Hackles rise and fur flies. As Maude Beelman, Deputy Managing Editor at the Dallas Morning News, explains in an essay cross-posted below, local newspapers have good reason to be wary of investigating their community’s most prestigious medical centers:
“Every place has its sacred cows,” she writes in a piece published on the Nieman Watchdog website, “individuals or institutions so prominent and respected that over time they become part of a community’s identity and culture. Questioning them is an affront to civic pride, and investigating them can be a high-stakes gamble.
“The University of Texas Southwestern Medical Center and Parkland Memorial Hospital are two such icons of Dallas,” she continues. “They have enjoyed largely positive press, some of it by design. Their leaders cultivated national profiles and courted some of the wealthiest and most influential Dallas residents, including media leaders, as advisers and donors.” (Many thanks to Gary Schwitzer at HealthNewsReview Blog, for calling attention to this story.)
So when the Dallas Morning News decided to follow up on insider tips alleging that patient safety was being compromised at these venerable institutions, the newspaper “faced a community backlash, including cancellation of advertising by UT Southwestern,” Beelman reports. “Many of Dallas’ wealthiest and most powerful residents are longtime donors and supporters of the medical center and hospital. Some key players have sought to delay, if not derail, the investigation. They have recruited key opinion leaders in Dallas and nationwide to try to discredit us.”
Beelman’s candid report helps explain why local newspapers rarely report infection rates, medication mix-ups, or disparities in pricing at their top-tier hospitals. If local health care costs seem exorbitant, most would rather blame insurers.
Hospitals, after all, are major advertisers. In recent years, while retailers have been cutting back on newspaper ads, hospitals have been positioning themselves for health care reform, which often means expanding their marketing budgets. Moreover, as Beelman emphasizes, the marquee hospital’s patrons tend to be powerful local figures. The newspaper’s publisher probably sits with them on various community boards. As for newspaper editors, some like to hobnob with the local elite. An editor is not likely to be invited to a table at an A-line charity event if his reporters are asking irritatingly indiscrete questions about the hospital that his host supports—and where that same host expects to get VIP treatment when he needs it.
Finally most readers really don’t want to hear that their local academic medical center is having problems with infections in the OR or the ICU. They would prefer to read a more reassuring piece about how luxurious the accommodations are in the New Wing.
In some cases, the relationship between local hospitals and local media has ventured beyond the pale, at least according to the Association of Health Care Journalists (ACHJ) and the Society of Professional Journalists. Two years ago, a newspaper in Maryland "sold" its health section to a local hospital, which then controlled content for the section. (I’m delighted to report that the arrangement was halted amid community protest after just one published issue.)
In other cases, TV stations have made an exclusive arrangement to run stories that one of the local hospitals suggests. At times, ACHJ reports, pre-packaged segments produced by a hospital have been aired “with hazy branding or no branding at all, leading viewers to believe the local station reported the story.”
Using the Dartmouth Data to Ask Questions
Few newspapers or local television stations have gone that far. But when they produce pieces about brand-name medical centers close to home, the story-line tends to be positive. If state regulators fine a local institution, the local newspaper will report the facts. But, with few exceptions, (the Dallas Morning News among those exceptions), hometown reporters don’t dig to uncover problems, even when patients, medical researchers, or whistle-blowers inside the institution try to draw attention to a story.
The Online Journalism Review’s Tom Grubisich has highlighted the problem. Grubisich asks why more newspapers don’t use their websites to publish the data that Dartmouth now makes easily available on local hospitals, offering numbers that allow reader to compare local hospitals to benchmark medical centers—hospitals that offer high quality care at prices well below the national average.
After all, “more spending on care, especially in the form of expensive testing and elective surgery doesn't produce better outcomes,” Gorbisich writes, linking to the non-partisan Medicare Payment Advisory Commission’s (MedPAC’s) June 2009 report. He also points out that the newest Dartmouth data makes it much easier to drill down and see how a local hospital stacks up when it comes to providing equal care at a lower price. (see www.Dartmouthatlas.org)
Granted the Dartmouth data on individual hospitals is not perfect. There are too many variables to weigh, even when researchers compare very similar patients at different hospitals. And, as Dartmouth researchers have acknowledged, adjustments for factors such as the comparative health of incoming patients remain tricky. Nevertheless, Dartmouth has been doing this work for more than two decades, with no financial axe to grind. This is why the cognoscenti of the health care world agree that this is far and away the best information we have. Without question, the Dartmouth research offers a superb starting point for a curious reporter who wants to begin his own investigation on the ground.
“It would take a bit of shoe-leather reporting,” Gorbisich observes. “But newspapers could find out why costs vary so widely within their metro area. Instead of just being passive platforms for rants, newspaper sites could invite (or, if necessary, arm-twist), local doctors, hospitals and outpatient centers to participate in live forums where they would explain and justify the disparities and answer user questions.” (This, in turn, would give hospitals that question the Dartmouth data an opportunity to provide evidence to support their arguments.)
