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From 1995 to 1997, Buffalo General Hospital performed more coronary artery bypass graft surgeries than any other hospital in the state, save one in Nassau County. That should have been a good sign, since the theory in medicine is that the more surgeries a doctor or hospital performs, the more expertly the procedure is likely to be done.

Not at General. Of the 33 hospitals that performed the procedure in New York, only one posted a worse mortality rate. Over at Millard Fillmore-Gates, things weren't much better. Its risk-adjusted mortality rate was sixth-worst in the state. Erie County Medical Center, by contrast, posted the state's 13th-best record.

The two Kaleida hospitals say the problems have been identified and, in fact, their recently posted numbers for 1998 were markedly improved, better than the state average. Nevertheless, executives at Blue Cross and Blue Shield of Western New York and other observers say the problems that showed up in 1997 are typical for Western New York.

A comparison of various mortality rates calculated in a business-led hospital profiling project suggest they are right. Those figures showed that, while mortality rates were about average in 85 percent of cases, patients were still more likely to die here than in the four other regions the project considered.

A big part of the problem, according to several players, including Blue Cross, is that many doctors resist adopting standards called "clinical pathways" -- that is, established methods of dealing with specific conditions -- deriding them as "cookbook medicine." The hospitals, meanwhile, perhaps worried about losing doctors -- and therefore patients -- refuse to impose those standards on physicians who want to practice in their buildings.

It's an important issue. The experience at two Rochester hospitals, Strong Memorial and Rochester General, shows that clinical pathways can be adopted to the benefit of doctors, hospitals and the patients they serve. In just one year, for example, that effort reduced by more than one-third the rate at which congestive heart failure patients were readmitted to Rochester General within 31 days of discharge, a spokesman said.

With Western New York's unacceptably high mortality rates, it should be clear that hospitals and doctors here need to work together to institute these kinds of guidelines. Failure to act is its own kind of malpractice.

Excess capacity reduces quality

But the number of hospitals in this region is also a significant issue, because, put bluntly, excess capacity diminishes quality.

Most obviously, hospitals that spend money on excess capacity are diverting resources that could go to improving patient care. Unneeded buildings are an expensive distraction.

More than that, they act as a kind of psychological catnip, encouraging unnecessary procedures. In a disturbing twist on the adage that work expands to fill the time allotted for it, evidence shows that hospital admissions expand in relation to the number of beds available.

Research by the Dartmouth Atlas of Health Care, a bible among medical professionals, demonstrated a clear link between the number of beds available and the rate of hospital admissions, a link that could not be explained by differences in rates of illness.

What's more, the 1999 report found outcomes were no worse in areas with fewer beds and, perhaps even more to the point, that mortality rates were no better in areas that had greater capacity and with more inpatient days per capita. So what's the point?

Statistics provided by Blue Cross and Blue Shield show Western New York is not immune to the phenomenon. Buffalo's rates of hospital admission, inpatient days and even surgery are all substantially higher than the composite rate of 15 urban markets including Atlanta, Minneapolis, New Haven, Rochester, Seattle and Portland, Ore. Although the figures are not adjusted to account for age, John Anderson, a senior vice president at Blue Cross and Blue Shield, says local numbers would remain high even then.

Paying for mediocrity

By another measure, the connection between quality and a region's number of hospitals can be boiled down to three digits. The federal Health Care Financing Administration uses a statistic called the "case mix index" to predict how well a hospital can provide complex medical and surgical care to Medicare patients. Hospitals should not fall below a value of 1.48, according to HCFA. But in Erie and Niagara counties, only three of the 15 hospitals measured meet that test. The reason: not enough patients to go around. Too many hospitals are performing too few tasks to achieve the minimum standard set by HCFA. Conclusion: We are subsidizing mediocrity.

On a political level, fewer hospitals could bolster quality by improving administrators' ability to encourage use of clinical pathways. Although doctors are not generally employees of the hospitals where they practice, hospitals will find it easier to move toward these guidelines when they are making money instead of losing it. It is not a prerequisite, though. Rochester hospitals lost $39 million in 1999, according to the Healthcare Association of New York State. If anything, improved quality is likely to bolster the bottom line.

HMOs may send patients out of the area

In truth, quality is a circular issue, because not only can closing hospitals improve quality, but the failure to improve quality may soon cost hospitals dearly. Blue Cross and Blue Shield says it is thinking about sending patients out of the region for certain procedures, believing the costs of travel will be more than made up for by better care. So are Univera and Independent Health, in response to requests by their members. Local hospitals may soon find a gun at their heads.

Indeed, John Friedlander, president of Kaleida, says that action would send the region's hospitals into a "death spiral," but if the insurers conclude the people they cover receive better care elsewhere, how can they refuse?

The answer has to be to improve quality here, and while hospitals can do more on their own to achieve that end -- instituting clinical pathways and closing buildings -- money helps. Higher reimbursements by insurers, public and private, could be put to good use.

It is fashionable these days to slam the HMOs, and they have deserved a lot of the criticism, but in some cases, they are the ones driving the issue of quality. It's a depressing thought that insurance companies need to force the issue of quality on doctors and hospitals, but there it is. Even more depressing, though, is that patients haven't done the same.

TUESDAY: The lack of data.

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