America’s increasingly atrocious access to maternity care, explained in 3 charts

“about 900 Americans died in 2020 from complications related to childbirth. Another 50,000 or more women experienced severe pregnancy-related complications. Four of five of those deaths were from preventable causes. In terms of scale and rate, America’s maternal mortality dwarfs the issues of other wealthy countries, and these gaps in maternity care shoulder much of the blame.”

Some Canadian Health Care Patients Say They’re Being Encouraged To Just Die Already

“The lesson here should not be that assisted suicide is bad, but heavy government involvement in health care decisions has an inescapable distorting influence. At the very least, how Canada manages health care access is a massive contributing factor. A survey from 2016 found that Canadians wait longer to access health care services than citizens in 11 other countries. The United States is one of the countries of comparison, but the survey also looks at other countries with government-managed health care systems like the United Kingdom and France. A 2020 study from the Canadian Family Physician journal notes that the country simply provides less freedom and opportunity for people seeking medical care than other countries, even when healthcare is centrally planned: ” What these countries do differently than Canada is they allow the private sector to provide core health care insurance and services, require patients to share in the cost of treatment, and fund hospitals based on activity (rather than the global budgets that are the norm in Canada).””

Why are American lives getting shorter?

“the US was one of only two among 21 selected similar wealthy countries — along with Israel — in which life expectancy continued to decline last year. While most countries suffered hundreds of thousands of untimely deaths during the first year of Covid-19, once people began to get vaccinated, life expectancies for almost all the 21 countries either stayed the same or began to rise again, many up to their pre-pandemic levels.

The US started off with lower pre-Covid life expectancies than other rich countries like South Korea, France, and Australia. It has been the case for decades that the United States spends exorbitant amounts on health care, yet has worse health outcomes than comparable countries. Even before the pandemic, people in the US faced the opioid epidemic, gun violence, and higher chronic disease rates than people in other rich countries.”

“Lack of health access and a robust public health care system exacerbated Covid-19’s effects, said Noreen Goldman, a professor of demography and public affairs at Princeton University. The lack of national coordination to address the pandemic, and lower vaccination rates, said Goldman, have also been a factor in outcomes being worse in the US than other comparable countries.
Young people were dying more from Covid-19 in 2021 than 2020, said Theresa Andrasfay, a demography researcher at the University of Southern California. While age remains the biggest risk factor, more middle-aged adults who are not vaccinated are dying. Additionally, she said, high rates of chronic disease, obesity, and diabetes had not yet affected mortality statistics, but when a disease — Covid-19 — came along that had these as risk factors, “it was like lighting a match.””

Why monkeypox is a repeat of the data mistakes made with Covid-19

“the roots of this deadly problem long predate monkeypox outbreaks or the Covid-19 pandemic. The US has always had a fragmented health care system, with widely disparate experiences for patients based on state, insurance company, or hospital chain. Without systems to reliably record and share population-level data between decision-makers, health care workers can’t focus on helping the patients who need it most. The consequences are worse for marginalized people — such as Indigenous people, people with disabilities, or youth at risk for teen pregnancy — who were already facing inadequate care before the pandemic.

It doesn’t have to be this way. The US has an opportunity to learn from the tough lessons of the last few years and build on work to improve transparency and data sharing. With monkeypox already a global public health emergency, it’s vital for the data to be available, promptly and accurately, to coordinate an effective public health response.”

“Data comes in from over 900 health systems, or chains of hospitals under shared management; the largest include about 200 hospitals. But that’s just a fraction of the over 6,000 hospitals across the country. So when, for example, positive test results for Covid-19 or monkeypox, or cases of workplace exposure to pesticides, have to be reported to the state, public health boards in every state must coordinate with hundreds of different organizations and aggregate their data before they can share it with federal agencies. Except during an officially declared public health emergency — which, for monkeypox, is only a week old — the CDC has limited legal power to mandate reporting.

Data also isn’t collected the same way everywhere. There is a large number of different electronic health record systems currently in use in the US. They allow medical professionals to document a patient’s diagnosis and treatment, and in theory, share them more efficiently than in the days of paper-based records. But the software systems aren’t designed to be compatible with each other, so they cannot easily exchange data.”

“Undertesting doesn’t just affect the case numbers reported, but hurts patients’ access to treatment. Tecovirimat, or TPOXX, an antiviral drug that is most effective for treating monkeypox if started early, can’t be prescribed until a test comes back positive, and since it’s not officially approved by the FDA for monkeypox treatment, doctors need to jump through bureaucratic hoops to prescribe it. This leaves many patients suffering from untreated painful lesions for days or weeks.”

“With monkeypox, the US can lean on the systems and infrastructure built during the Covid-19 pandemic, but some programs, like those that reimburse providers for treating uninsured patients or provide free Covid-19 tests, vaccines, and antiviral drugs to community health centers, were already scaled down after funding was decreased. In order to pull together a national response, the US needs straightforward, transparent data reporting that can be compared and combined on a national level.