Courage: The Boston Globe
When it comes to ignoring local pressure, The Boston Globe deserves kudos for running a six-week investigative series on how the state’s brand-name medical centers have used their top-drawer names to force health-insurance companies to pay sky-high rates for the most common procedures—even though, when it comes to basic services, there is no evidence that these hospitals provide better care.
According to a Globe Spotlight Team, their review of private insurance data found that some hospitals in the state charge 15% to 60% more than competing hospitals for the same uncomplicated procedures. (This goes a long way toward explaining why health care in Massachusetts is so pricey.)
Boston’s most prestigious medical centers are not alone. When hospitals have the market clout, many charge much higher fees for routine procedures, and insurers pay up, passing the costs along in the form of higher premiums. But newspapers in New York, Los Angeles and other high-cost cities rarely investigate pricing in their own town’s top hospitals.
More importantly, patient safety cries out for media attention. Unfortunately, patients are at risk even at some of the nation’s most illustrious names. According to the Agency for Healthcare Research and Quality (AHRQ), medical records show that 11 percent of hospital patients suffer “adverse events …ranging from hospital-acquired infections to surgical complications.” Even worse, AHRQ reports that when patients are interviewed, fully 23 % report similar events, though close to half of those incidents seem never to have made it into the patients’ medical records.
Hospitals are places where vulnerable human beings are treated by fallible human beings: complications and mistakes are inevitable. But we can never learn which adverse events could have been prevented—and how to avoid them—unless they are reported and studied. Patients also have a right to know if certain hospitals are outliers, even if they boast a brand name.
Luckily, under the Patient Protection and Affordable Care Act, some adverse events will be publicly reported. Already, the legislation has spurred forward-looking hospitals to shift their focus from new construction to new rules that will protect patients.
In the meantime, the media could help the public understand why we need reform by acknowledging the challenges that even our very best hospitals face. Yet local news outlets are reluctant to question their community’s most esteemed institutions.
Below, the Dallas Morning News’ Deputy Managing Editor Maud Beelman reports on what happened when her newspaper dug into a story about two of her city’s leading hospitals. (Hat-tip to Harvard’s Nieman Watchdog for featuring this essay.)
The Morning News takes a long, hard look at hospital care in Dallas
By MAUD BEELMAN
Dallas Morning News Deputy Managing Editor
DALLAS—Every place has its sacred cows – individuals or institutions so prominent and respected that over time they become part of a community’s identity and culture. Questioning them is an affront to civic pride, and investigating them can be a high-stakes gamble.
The University of Texas Southwestern Medical Center and Parkland Memorial Hospital are two such icons of Dallas.
The medical center boasts of “world-class” research and residency programs that have turned out generations of excellent doctors. Parkland, which received a mortally wounded President John F. Kennedy, is the main training ground for the school’s new doctors. As a public hospital and major trauma center, it is also a safety net for the region’s most vulnerable patients.
Over the years, the two institutions have enjoyed largely positive press, some of it by design. Their leaders cultivated national profiles and courted some of the wealthiest and most influential Dallas residents, including media leaders, as advisers and donors. But after receiving a few insider tips and learning of the allegations in a whistleblower lawsuit, the newspaper decided it was time to investigate.
What we found was a system that for decades had deceived virtually all of its patients, put many at risk and, by the hospital’s own estimate, seriously and often needlessly harmed on average two people a day. Internal records from the two institutions, sworn testimony by current and former employees and federal inquiries also documented instances of a cowboy mentality among loosely supervised residents, a class-based culture of care and possible Medicare billing fraud.
Starting last March, we published on 15 different occasions over a nine-month period. Some were large packages of multiple stories and some were individual articles. We have linked everything we’ve done – stories, update posts on our “DMN Investigates” blog, video, original source documents, “ask the editor” columns – from one online site, which you can find at www.dallasnews.com/medinvestigation.
Among our findings:
• Patients checking into Parkland had, for years, not been told that the experienced UT Southwestern faculty doctors who they thought would be operating on them would not actually perform the surgery. They might not even be present in the hospital at the time.
• Most of the patient care at Parkland was delivered by doctors in training – first-year interns and other residents. Some patient care was even handled by students who had not yet graduated from medical school.
• The UT Southwestern residents at Parkland were often left to their own devices. Residents supervised and trained interns and other residents. Faculty doctors often played little role in supervising. Institutional policies allowed faculty to claim they were supervising some procedures if they were available by cell phone. When some faculty did try to exert direct supervision, residents often bristled.
• While junior staff members were tending to poorer, uninsured patients at Parkland, UT Southwestern’s faculty physicians focused on research and treating privately insured patients at the medical center’s other hospitals.
• Some doctors within Parkland and UT Southwestern had complained that the lax supervision was hurting patients and offered specific examples of that harm. They were soon ostracized, and most left for other jobs.
• Patients were harmed during surgeries by resident physicians, including a young mother whose common bile duct was severed during a gallbladder operation and a former Parkland employee who eventually had her leg amputated after knee-replacement and post-surgical care provided, in part, by medical students.
