COMMENTARY

Hospital of the Future: 0% Autopsy Rate

Disclosures

December 17, 2019

This transcript has been edited for clarity.

This column is intended especially for all of the many honorable and well-intentioned employees at the Centers for Medicare & Medicaid Services (CMS). Please read.

Hello and welcome. I'm Dr George Lundberg and this is At Large at Medscape.

How do you evaluate the quality of care given to the sickest patients—the ones who die? I posed this question to the chief executive officer and senior staff of a major health quality accreditor in Washington many decades ago. Blank faces. No words.

If the word "autopsy" is not the first answer to that question, I'd suggest you think again.

From its beginning in 1965, Medicare always paid for autopsies on Medicare Part A patients who died in the hospital. All major health insurance companies did the same. Medicaid never did.

When diagnosis-related groups (DRGs) were introduced, I was concerned about this reimbursement continuing. So, while I was the editor of JAMA, I met with Carolyne Davis, RN, PhD, the administrator of the Health Care Financing Administration (HCFA) from 1981 to 1985. (HCFA preceded CMS.) She told me not to worry because the DRG architects had built the expense payments for autopsies on Medicare patients into the various DRGs of the prospective payment systems.

As time went by, the plunge in hospital autopsy rates that had begun in 1967 continued to alarm me.

In fact, medical students in 1983 understood the problem and brought an autopsy resolution to the American Medical Association (AMA) that became established AMA policy.

I met in person with successive administrators of HCFA from 1986 until 2000* and pitched the problem to them, suggesting that Medicare needed to introduce a budgetary line item to reimburse for autopsy. All agreed that the autopsy was important, and all agreed to try to fix the payment problem. Alas, they did not.

Many credit Dr Lucian Leape's 1994 JAMA article, "Error in Medicine," as the beginning of the American patient safety movement.

Autopsy has always been a key way to discover serious errors in medicine and to figure out how to prevent them—as is known by every hospital and forensic pathologist.

In June 1999, MedPAC recommended to Congress that errors in medicine could be addressed in part by increasing use of the autopsy and that legislation was needed to accomplish this. None eventuated.

Two Institute of Medicine monographs, "To Err is Human" and "Crossing the Quality Chasm," accelerated the patient safety movement with the startling finding that 44,000 to 98,000 Americans die annually from errors in hospitals.

Continuing this safety theme, the Institute of Medicine issued a book entitled "Improving Diagnosis in Health Care" in 2015. An entire section is devoted to the value of autopsy.

After Justice Antonin Scalia's sudden death, I—and others—lamented the failure of Texas authorities to perform an autopsy. In an article at that time, I listed the 11 positive benefits of autopsy.

For many years, Medicare has functioned under a rule that requires autopsies in all cases of unusual deaths as a condition for participation (meaning, for a hospital to get paid by Medicare for anything) for both medico-legal and educational reasons.

In September 2018, CMS issued a long (over 2000 pages), complicated set of proposed rules to diminish administrative burdens. Many of these are welcome. One is not.

Horror of horrors. In September 2019, CMS announced its Omnibus Burden Reduction Final Rule, which, despite heavy opposition from parts of organized medicine, eliminated the autopsy requirement in order for hospitals to participate in Medicare.

Donald Trump's CMS Administrator, Seema Verma, is a smart woman, educated in health policy at Hopkins, and has a physician husband (psychiatrist); but on this issue, she and her medical staff are wrong. Let's educate them.

Today, the first day of the rest of our lives, is when our knowledgeable medical organizations, especially AMA, College of American Pathologists, American Society for Clinical Pathology, United States & Canadian Academy of Pathology, National Association of Medical Examiners, and Association for Molecular Pathology, plus the professionals of CMS, simply must overturn this new rule.

Already on death's door outside of medical examiner-coroner and better academic medical center settings, the autopsy will otherwise simply disappear from hospital medicine in America.

I once asked (on the record) 13 super-experts across US healthcare a series of questions about the autopsy, including, "How would you feel personally about being in a hospital with a 0% autopsy rate?" Dr John Affeldt, the president of the Joint Commission on Accreditation of Hospitals, replied, "No such hospital would be a good hospital."

Frankly, that will be the great majority of American hospitals if this rule stands.

Who loses? All American patients who wish to be safe and to benefit from high-quality hospital care.

That's my opinion. I'm Dr George Lundberg, at large for Medscape.

*William Roper, MD, MPH: 1986-1989; Gail Wilensky, PhD: 1990-1992; Bruce Vladeck, PhD: 1993-1997; Nancy-Ann Min DeParle, JD: 1997-2000. After I left JAMA in 1999, I continued to support the value of autopsy through writing, but I did not again meet with HCFA, CMS, or Health and Human Services officials to discuss this concern. Sadly, although two subsequent CMS administrators were physicians (Mark McClellan and Don Berwick), they also did not fix the problem. Since about 2000, institutional memory, which was not codified into payment, lapsed, and the fact that Medicare pays for autopsies faded from understanding. Carolyne Davis herself died in 2003.

 

George Lundberg, MD, is editor-at-large at Medscape, editor-in-chief at Cancer Commons, president and chair of the board of directors of The Lundberg Institute, and a clinical professor of pathology at Northwestern University. Previously, Dr Lundberg served as editor-in-chief of JAMA (including 10 specialty journals), AMA News, and Medscape.

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