The ink was barely dry

The ink on the new healthcare legislation was barely dry before, it seemed, the trade press was full of new information about its impact.

Quoting a report from Moody's, HealthLeaders Media said last week that "healthcare reform is a long-term net negative for the not-for-profit hospital sector because it will effectively reduce revenues to hospitals." The report, as referenced, is Long-term Credit Challenges of Healthcare Reform Outweigh Benefits for Not-for-Profit Hospitals.

A posting on the website of health care financial executives, hfma, said the "reform legislation will squeeze savings out of Medicare and increase regulatory oversight for private insurers, resulting in more difficult negotiations with commercial and managed care payers. Many not-for-profit hospitals will struggle. . . "

Two weeks ago an article in the New England Journal of Medicine took an ominous look at the untenable growth of federal debt in the light of health care reform. In "The Specter of Financial Armageddon -- Health Care and Federal Debt in the United States," NEJM said, "Growth in health care spending in one of the primary contributors to increases in (federal) debt over the long run, so the long-term strategy must involve slowing the growth."

The ratio of debt to gross domestic product (GDP) was 53% in the US last year. "Economies can bear substantial debt . . ." according to the NEJM authors, "but there is a limit to how high debt can rise and still be financed without causing serious economic harm." The debt-to-GDP limit set by the European Union is 60%, although some European countries exceed that and some experts apparently claim that a 90% ratio is OK. The authors report the trend of federal income and expense suggests the US will blow past a 90% debt-to-GDP ratio by 2020. "[O]ur structural debt places us on a path of debt growth that is unsustainable," they say, "largely because of health care programs."

Last week HANYS, New York's hospital association, predicted the impact of health care reform over a ten-year period for each hospital in the state. It's a stark picture. The health care reform legislation is expected to reduce New York's hospital revenues by $13.5 billion over the period.

There are 26 hospitals in the Central New York region, including four in Syracuse. The total impact in Central New York, according to HANYS, will be a negative $910 million. That affects 26 hospitals at an average $34.7 million reduction each (again, over ten years). If anything, this may be understated since the combined impact of the Patient Protection and Affordable Care Act and the Health Care and Education Affordability Reconciliation Act will be phased over a number of years.

Because of healthcare reform, Community General is expected to receive $36.3 million less, according to the HANYS model. The total reduction for the four non-federal Syracuse hospitals is estimated at $425.1 million.

HANYS has not estimated the increased revenues hospitals would receive because more patients are expected to have health insurance as a result of health care reform. There is, as yet, no forecast of that additional revenue, but it is hard to believe it could offset the magnitude of lost revenue -- or even come close.

The health care reform legislation has many parts, and its impact will be felt in many ways over the coming years. This much seems pretty clear: the legislation will be transformative.

A just culture

When there was a wrong side surgery at Community in 2004, one of the many things we did was to seek help from the Joint Commission.

Our surgical mistake was the result of several factors, not an intentional act. Our follow-up naturally involved questions of system risk and individual responsibility. I asked the Joint Commission consultant where to draw the line between an individual's error and a system failure. She spoke about a blame-free work culture as one that emphasizes system solutions while a punitive culture focuses on individual responsibility. The pendulum, she said, was moving somewhere between these two points.

Two authorities, who will be in Syracuse next week for presentations at the Syracuse Healthcare Quality Forum, recently co-authored an article that addresses this issue. Drs. Peter Provonost and Robert Wachter, writing in the New England Journal of Medicine, say that in the last decade

[m]ost health care providers embraced the "no blame" model as a refreshing change from an errors landscape previously dominated by a malpractice system that was generally judged as punitive and arbitrary. . . . Many health care organizations (however). . . have (since) recognized that a unidimensional focus on creating a blame-free culture carries its own safety risks.

They authors discuss a patient safety approach that balances individual responsibility with system risk. This is the "just culture." They identify three types of risk: human error, risky behavior, and reckless behavior. Here are examples:

- When I drive through a red light because the sun is shining in my eyes, the traffic risk for which I am responsible is inadvertent -- human error.

- If I drive through the traffic signal because I am in a hurry, I am engaging in risky behavior. In this case, I am choosing to accept the additional risk of a traffic accident as preferable to the consequences of being late for work.

- If I choose to drive through red lights whenever intersections are not busy, then my behavior is not just risky, it is reckless. In other words, I am repeatedly engaging in risky behavior.