• The Parkland culture has been based on a “see one, do one, teach one” style of medical training that emphasizes resident autonomy. The head of one UT Southwestern residency program even told colleagues that higher rates of patient harm were an acceptable price to pay for doctor training.
• If patients and family ever learn they have been victims of medical error, which few seldom do, medical malpractice damage limits in Texas ensure that they often have little recourse.
• Federal regulators don’t track such instances of patient harm. That’s because, while Medicare mandates levels of supervision for doctors to follow in billing for their services, it doesn’t do the same when it comes to patient safety. There are also no accepted “best practice” standards to guard against patient harm at the nation’s teaching hospitals, which treat more than half of all patients and account for about 70 percent of all charity care costs.
• The kinds of problems identified at UT Southwestern and Parkland have occurred at other teaching hospitals around the country, especially ones in large urban settings.
• Medicare billing fraud was found at two dozen academic medical centers and teaching hospitals in nationwide audits conducted several years ago – until the industry managed to quash the federal reviews. As a result, patients have suffered avoidable harm nationally because the business and culture of medicine have resisted meaningful change.
• Alleged billing fraud by UT Southwestern and Parkland goes back decades. The institutions had previously been investigated for falsely billing the government insurance programs for the poor and elderly and are under current investigation by the U.S. Justice Department.
Getting to these truths has been a huge challenge.
UT Southwestern and Parkland told their employees not to talk to us, and they refused to share any aggregate data on patient outcome. Parkland’s $1.2 billion annual budget is supported almost entirely by local, state, and federal taxes, but it insisted that little if anything about its operations or outcomes should be open to public scrutiny. Even when we had signed legal waivers from former patients, who had released to us their entire medical record, the institutions refused to talk.
Our knowledge and ability to tell the stories accurately and fully depended almost solely on source development and the vigorous use of open-records laws. Our reporting team read through thousands of pages of hospital and medical center records obtained under the Texas Public Information Act, as well as documents from local and state courts and from the U.S. departments of Justice and Health and Human Services.
We often obtained records only over fierce, and sometimes comical, resistance by the two institutions. (Medical center officials once claimed it would cost them $1 million to produce a list of checks they had written.) The roadblocks forced us to hire a full-time public records lawyer, and the newspaper has filed four lawsuits in state court to compel the hospital and medical center to follow the open records law.
In response, the taxpayer-funded institutions have hired additional law firms, including one headed by a former Texas Supreme Court justice, and developed lobbying plans to try to force the state Legislature in 2011 to weaken the Texas Public Information Act. They have also hired public relations consultants to try to create public skepticism about the findings of our investigation into what have been two of Dallas’s most-venerable institutions.
The newspaper has also faced a community backlash, including cancellation of advertising by UT Southwestern. Many of Dallas’ wealthiest and most powerful residents are longtime donors and supporters of
the medical center and hospital. Some key players have sought to delay, if not derail, the investigation. They have recruited key opinion leaders in Dallas and nationwide to try to discredit us. We have responded with absolute transparency, posting original research documents online at the time of our various publications and again in connection with three “Ask the Editor” columns the paper has published online to answer questions and address the criticism.
Behind the scenes, our reporting has attracted the attention of the Justice Department and Health and Human Services’ Office of Inspector General. A previously unknown investigation into alleged Medicare fraud was reinvigorated after The News released internal hospital documents showing that Parkland once estimated it owed the federal government up to $50 million but had withheld information from its own auditors in order to hide it from federal investigators. The Joint Commission, which accredits hospitals nationwide, confirmed in late December it was investigating one of the cases of patient harm we revealed in November. Jessie Mae Ned, who lost her leg after a doctor-in-training botched her knee replacement surgery, contacted us after reading an earlier story on patient harm at Parkland and realizing she was not alone.
But as our final major investigative story of 2010 showed, what happens in the nation’s teaching hospitals is clearly a topic the industry does not want discussed openly – despite the documented human toll. The medical community has fought for years to preserve what it calls “the privilege of self regulation,” and it spends hundreds of millions on lobbying Congress to protect that. Nobody wants to see patients needlessly harmed, but our reporting has shown that some in the medical industry see the alternative as giving up the cheap labor of residents, and others believe that new doctors can, in effect, learn only from their own mistakes.
Dallas County residents, however, now have enough information to question some of these practices and perhaps prevent future problems. And there are signs that change may be underway. Hospital insiders tell us that resident supervision is being newly emphasized in some departments. There are preliminary indications that some hospital performance measures may be improving. Several key officials at the hospital and medical center have been replaced, and county commissioners are said to be quietly considering plans to alter the special relationship between the public hospital and the medical center. While encouraged by these early signs, we realize there is much we still do not know. So, our investigation continues. With billions of dollars and thousands of lives at stake, we believe we have no other choice.
Maud Beelman is a deputy managing editor at The Dallas Morning News, where she directs a team of investigative and special projects reporters.