TennCare to initiate financial sanctions
by Getahn Ward | The Tennessean | Oct. 31, 2011
A young woman goes to her family doctor with a cough and chest pain and is told the ailment is chest arthritis.
Wrong. She suffers a nearly fatal stroke as fluid fills her lungs from pneumonia over the next five days.
Another patient has a breast biopsy and gets a clean bill of health, only to learn later that she really does have cancer and the lab screwed up; her results were mixed up with another patient's test.
And then there's the patient with cancer in her left kidney, but doctors mistakenly remove the right kidney during surgery.
Hospitals and doctors that make mistakes now face tougher sanctions. Two years ago, Medicare began refusing to pay doctors and hospitals if the wrong procedure was used or medical missteps led to unnecessary complications. Now, many private insurers and the state's TennCare Medicaid program are following suit.
Some observers consider such financial sanctions a first step but not a full cure.
“It moves things in the right direction because it gets people thinking more about safety,” said Timothy J. Vogus, an assistant professor of management and organization studies with Vanderbilt University's graduate business school. “But it's insufficient because it can also lead to people thinking narrowly about it - where we just have to solve these handful of problems for which we can get penalized.”
Starting July, TennCare plans to stop paying for conditions related to a foreign object being left in the patient's body after surgery; for the wrong surgery or invasive procedures being done; for the wrong body part being operated on; or for cases of mistaken identity that lead to other errors in treatment.
A spokeswoman said TennCare doesn't expect a huge financial savings because it's rare for providers to bill patients in such cases anyway. Medical providers often cover the costs of their mistakes.
Insufficient data
A significant number of medical errors are related to misdiagnosis, often involving doctors or other medical professionals who act on insufficient information. Nationwide, 1 in every 5 medical diagnoses and treatment plans may be the wrong one, resulting in an estimated 40,000 to 80,000 hospital deaths each year, medical surveys estimate.
It's an issue that not only takes a medical, emotional and financial toll on the patient and his or her family, but also can add many millions of dollars in unnecessary tests and treatments. Such errors also spark about 40 percent of all malpractice lawsuits.
“I call it a public health problem,” said Evan Falchuk, president of Boston-based Best Doctors Inc., which helps employees of its client companies obtain second opinions from top-notch medical specialists who review diagnoses and treatment plans.
Falchuk says the chief culprit behind mistakes is a fragmented health-care system in which patients deal with a wide array of doctors, specialists and other providers (including labs) that don't have all their information in one place.
In addition, he said, a revolving-door climate in today's overburdened health-care system in which doctors see as many patients as possible each day - and don't spend enough time with them - can lead to errors.
“When people jump to conclusions too quickly without considering a lot of the common and uncommon causes of the patients' symptoms, then often the patient is misdiagnosed and the real underlying problem isn't addressed,” said Dr. Jim Jirjis, an assistant professor of medicine and chief medical information officer for outpatient services at Vanderbilt. “A good doctor is somebody who listens to you, who thinks and has broad experience and knowledge - and can bring it all together.”
Patients are coming to hospitals sicker and with more complicated cases than they did 20 years ago, which increases the chance of diagnostic errors, medical experts say.
“The difficult part is when a doctor (is faced with) a rare condition and all the symptoms point to something else,” Jirjis said. “Even the best of physicians may not pick up on that.”
Vanderbilt is using advanced information systems to get better at pinpointing or heading off conditions, Jirjis said.
For instance, a diagnostic tool in the hospital's intensive care unit helps to predict diagnosis of sepsis - a potentially fatal inflammatory condition linked to infections - before typical clinical signs can be measured. It uses patterns in a patient's vital signs, lab tests and other data to gauge the risks.
Others consider misdiagnosis and other medical errors as simply a reflection of medicine not being an exact science.
“Medicine is still an art; it's not always a science,” said Craig Becker, president of the Tennessee Hospital Association, an industry trade group. “Yet, we try to take as much of the human factor out of it, but each individual patient is different.”
“Doctors are trying to do the best they can,” said Dr. Brian Fengler, an emergency physician in Murfreesboro. “It's just human nature to make some of these errors. They're not doing that to be lazy or neglectful.”
But Randy Kinnard, past president of the Tennessee Association for Justice, an association of trial attorneys, said the reality is that patients are misdiagnosed far more than people might want to believe.
“Carelessness occurs and causes not only damage to the patient concerned and their family, but to the whole health-care system,” said Kinnard, a personal injury lawyer. “Needless further medical care is required, bills are generated, and lives are devastated and often lost.”
Second opinions offered as a benefit
More employers and health plans are offering second opinions as a benefit to workers or their member companies for review of diagnoses and treatment plans. The idea is to reduce diagnostic error rates, and to save money.
Players in that niche include the Premerus unit of Franklin-based radiology benefits manager MedSolutions, which works with health plans to transmit CT and MRI scans to expert imaging specialists.
Dr. Norm Scarborough, a radiologist and Premerus' vice president and senior medical director, said studies have shown a 25 percent to 32 percent chance of missing evidence of disease in a radiology test. Citing the value of top-notch specialists, he also referred to studies that show that breast imaging specialists find 75 percent more breast cancers with screening mammograms than do general radiologists.
“It's like anything else: The more often you do a task in a narrowed field, the better you are at it,” Scarborough said.
Willis Group is among clients using Best Doctors' services, through which the insurance broker's employees (including 643 in Nashville) can receive an independent evaluation of a diagnosis or treatment plan and get help finding a specialist.
Last year, Willis saved 46 cents on each dollar spent on the program, says Marc Bilodeau, a senior vice president with its human capital practice in Atlanta. “It's a comfort level to the associate that it's reviewed,” Bilodeau said.