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The American health care system almost killed me. I won’t bore you with the details because chances are someone you know has had a similar experience. That is because medical errors are far more common than people realize.
The Third Leading Cause of Death
Ask anyone in the world if they had one country to pick in which to be seriously ill and the odds are that the answer would be the United States. And that answer would be wrong.
While our medical technology, our complex transplant surgery, and our miracle drugs inspire something akin to awe from the rest of the world, what is generally less known—even by most Americans—is that in what health care experts regard as key measures of a system’s true effectiveness our performance is mediocre.
This is nothing new. In a 2000 article in the Journal of the American Medical Association Dr. Barbara Starfield quantified the problem, declaring:
America’s health care-system-induced deaths are the third-leading cause of the death in the U.S., after heart disease and cancer.
She noted:
• 12,000 deaths per year due to unnecessary surgery
• 7000 deaths per year due to medication errors in hospitals
• 20,000 deaths per year due to other errors in hospitals
• 80,000 deaths per year due to infections in hospitals
• 106,000 deaths per year due to negative effects of drugs
Since Starfield first issued her study several others have followed up on her findings. In 2006 HealthGrades, the leading independent health care ratings organization, examined the records of Medicare beneficiaries treated at about 5,000 hospitals nationwide between 2002 and 2004 and used 13 patient safety indicators developed by the federal government to evaluate admissions.
The study found that instead of getting better since the Starfield study, the system had become worse.
About 1.24 million patient safety incidents occurred between 2002 and 2004, compared with 1.14 million between 2000 and 2002, at a cost of $9.3 billion.
Samantha Collier, vice president of medical affairs for HealthGrades, said,
Overall, we see the number of patient safety incidents in American hospitals continuing to increase, at an enormous cost, and we still see a large gap between the incidence rates at the nation’s top-performing and worst-performing hospitals.
A year later a study by the Millennium Research group of acute care clinical information systems dropped medical errors from the third to fifth leading cause of death. David Plow, Senior Analyst at MRG, found many of the same causes as Starfield and HealthGrades:
Medical errors in the healthcare system arise from miscommunication, physician order transcription errors, adverse drug events, or incomplete patient medical records.
Other Rankings
According to the World Health Organization (WHO) you will live longer if you are born in Spain, Singapore, Portugal, the Netherlands, Italy, Greece, Costa Rica and a host of other countries than in this country. In fact in terms of life expectancy, our 78 years average for men and women ranks with Kuwait, Chile and Cuba.
Our neonatality mortality rate–a key indicator of national health care quality–ranks us with the United Arab Emirates, Slovakia, Korea, and Estonia and below all advanced industrialized nations. Our infant mortality rate is the same as Slovakia’s, Thailand’s, and Poland’s. Meanwhile our adult mortality rate for men and women is 108, while Singapore’s is 64; Sweden’s is 63 and Switzerland’s 62. San Marino’s 53 is less than half ours.
The last year WHO did national rankings of national health care quality was 2000 and that survey ranked the U.S. 37th!
What Is the Problem?
What I refer to as the paradox of American health care has become one of the most crucial questions of our times: how can we have such advanced technology, skilled professionals, and exemplary research and yet at the same time rank so poorly in so many key measures? That something is wrong with the system has been the staple of political and talk show rhetoric for several decades. Scarcely a campaign passes without candidates offering this or that fix. Yet virtually all these policy initiatives focus on cost.
Turn on the television and you are likely to hear someone lament, “Why do health care costs continue to rise to the consternation of everyone including the insurers who finance the system? The typical answers from the left blame greedy insurers, penurious corporations, and overpriced doctors while those on the right trot out their long-time bugaboos of government regulation, lack of a free market and spurious lawsuits.
Over the last several decades programs based on many of these assumptions have sought to rein in costs but their efforts have had all the quality of Sisyphus trying to push that immense boulder up a precipitous incline. Right now lots of folks feel like they are digging in their heels while the boulder pushes them backwards down a slippery slope.
The paradox puts a more disturbing spin on this. It asks all of us whether we are getting our money’s worth. Many of us do not need to consult health care statistics to give an answer. Virtually everyone I know can relate a horror story–some major, some minor–of an encounter with the system.
Here the paradox becomes intensely personal for what statisticians term the Lake Wobegon effect seems to operate in many of our minds. Other people may have their horror stories, but our doctors, our nurses, our clinics are all above average.
What System?
