Landmark studies To Err is Human (1999) and Crossing the Quality Chasm
(2001) from the Institute of Medicine (IOM) identified medical errors
are causing harm and death to almost 45,000 Americans and costing over
$29 billion every year. Other studies have indicated preventable
healthcare associated conditions (HACs) such as infections, sepsis, CHF,
and pneumonia are main contributors for increasing the length of
patient stays, the cost of care, and the likelihood of mortality
(death).
Consider the below case study:
Margret Spinner-Ramirez is a 66 y/o female Hispanic-American who
speaks both Spanish and English fluently. She is retired, lives alone,
and has Medicaid as her primary insurance. Ms. Spinner-Ramirez was
scratched by a stray cat that she feeds on her back porch daily. She has
been cleaning the wound daily; however, after 2 days she went to her
local ER for increased pain, redness, and swelling in her left lower leg
wound where she was scratched by the stray cat. Ms. Spinner-Ramirez
explained she recently had her left knee replaced about 6 months ago and
verbalized new difficulty with baring weight on that extremity to the
point that she was having to use her cane again. Her vital signs at the
ER visit were stable. Her left leg wound was cleaned and redressed.
After 5 hours in the ER, Ms. Spinner-Ramirez was discharged to home on
oral Keflex for her left lower leg infection and was instructed to call
her primary care physician for a follow-up appointment. Five days later
Ms. Spinner-Ramirez was taken back to the same ER via ambulance. Her
neighbor found her lethargic, short of breath, and was experiencing
difficulty being able to move. A CT scan and blood work revealed that
Ms. Spinner-Ramirez’s knee replacement in her left leg was infected
secondary to the cat scratch. She was admitted as an inpatient for
sepsis. She needed to have a second left knee replacement surgery with
wound irrigation and debridement, which extended her inpatient stay to 3
weeks. Once she was discharged to home, she required six weeks of IV
antibiotics, extensive rehab, and home health.
If you were in charge of a healthcare insurance company:
Explain why insurance companies (which are considered payers) should or should not
pay (reimburse) for injuries, extended costs, readmissions, or death
(mortality) from a hospital-acquired infection or medical error. Support
your why or why not?
Describe two ways (initiatives) healthcare quality can be improved to help reduce errors and improve patient safety.
Discuss how creating incentives for providers (healthcare
organizations) can improve quality and reimbursements (payments) for
services/care.
Resources:
Understanding Health Insurance https://www.consumerreports.org/health-insurance/guide-to-health-insurance/
What’s Behind the Health Insurance Rankings https://www.consumerreports.org/cro/2012/09/what-s-behind-the-health-insurance-rankings/index.htm
Hospitals will have to Pay for their Mistakes https://www.consumerreports.org/cro/news/2008/08/hospitals-will-have-to-pay-for-their-mistakes/index.htm
Medical Errors: Focusing More on What and Why, Less on Who https://ascopubs.org/doi/full/10.1200/jop.0723501
National Business Coalition on Health: Health Care Purchaser Toolkit https://www.nationalalliancehealth.org/home
Agency for Healthcare Research and Quality https://www.ahrq.gov/patient-safety/quality-measures/21st-century/index.html
Rubric
Fully explains
why insurance
companies should
or should not pay
(reimburse) for
injuries, extended
costs,
readmissions or
death (mortality)
from a hospital
acquired
infection or
medical error
Fully describes
two ways
(initiatives)
healthcare quality
can be improved
to help reduce
errors and
improve patient
safety.
Fully discusses
how creating
incentives for
providers
(healthcare
organizations)
can improve quality and
reimbursements
(payments) for
services/care.
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