The final difficulty will be in keeping this momentum going. The declaration of a new public health emergency for monkeypox will help keep federal funding flowing toward projects like the new NCATS OpenData portal for monkeypox, but the need for better health care infrastructure won’t end when the emergency does. In a chronically underfunded public health system, short-term efforts may not be enough.”

Health systems want government help fighting off the hackers

“Cyberattacks on health systems are on a steady rise, and their costs are mushrooming. Experts said there are a variety of reasons for the increase, including that criminals are getting more advanced and more aspects of health care are online.

When a cyberattack struck Sky Lakes Medical Center, a community hospital in southern Oregon, in late October 2020, its computers were down for three weeks. The most mundane tasks became arduous. Nurses had to check on critical patients every 15 minutes in case their vital signs changed. Doctors scribbled down their orders and the swelling mounds of paper took over whole rooms. In three weeks, the hospital ran through 60,000 sheets of paper.

Sky Lakes had to rebuild or replace 2,500 computers and clean its network to get back online. Even after it hired extra staff, it took six months to input all the paper records into the system. In total, John Gaede, Sky Lakes director of information services, says his organization spent $10 million — a big expense for a nonprofit with roughly $4.4 million in annual operating income (the organization did not pay a ransom).

For hospitals with limited budgets, there are questions about how well they can protect themselves. The attack on Sky Lakes was part of a wave of attacks in 2020 and 2021 connected to a criminal group in Eastern Europe.

“Our budgets typically have a margin of maybe 3 percent a year,” Gaede said, “but we’re supposed to compete with nation-state actors?”

Health data is lucrative on the black market, making hospitals a popular target. Plus, if a health system has ransomware insurance, criminals may think they’re guaranteed a payout. Ransomware ties up hospital records in encrypted files until a fee is paid.

“Back when ransoms were $50,000, it was cheaper to pay them than to deal with a lawsuit that would have cost far more,” says Omid Rahmani, associate director at Fitch Ratings, a credit rating agency, adding that ransoms now cost millions. “The landscape’s changed and because of that the cyber insurance side has changed — and that’s really connected to the rise of ransomware.”

In its annual cost of a data breach report, IBM writes the global average cost of an attack on a health system rose from about $7 million to over $9 million in 2021. But remediating these violations in the U.S. can be far more expensive.”

A nurse made a fatal error. Why was she charged with a crime?

“The argument here is not about whether nurses should be held accountable for their errors; everyone I spoke with about Vaught’s case agrees she bears responsibility for her actions and should face consequences. The real issue is that criminalizing a nurse’s error lets hospitals off the hook for the systemic changes that would improve patient safety.

“Almost no mistakes happen in a hospital by just one person,” said Gatter. Systems exist to prevent medical errors, he said. If those systems don’t work or exist only on paper, errors will happen.

In this case, the system failures were clear: During an unannounced visit to Vanderbilt University Medical Center in late 2018, federal investigators found multiple deficiencies, some of which placed patients at “serious and immediate threat,” according to the 105-page memo documenting the details. For example, hospital policies didn’t require that a second nurse sign off on the use of a highly dangerous medication like vecuronium, nor did it require that patients receiving sedatives be hooked up to a heart and lung monitor. Focusing the blame on one nurse’s error shifts the attention away from those deficiencies.

“I’m quite concerned that this nurse is getting thrown under the bus, and in the hubbub of giving her a jail sentence, that the system itself will escape close examination,” said Gatter.

Even if a nurse were solely responsible for a medical error resulting in patient harm, the way to prevent that nurse from causing further harm is to revoke their license, said Gatter. It’s much harder to explain how punishing a nurse with jail time further prevents them from endangering others.

However, it’s easy to see how that type of punishment can itself create and compound safety risks, he said.

That’s because severely punishing individuals for systemic problems has a chilling effect on others’ willingness to report mistakes.”

“Less transparency in error reporting also means hospitals have fewer opportunities to correct big problems. That means faulty systems stay in place, which translates into more vulnerability and stress for health care providers and less safety for patients.”

“The consequences for professional malpractice should ideally deter wrongdoing without discouraging people from entering the profession altogether — but finding that balance is challenging.”

“American nursing was under enormous strain well before the pandemic. But with the US population aging, surging retirements among bedside nurses and nurse educators, and nurse staffing levels reduced ever lower to contain costs, the pandemic has tipped parts of the country into a full-on nursing shortage.
The last thing the profession needs is another reason for nurses to leave jobs providing direct patient care, but that’s exactly the effect the Vaught ruling is having”

Why well-qualified medical school graduates can’t get jobs — despite doctor shortages

“despite the great need for more doctors, there are still huge gaps between the number of aspiring physicians and the space available to train them, a dynamic that keeps perfectly well-qualified medical school applicants and graduates out of the pipeline.

In 2021, for instance, there were a record-setting 42,508 active applicants for residency programs — 3,741 more than in 2020 — but only 35,194 first-year positions, according to the National Resident Matching Program. Although the number of residency spots has been creeping upward in recent years, the growth has not been fast enough to close the gap.