A decade ago two reports on the health care industry made it clear improvements were necessary in patient safety. These were To Err is Human: Building a Safer Health System and Crossing the Culture Chasm: a New Health System for the 21st Century. In the years since, hospitals have understood how risky healthcare environments can be and how important is systems thinking in reducing the risk.

As a result, hospitals focused more on safer processes (such as using check lists to prevent central line infections and requiring 100% compliance with the universal protocol to prevent wrong-side surgery). They have also focused on technical support for safe practices (such as making hand washing easier with more conveniently located sanitizers and computer order entry to reduce transcription and handwriting errors).

Such changes have improved patient safety, yet hospitals are still not as safe as they should be. Drs. Wachter and Provonost challenge us to create a just culture by a better balance between process and technology changes (system safety) and the importance of following safe practices consistently (accountability):

[W]e have shuffled this issue (the balance between a blame-free and an accountable culture) to the bottom of the deck, preferring to work on easier, less contentious safety activities, such as computerization and checklists. It is time to raise this topic to the top of our agenda.

These are thoughtful observations from speakers we will have the opportunity to listen to next week. The Syracuse Healthcare Quality Forum is free for healthcare professionals.

And there is still time to register here.

The builder

I recently met Clarence Lee, who helped build Community General Hospital.

I learned about Mr. Lee from his daughter Debora Vanni when she called to inquire about this old photo of the hospital during construction.



Mr. Lee had seen this photo displayed in the corridor that connects the diagnostic center with the main hospital. "That's me," he said, pointing to the construction crane hoisting concrete as the original hospital building took shape in 1960.

For many years Mr. Lee operated a crane for the J.D. Taylor Construction Company, and he worked on projects throughout Upstate New York. He recites his past work like book titles: the construction of I81 and I90, Wetzel Road Elementary School, the Carrier Dome and Bird Library, Upstate University Hospital, and Community General Hospital.

Mr. Lee was part of the decades-long building boom that started after World War II and created much of the infrastructure Central New York still relies upon. In addition to the photo Mr. Lee admired, I gave him several additional snapshots of his crane that were taken by Charles Calligaris, Community's second employee.

I'm going to mention you in my blog, I told Mr. Lee. "Well, you'd better call me 'Skip,'" he said. "No one will recognize me as 'Clarence.'"

Smart hospitals

There is an important seminar on patient safety and quality this month in Syracuse, NY. The presenters are nationally recognized, and the seminar is free for healthcare professionals: 12:30 - 5:30 p.m., April 21.

You can register here.

The 2nd annual Syracuse Healthcare Quality Forum features these authorities:

Peter Pronovost, MD, PhD on Safe Patients, Smart Hospitals

Rick Boothman, JD on Medical Injury and Transparency

Robert Wacther, MD, of The Patient Safety Movement Ten Years Later

Ann Scout Blouin, PhD, RN on Transforming Healthcare into a High-Reliability Industry

Dr. Provonost is a professor of anesthesiology and critical care medicine at The Johns Hopkins School of Medicine, and Time Magazine called him one of the 100 most influential people in 2008. The author of Safe Patients, Smart Hospitals, Dr. Provonost is recognized for his work in patient safety, especially checklists that reduce patient infections in complex environments.

Dr. Boothman is the chief risk officer at the University of Michigan Health System -- he is nationally recognized for his principled, honest approach to patient injuries and patient safety.

Dr. Wachter, a professor and associate chairman in the Department of Medicine at the University of California, San Francisco, CA, is a pioneer in the "hospitalist" movement. He is the co-author of "Internal Bleeding: The Truth Behind America's Terrifying Epidemic of Medical Mistakes."

Dr. Blouin is the Executive Vice present at the Joint Commission. She has consulted, lectured, and published extensively on health care topics.

This important seminar began last year, thanks to the efforts of Fred Goldberg, MD, Vice President - Medical Affairs and Chief Medical Officer at Community General Hospital.

The Syracuse Healthcare Quality Forum is made possible by contributions from SUNY Upstate Medical University and the medical staffs of Community General Hospital, Crouse Hospital, and St. Joseph's Hospital Health Center with grants from Siemens, Welch Allyn, Laboratory Alliance of Central New York, Excellus BlueCross BlueShield, and VHA Empire-Metro.