the Florida Canyon site for the hospital’s several multi-story buildings and plans for thousands of parking spaces and wrapped it up in 1988.
Jones spoke to park forefather George Marston’s grandson, Hamilton Marston, who was 84 in 1994. Marston said the juxtaposition was tragic.
Here’s how Jones encapsulated Marston’s point: “The Navy and the park are two great institutions forced to coexist where they each could have enjoyed room to flourish.”
In the summer of 2010, a troubling letter reached the chief ethics officer of the hospital giant HCA, written by a former nurse at one of the company’s hospitals in Florida.
In a follow-up interview, the nurse said a doctor at the Lawnwood Regional Medical Center, in the small coastal city of Fort Pierce, had been performing heart procedures on patients who did not need them, putting their lives at risk.
“It bothered me,” the nurse, C. T. Tomlinson, said in a telephone interview. “I’m a registered nurse. I care about my patients.”
In less than two months, an internal investigation by HCA concluded the nurse was right.
“The allegations related to unnecessary procedures being performed in the cath lab are substantiated,” according to a confidential memo written by a company ethics officer, Stephen Johnson, and reviewed by The New York Times.
Mr. Tomlinson’s contract was not renewed, a move that Mr. Johnson said in the memo was in retaliation for his complaints.
But the nurse’s complaint was far from the only evidence that unnecessary — even dangerous — procedures were taking place at some HCA hospitals, driving up costs and increasing profits.
HCA, the largest for-profit hospital chain in the United States with 163 facilities, had uncovered evidence as far back as 2002 and as recently as late 2010 showing that some cardiologists at several of its hospitals in Florida were unable to justify many of the procedures they were performing. Those hospitals included the Cedars Medical Center in Miami, which the company no longer owns, and the Regional Medical Center Bayonet Point. In some cases, the doctors made misleading statements in medical records that made it appear the procedures were necessary, according to internal reports.
Questions about the necessity of medical procedures — especially in the realm of cardiology — are not uncommon. None of the internal documents reviewed calculate just how many such procedures there were or how many patients might have died or been injured as a result. But the documents suggest that the problems at HCA went beyond a rogue doctor or two.
At Lawnwood, where an invasive diagnostic test known as a cardiac catheterization is performed, about half the procedures, or 1,200, were determined to have been done on patients without significant heart disease, according to a confidential 2010 review. HCA countered recently with a different analysis, saying the percentage of patients without disease was much lower and in keeping with national averages.
At Bayonet Point, a 44-year-old man who arrived at the emergency room complaining of chest pain suffered a punctured blood vessel and a near-fatal irregular heartbeat after a doctor performed a procedure that an outside expert later suggested might have been unnecessary, documents show. The man had to be revived. “They shocked him twice and got him back,” according to the testimony of Dr. Aaron Kugelmass in a medical hearing on the case.
In another incident, an outside expert described how a woman with no significant heart disease went into cardiac arrest after a vessel was cut when a Bayonet Point cardiologist inserted a stent, a meshlike device that opens coronary arteries. She remained hospitalized for several days, according to a person who has reviewed internal reports.
JUDY WOODRUFF (Newshour): ..... A new documentary chronicles what life is like for patients and doctors at a busy, safety net hospital in California.
And again to Jeff, who recorded this conversation recently.
JEFFREY BROWN (Newshour): The daily life of a large, under-resourced, urban public hospital, a new documentary offers no experts and no statistics, just a rare fly-on-the-wall look inside an overwhelmed and at times overwhelming system and its impact on patients and staff.
"The Waiting Room" -- and there is indeed a lot of waiting going on -- is set in Highland Hospital in Oakland, California. The film has been screening at film festivals around the country and has already won several awards. It will get a national theater release in the fall, and will air on PBS' "Independent Lens" next year.
Hospital patients waiting in an emergency room or convalescing after surgery are being confronted by an unexpected visitor: a debt collector at bedside.
This and other aggressive tactics by one of the nation’s largest collectors of medical debts, Accretive Health, were revealed on Tuesday by the Minnesota attorney general, raising concerns that such practices have become common at hospitals across the country.
The tactics, like embedding debt collectors as employees in emergency rooms and demanding that patients pay before receiving treatment, were outlined in hundreds of company documents released by the attorney general. And they cast a spotlight on the increasingly desperate strategies among hospitals to recoup payments as their unpaid debts mount.
To patients, the debt collectors may look indistinguishable from hospital employees, may demand they pay outstanding bills and may discourage them from seeking emergency care at all, even using scripts like those in collection boiler rooms, according to the documents and employees interviewed by The New York Times.
In some cases, the company’s workers had access to health information while persuading patients to pay overdue bills, possibly in violation of federal privacy laws, the documents indicate.
The attorney general, Lori Swanson, also said that Accretive employees may have broken the law by not clearly identifying themselves as debt collectors.
Accretive Health has contracts not only with two hospitals cited in Minnesota but also with some of the largest hospital systems in the country, including Henry Ford Health System in Michigan and Intermountain Healthcare in Utah. Company executives declined to comment on Tuesday.