At the root of the mismatch between physician supply and demand are decades-old limits on medical school enrollment and outdated rules governing the federal funding for most residency programs. While Congress has taken some baby steps toward increasing that funding, it has yet to make the kinds of bold changes necessary to create a sustainable and pandemic-resilient physician workforce.”

“The US medical system falls behind those of our peer countries in so many ways. We have higher administrative costs and worse outcomes than other high-income countries — and we also have fewer physicians available per person.

“If you take a look at EU countries that have sophisticated medical systems,” explained Janis Orlowski, chief health care officer at the AAMC, “they have between 30 and 40 physicians per 10,000 people. In the United States, we have about 26 to 27.”

It’s not an apples-to-apples comparison, in part because physicians use their time differently in different systems. But it’s clear the shortage is a burden, and it’s likely to get worse as the US population grows larger and older.”

“In a December 2021 survey conducted by the American Medical Association, one in five physicians said they would likely leave their current practice within two years, and about a third said they’d likely reduce their work hours in the next year.

The larger workforce trend has been dubbed the “Great Resignation,” and the reasons doctors are quitting echo the factors contributing to shortfalls among other health professionals, including nurses, medical assistants, physical therapists, and pharmacists. Burnout, fear of exposure, pandemic-related mood changes, and workload were all associated with intent to leave the profession.”

“It’s easy to imagine a simple solution for this problem: Incentivizing doctors from other countries to immigrate to the US. But this is not as quick a fix as it seems. Most states require doctors to complete residency training in the US, which takes at least three years. That applies even for doctors who practiced independently at expert levels in other countries; the chief of surgery at the fanciest hospital in India would still have to repeat residency in order to practice in the US.

About 13,000 of the residency match applicants this year were graduates of international medical schools, 8,000 of whom were not US citizens. But no matter how many additional doctors want to jump through the hoops necessary to practice in the US, long waits for visas and restrictive terms limiting where and for how long they can practice in the US make it unlikely many more will be added to the health care workforce in the near term.”

“One major bottleneck in the physician pipeline is medical school admissions, which are only graduating about 27,000 students each year. “That started in the 1980s with the freakout over a physician surplus,” said Robert Orr, a social policy analyst at the Niskanen Center in Washington, DC. At the time, miscalculations about population growth and changes in medical care delivery contributed to a moratorium on medical school enrollment that lasted until 2005.

Although medical schools have since continued to grow, expanding too quickly could result in a surplus of medical graduates with nowhere to do their residencies. That’s because of the other major bottleneck in the pipeline — the low number of residency positions. This year’s 36,000 first-year residency slots are inadequate to meet the US need for physicians and inadequate to provide training positions for all the applicants seeking them — and like the dearth of medical school seats, it is a consequence of restrictions created long ago with arguably good intentions.

Since the Medicare and Medicaid Act was first passed in 1965, medical residents have been paid for mostly by the Medicare and Medicaid programs. The goal was to ensure Medicare beneficiaries had access to the best health care, which was thought to be found in teaching hospitals.

In 1983, Medicare made changes to the way it reimbursed hospitals for residency programs. At that time, it created formulas that calculated the dollar amount of residency training funds it supplied to each hospital as a percentage of that hospital’s care expenditures and its volume of Medicare patients — sort of like a restaurant tip, said Orr.

Those formulas have never been updated — and because they tie funding to the cost of care, they have resulted in better funding for hospitals providing high-cost care in high-cost (usually urban) areas.

Over the years, this inequitable distribution of residency program funding has meant that hospitals prioritizing primary care services in rural areas get less funding and fewer residents than those that perform lots of expensive procedures in cities. That leads to fewer primary care specialists, and because physicians often practice near where they train, fewer rural physicians.

This fee structure also incentivizes hospitals to raise the cost of the care they deliver, and results in lower funding for residency programs at hospitals that treat younger populations less likely to be covered by Medicare.

Worse yet, to reduce Medicare expenditures, the Balanced Budget Act of 1997 capped the number of resident slots that could be funded by Medicare each year. It also capped the number of residents each hospital could have at their 1996 levels, which meant hospitals couldn’t get additional residents even if the population they served ballooned in size. Obamacare undid this restriction in 2010, and since then, the number of residency spots has grown modestly.

In 2020, Congress passed a federal budget bill that provided for 1,000 new Medicare-funded residency slots to be added over the next five years. But that’s nowhere near enough to close the current gaps.

Money donated by private insurers funds some residency positions at “the hospitals with the prestige and market power to extract it,” said Orr, but “it’s not a super-equitable way of trying to get residents out to different hospitals where maybe the population isn’t as well served.””

“There are also some solutions that sidestep the residency bottleneck entirely. One of the more promising fixes to the physician shortage is to allow other highly trained providers, like nurse practitioners, physician assistants, and pharmacists, to practice independently of doctors. The American Medical Association has vigorously fought this change for more than 30 years, and physicians who oppose the move often cite patient safety concerns, although they are not substantiated by safety studies.

Much of the real motivation to prevent these providers from practicing independently may be about money and professional sovereignty; private practice doctors in particular are financially disincentivized from expanding the scope of other practitioners.”