Many advocate changing the system, many of them proposing some variation of a single payer solution that guarantees care for all. But is care for all the answer if the care they are getting is mediocre at best?
It occurs to me that no matter how we propose to pay for health care, whether by government, private insurers or some combination of the two, we need to understand why this country was spending so much for such mediocre quality. Statistics like the ones above about the quality of American health care show we spend a lot of money and have some of the world’s most advanced technologies, but do not get the results of other countries. No matter how we propose to pay for health care, whether by government, private insurers or some combination of the two, we need to understand why this country spends so much for such mediocre quality.
If we do not know where the problems in the existing system lie, then how can we fix it? For example, if doctors are the problem then it does not matter if we have universal coverage or a single payer system. Patients will still receive inadequate care.
A Need for Systemic Answers
Since the early studies about health care errors, the same systemic ingredients have been identified by virtually all of them: infections, communications errors in prescriptions and orders, unnecessary surgery, lethal drug reactions. Starfield identified these almost a decade ago and subsequent studies confirm they continue. As in so many cases, proposals to “fix” the system focus on one of these elements without understanding their relationship to the others.
The heath care fixes currently on the table (more on them in future issues) fail to elucidate how the pieces of the system fit together and interact with each other. Take the case of prescription errors. Fixes have included having doctors use hand-held computers so their notoriously difficult-to-decipher handwriting does not cause an adverse event and computerizing records so it is clear what drugs the patient is receiving to prevent potentially fatal interactions.
Yet what if the systemic problem is more basic such as doctors, nurses and pharmacists not having enough time to properly think about their actions or monitor them? Or what if the real issue lies in the rigid hierarchical relationship between doctors and nurses, so nurses are afraid to question a physician’s decision even when they know them to be wrong? What if they lie in the administrative procedures of the hospital?
The fact that at the moment we do not have the answers to such questions shows how inadequate is our systemic understanding of the health care system in this country. We continue to approach it–as we do other problems such as education and unemployment–as a series of pieces, which curiously is how we tend to approach health care in general, with a specialist assigned to each part of our bodies.
Some Systemic Issues
The current system emphasizes a patient declaring a “primary physician” who usually is a general practitioner who is often under pressure to deal with as many cases as possible within a day. This focus on cutting time to save money may in fact be our health care system’s most serious systemic issue for it means no one truly knows you as a patient.
My HMO allows me one exam per year with my “primary,” which is scheduled for about half and hour. Any other time I see him I have to have a problem–the flu, an accident, something going wrong. A half hour to know each patient both physiologically and psychologically is ridiculous. That half hour per year becomes the primary “feedback” mechanism for dealing with a patient’s problems. My car gets more time from its mechanic that I do from my physician.
A second issue is that in order to control costs, insurers have “tightened” the system. Statistical tables now control what drugs you take and what procedures are used for various ailments. This actually takes medicine back to the adolescence of the Industrial Age when various “efficiency experts” plotted how to get more productivity out of workers on the assembly line. The famous scene of Charlie Chaplin in Modern Times being subjected to one of these gurus could just as well be fast-forwarded into our present health care system where doctors and nurses often feel like poor Charlie.
As my surgeon-father used to say, “Statistics don’t matter much in individual cases.” What he was trying to say is that a good physician does not practice medicine by statistics alone, otherwise we could have robots in charge of our health care. I vaguely remember a Star Trek episode that posited just such a scenario where Dr. McCoy found himself pitted against a medical cyborg trying to save the life of Captain Kirk.
The Big Question
Both my parents were physicians. I still retain childhood memories of one of my father’s closest friends, a gifted researcher who died before he could receive the Nobel Prize everyone felt he deserved, but which was given instead to his research assistant because they don’t give Medical Nobels to dead people. I also remember seeing and hearing the grief of my parents when they lost a patient.
Fingering particular people for our health care problems seems as counter-productive as blaming a specific person for our failure to prevent 9/11. The system is ours, and all of us–not merely health care professionals–need to reflect on the options and make our voices heard.
One thing is clear: after ten years of studies we know that merely providing coverage for more people or lowering the cost of coverage will not cure the quality problems that plague American health care. Some systems people would even argue that it could make them worse because of the Law of Unintended Consequences, which to systems people hold that if you don’t really understand the system you are liable to make it worse by messing with it.
As one system dynamics person told me, it is a bit like trying to fix a pr0blem with your car when you nothing about its mechanics. That is why we need to understand the reasons the system produces so many errors. Why? Because I do not wish anyone to go through what I experienced.
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