One Example of Healthcare Misinformation

On June 21^st  NBC News aired an investigation into HCA Healthcare accusing HCA administration of pressuring doctors, nurses and family to have patients enter hospice care or be discharged (1). Patients entering hospice care can lower inpatient mortality rate and length of stay, increasing profits and bonuses for executives. It works this way — if a patient passes away in a hospital, that death adds to the facility’s inpatient mortality figures. But if that person dies after a transfer to hospice care — even if the patient stays at the same hospital in the same bed — the death doesn’t count toward the facility’s inpatient mortality rate because the patient was technically discharged from the hospital. A reduction in lengthy patient stays is a secondary benefit according to an internal HCA hospital document (1). Under end-of-life care, patients don’t typically live long, so the practice can allow HCA to replace patients that may be costing the facility money because their insurance has run out with those who generate fresh revenues.

These practices are not unique to HCA nor are they new. Manipulation of patient data such as mortality go back at least until the 1990’s. For example, at the Phoenix VA the floor inpatient mortality rate was low while the ICU mortality rate was high. This was apparently due to excess mortality in floor to ICU transfers (2). Reduction of inappropriate ICU transfers from the hospital floor corrected the high ICU mortality rate. Similar changes were seen for length of stay. There were also dramatic reductions in the incidence of ICU ventilator-associated pneumonias and central line-associated blood stream infections just by alternating the reported cause of pneumonia or sepsis. For example, ventilator-associated pneumonia was called “delayed onset community acquired pneumonia” and sepsis was blamed on a source other than the presence of a central line.

These data manipulations were not restricted to the inpatient mortality or length of stay. Outrageously exaggerated claims of improvement and lives saved became almost the norm. In 2003 Jonathan B. Perlin, then VA Undersecretary of Health, realized that outcome data was needed for interventions such as pneumococcal vaccination with the 23-polyvalent pneumococcal vaccine. On August 11, 2003 at the First Annual VA Preventive Medicine Training Conference in Albuquerque, NM, Perlin claimed that the increase in pneumococcal vaccination saved 3914 lives between 1996 and 1998 (3) (For a copy of the slides used by Perlin click here). Furthermore, Perlin claimed pneumococcal vaccination resulted in 8000 fewer admissions and 9500 fewer days of bed care between 1999 and 2001. However, these data were not measured but based on extrapolation from a single, non-randomized, observational study (4). Most studies have suggested that the 23-polyvalent vaccine is of little or no value in adults (5).

It raises the question of why bother to manipulate these data? The common denominator is money. Administrators demand that the numbers meet the requirements to receive their bonuses (1). At the VA the focus changed from meeting the needs of the patient to meeting the performance measures. HCA administration is accused of similar manipulations. Speculation is that many if not most healthcare administrators behave similarly. The rationale is that the performance measures represent good care which is not necessarily true (5).

Who can prevent this pressuring of care givers and patient families to make the numbers look better? One would expect that regulatory organizations such as the Joint Commission, Institute of Medicine, Centers for Medicare and Medicaid Services, Department of Health and Human Services, and Department of Veterans Affairs would require the data reported be accurate. However, to date they have shown little interest in questioning data which makes their administration look good. The Joint Commission is a National Regulatory group that is prominent in healthcare regulation. After leaving the VA in 2006, Perlin was named the President, Clinical Operations and Chief Medical Officer of Nashville, Tennessee-based HCA Healthcare prior to being named the President and subsequently CEO of the Joint Commission in 2022. When regulatory organizations get caught burying their heads in the sand, administrators usually respond by blaming the malfeasance on a few bad apples. An example is the VA wait scandal that led to the ouster of the Secretary of Veterans Affairs, Eric Shinseki, and the termination of multiple administrators at the Phoenix VA. It should be noted that although Phoenix was the focus of the VA Inspector General at least 70% of medical centers were misreporting the wait times similarly to Phoenix (6).

Who should be the watchdogs and whistleblowers on these and other questionable practices – obviously, the hospital doctors and nurses. However, the hospitals have these employees so under their thumb that any complaint is often met with the harshest and most severe sanctions. Doctors or nurses who complain are often labeled “disruptive” or are accused of being substandard. The latter can be accomplished by a sham review of patient care and reporting to the physician or nurse to a regulatory authority such as the National Practitioner’s Databank or state boards of medicine or nursing (7). Financial data may be even easier to manipulate (8). A recent example comes from Kern County Hospital in Bakersville, CA (9). There the hospital’s employee union accuses the hospital of $23 million in overpayment to the hospital executives over 4 years. According to the union the hospital tried to cover up the overpayment. Now the executives have requested the hospital board to cover the overpayments.

