Performing surgery on the wrong leg, having a patient go missing, leaving a sponge in a patient after surgery, artificial insemination with the wrong sperm or egg donor — these are examples of “never events” designated by the National Quality Forum (NQF). The NQF created this category of preventable but very serious events in 2002 to set a higher standard for patient safety at hospitals and motivate quality improvement.
However, hospitals cause other preventable harms to patients outside of clinical care, and doctors are taking a stand to declare these harms as unacceptable. In a recent article in JAMA Health Forum, Dr. Dave Chokshi at the CUNY School of Public Health and Health Policy and Dr. Adam Beckman at Harvard Medical School propose another list of hospital “never events” around social responsibility.
These five events are the social equivalent of operating on the wrong limb…
1. Aggressively pursuing medical debt
In the past few years, hospitals have come under fire for taking excessive actions to pursue outstanding medical bills, including suing patients, taking out liens on their houses, garnishing wages, and raiding their accident settlements. Some hospitals kept suing patients throughout the COVID-19 pandemic.These actions disproportionately harm low-income and Black patients and contribute to our country’s crisis of medical debt.
Regulations around hospital lawsuits are minimal. Nonprofit hospitals are required to assess patients’ eligibility for financial assistance before taking “extraordinary” debt collection actions. But that assessment can be as cursory as hospitals informing patients that financial assistance exists, putting it on patients to look up the financial assistance policies and apply. In other cases, like with Providence health system, hospitals skirt around financial assistance entirely, and hound patients to pay regardless of whether they are eligible.
2. Spending less than their fair share on meaningful community benefits
Nonprofit hospitals gain billions by being exempt from federal, state, and local taxes, but relatively few give as much back in financial assistance and programs to improve community health. In a report released earlier this year, the Lown Institute found that the combined “fair share deficit” for nonprofit hospital systems exceeded $18 billion in 2019. That’s the amount hospitals received in tax breaks but did not give back to communities.
When hospitals skimp on providing financial assistance, they make it harder for patients to afford care (again, contributing to the medical debt crisis). Additionally, the money hospitals receive in tax breaks could have gone to education, social welfare programs, and public health initiatives, which can leave communities underresourced. Given that communities are investing in hospitals with their tax dollars, hospitals should provide a return on this investment, by addressing the social drivers of health in their communities.
3. Failing to comply with price transparency rules
In January 2021, a new government rule went into effect, mandating that hospitals make their prices for all services publicly available. While most hospitals had previously posted their “chargemaster” prices (the full price before any negotiations with insurers), that’s not very helpful information for the nearly 300 million Americans who have insurance.
The new rule was designed to help solve this problem: hospitals are now required to publish the prices they charge for every payer for all services, and make the negotiated prices for 300 “shoppable” services available in a consumer-friendly format.
While the rule has the potential to help patients and payers reduce their healthcare costs, it can’t work if hospitals don’t comply. Disappointingly, study after study shows that few hospitals are abiding by the rule, leaving patients in the dark about how much care will cost them.
4. Providing less than a living wage for all hospital workers
There are many more housekeepers, food services workers, and custodians working in U.S. hospitals than there are doctors. While these workers are essential for keeping hospitals running, they are often paid less than a living wage. At the same time, hospital chief executives are the highest-paid category of nonprofit executives, making triple what most other nonprofit leaders make on average.
Research from the Lown Institute Hospitals Index shows that pay equity at nonprofit hospitals varies widely. On average, CEOs make eight times the rate of hospital workers without advanced degrees, but this ratio varies from 2:1 at the top-ranked hospitals to 26:1 at the bottom-ranked ones.
COVID-19 threw the issue of pay equity in the spotlight, as hospital workers were labeled essential but treated as disposable. For example, in 2020 a hospital technician whose take-home pay was $30,000 per year contracted COVID-19 on the job. Upon his return to work, he was named employee of the month and given a $6 gift voucher for the hospital cafeteria. The hospital system CEO—who was not on the frontlines of COVID-19—received a 13 percent boost in his total compensation, which was worth $30.4 million.
5. Contributing to racially segregated healthcare by underserving communities of color
Legal segregation of hospitals by race ended in 1967, but de facto hospital segregation still exists. As much as hospitals would like to believe they are “colorblind,” some hospitals disproportionately serve patients from Black and Brown communities while other hospitals draw their patients from whiter, wealthier communities.
The Lown Hospitals Index, which measures hospital racial inclusivity, found that racial segregation in US cities is common. In cities like Detroit, St Louis, and Kansas City, at least 75% of hospitals are either overserving or underserving patients from communities of color.
This hospital segregation leads to disparities in access and quality of care. For example, Black and Indigenous individuals are deeply underrepresented in clinical trials of new cancer drugs, in part because they have less access to the hospitals that run these studies. Lower-quality care at some safety net hospitals also contributes to higher rates of COVID-19 mortality and life-threatening birth complications for Black people. Yet hospitals are not motivated to address this problem, because they get paid more to take care of privately insured patients, who are more likely to be white.
A new category of “never events”
What is the purpose of identifying these new “never events”? One is to shine a light on the preventable harms that hospitals are causing to patients and communities — even those hospitals that claim to be concerned with environmental, social, and governance (ESG) issues. Chokshi and Beckman point out this contradiction:
“Private hospitals have expanded their purview to include addressing patients’ social drivers of health, spending billions of dollars by providing resources such as assistance with housing or establishing food pharmacies. While such programs can be beneficial to patients, it is now possible for a hospital to provide one patient a free taxi ride to overcome transportation barriers and simultaneously sue another patient for medical debt. Hospitals’ first responsibility should be to stop creating social harms.”
The authors also hope that categorizing certain events as unacceptable will drive regulators such as CMS to adjust hospital payments to those engaged in “egregious administrative practices.” On a state level, regulators could require reporting of data on hospital lawsuits (which are currently available through court records but are difficult to compare by hospital) or the value of hospitals’ property tax exemptions. Regulators on the state and federal level could also use these events to assess hospitals’ continued tax-exempt status.
The five hospital policies that Chokshi and Beckman outline are egregious, but there are undoubtedly more administrative actions that harm patients and must be curtailed. (We’ve showcased some of these in the Shkreli Awards, our annual “worst in healthcare” list.) As hospitals become more invested in their social responsibility, they must work to eliminate these preventable harms. And we’ll be tracking their progress along the way.