The point is that hospital data can be manipulated. One should always look at self-reported data with healthy skepticism, especially if administrative bonuses are dependent on the data. Some regulatory authority needs to examine and certify that the reported data is correct. It seems unlikely that Dr. Perlin’s Joint Commission will carefully examine and report accurate hospital data. Hopefully, another regulator will accept the charge of ensuring that hospital data is accurate and reliable.

Richard A. Robbins, MD

Editor, SWJPCCS

References

1. NBC News. HCA Hospitals Urge Staff to Move Patients to Hospice to Improve Mortality Stats Doctors and Nurses Say. June 21, 2023. Available at: https://www.nbcnews.com/nightly-news/video/hca-hospitals-urge-staff-to-move-patients-to-hospice-to-improve-mortality-stats-doctors-and-nurses-say-183585349871 (accessed 6/28/23).
2. Robbins RA. Unpublished observations.
3. Perlin JB. Prevention in the 21^st Century: Using Advanced Technology and Care Models to Move from the Hospital and Clinic to the Community and Caring. Building the Prevention Workforce: August 11, 2003. First Annual VA Preventive Medicine Training Conference. Albuquerque, NM.   
4. Nichol KL, Baken L, Wuorenma J, Nelson A. The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med. 1999;159(20):2437-42. [CrossRef] [PubMed]
5. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]
6. Department of Veterans Affairs Office of Inspector General. Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time Data. April 7, 2022. Available at: https://www.va.gov/oig/pubs/VAOIG-21-02761-125.pdf (accessed 6/28/23).
7. Chalifoux R Jr. So, what is a sham peer review? MedGenMed. 2005 Nov 15;7(4):47; discussion 48. [PubMed].
8. Beattie A. Common Clues of Financial Statement Manipulation. Investopedia. April 29, 2022. Available at: https://www.investopedia.com/articles/07/statementmanipulation.asp (accessed 7/28/23).
9. Kayser A. California Hospital Accused of Overpaying for Executive Services. Becker’s Hospital Review. June 28, 2023. Available at: https://www.beckershospitalreview.com/compensation-issues/california-hospital-accused-of-overpaying-for-executive-services.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=6133H6750001J5K  (accessed 6/29/23).

Cite as: Robbins RA. One Example of Healthcare Misinformation. Southwest J Pulm Crit Care Sleep. 2023;27(1):8-10. doi: https://doi.org/10.13175/swjpccs029-23 PDF

A Labor Day Warning

Today is Labor Day, a public holiday honoring the American labor movement and the contributions that workers have made to the strength, prosperity, laws, and well-being of the country. Though this holiday dates back to the end of the nineteenth century, the concept of organized labor is under increasing attack. While many of the physician and nurse readers may think that “labor” does not apply to them, after all they are professionals, management would likely disagree.

In Arizona v. Maricopa County Medical Society in 1982, the Supreme Court ruled that when physicians negotiate collectively with insurers about fees, and as a consequence do not compete with one another, such negotiations represent a horizontal agreement among competitors to fix prices (1). This was based on the concept of physicians being independent from hospitals or healthcare systems. However, more physicians are now hospital employed which has been in no small part due to cuts in physician compensation by Medicare with the insurers rapidly following. This increase in physician employment has been associated with increased billings leading to increased profits and decreased physician compensation (2,3).

The Nation’s largest healthcare system is the Department of Veterans Affairs (VA). The pace of VA hiring has not kept pace with the growth of patients leading to prolonged wait times first reported in Phoenix (4). Two recent decisions will likely affect physician hiring and retention at the VA. First, President Trump announced cancellation of the the planned salary increase for civilian employees (5). Second, VA Secretary Robert Wilkie, cancelled collective bargaining rights when it comes to professional conduct and patient care by VA providers (6). In the private sector, hospital employed physicians seem to becoming increasingly discontented because of 1. Having to deal with a lot of rules; 2. Having to deal with a large bureaucracy. 3. Not having a staff under their control; and 4. Having little control over compensation models (7).

All in all, this does not bode well for physicians or patients. The data suggest that the Medicare has helped destroy independently employed physicians while over compensating hospital employed physicians whose fees are collected by the hospital (7). This trend will likely continue until Medicare realizes that the existence of the independent practitioner keeps healthcare costs down. By financially squeezing the independent practitioner Medicare’s actions lead to decreased competition and increased healthcare costs.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Halper HR. Arizona v. Maricopa County: a stern antitrust warning to healthcare providers. Healthc Financ Manage. 1982 Oct;36(10):38-42. [PubMed]
2. Lowes R. Hospital-employed physicians cost Medicare more, study says. Medscape. November 16, 2017. Available at: https://www.medscape.com/viewarticle/888772#vp_1 (accessed 9/3/18).
3. Kane L. Medscape physician compensation report 2018. Medscape. April 11, 2018. Available at: https://www.medscape.com/slideshow/2018-compensation-overview-6009667#12 (accessed 9/3/18).
4. Davidson J. VA doctor shortage fueled by management issues, poor pay The Washington Post. July 16, 2018. Available at: https://www.washingtonpost.com/news/powerpost/wp/2018/07/16/va-doctor-shortage-fueled-by-management-issues-poor-pay/?utm_term=.070275d06e2a  (accessed 9/3/18).
5. Liptak K. Trump cancels pay raises for federal employees. CNN. August 31, 2018. Available at: https://www.cnn.com/2018/08/30/politics/trump-cancels-federal-employee-pay-raises/index.html (accessed 9/3/18).
6. Department of Veterans Affairs. VA secretary clarifies collective bargaining authority for patient care. August 29, 2018. Available at: https://www.managedhealthcareconnect.com/content/va-secretary-clarifies-collective-bargaining-authority-patient-care?hmpid=cmlja3JvYmJpbnNAY294Lm5ldA== (accessed 9/3/18).
7. Mertz GJ. Physicians employed by hospitals. Medscape. January 01, 2018. Available at: https://www.medscape.com/viewarticle/891120#vp_1 (accessed 9/3/18).
8. Lowes R. Hospital-employed physicians cost medicare more, study says. Medscape. November 16, 2017. Available at: https://www.medscape.com/viewarticle/888772 (accessed 9/3/18).

Cite as: Robbins RA. A labor day warning. Southwest J Pulm Crit Care. 2018;17(3):95-6. doi: https://doi.org/10.13175/swjpcc106-18 PDF 

The VA Mission Act: Funding to Fail?

Yesterday on D-Day, the 74^th anniversary of the invasion of Normandy, President Trump signed the VA Mission Act. The law directs the VA to combine a number of existing private-care programs, including the so-called Choice program, which was created in 2014 after veterans died waiting for appointments at the Phoenix VA (1). During the signing Trump touted the new law saying “there has never been anything like this in the history of the VA” and saying that veterans “can go right outside [the VA] to a private doctor”-but can they? Although the bill authorizes private care, it appropriates no money to pay for it. Although a bipartisan plan to fund the expansion is proposed in the House, the White House has been lobbying Republicans to vote the plan down (2). Instead Trump has been asking Congress to pay for veteran’s programs by cutting spending elsewhere (2).

We in Arizona are very familiar with what is likely ahead if the VA Mission Act goes unfunded. One example is Arizona Child Protective Services (CPS). After enduring years of funding cuts after the 2007 recession, many CPS employees left and the caseloads of those remaining became unmanageable. In 2013 a scandal erupted when it was uncovered that over 6000 cases of child abuse or neglect were not investigated (3). Many legislators who were responsible for the funding cuts blamed poor management and eventually CPS was reformed as a separate agency.

Arizona schools may be going to the same direction as CPS. After reducing funding to the point that Arizona schools spend less per pupil that any state in the nation, Governor Doug Ducey and many of the Arizona legislators favor charter/private schools (4). However, tax dollars are funneled away from public schools by the expansion of the charter/private school voucher system (4).

The VA may also be getting this “funding to fail” treatment with the VA Mission Act. If confirmed, Veterans Affairs Secretary nominee, Robert Wilkie, would lead the effort to implement the VA Mission Care Act (2). With no funding Wilkie will undoubtedly need to take money from other VA programs leading to their failure. Down the road, he can expect criticism for the failed programs and be fired by a tweet as did the previous Secretary for Veterans Affairs (5).

Un- or under-funded mandates have become a favorite of politicians who take credit for voting for something good but avoid the blame of voting to pay for it. However, at the moment the economy seems sufficiently strong that Congress enacted a $1.5 trillion tax cut and can fund an expensive border wall. The VA Mission Act can provide the healthcare the VA has been unable to perform but only if accompanied by the $50 billion funding it requires to be successful.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Slack D. Trump signs VA law to provide veterans more private health care choices. USA TODAY. June 6, 2018. Available at: https://www.usatoday.com/story/news/politics/2018/06/06/trump-signs-law-expanding-vets-healthcare-choices/673906002/ (accessed 6/7/18)
2. Werner E, Rein L. Trump signs veterans health bill as White House works against bipartisan plan to fund it. Washington Post. June 6, 2018. Available at: http://www.chicagotribune.com/news/nationworld/politics/ct-trump-veterans-health-bill-20180606-story.html (accessed 6/7/18)
3. Santos F. Thousands of ignored child abuse allegations plague Arizona welfare agency. NY Times. December 10, 2013. Available at: https://www.nytimes.com/2013/12/11/us/thousands-of-ignored-abuse-allegations-plague-arizona-welfare-agency.html (accessed 6/7/18)
4. Alan Singer. How charter schools buy political support. Huffington Post. August 10, 2017. Available at: https://www.huffingtonpost.com/entry/how-charter-schools-buy-political-support_us_598c3149e4b08a4c247f287d (accessed 6/7/18).
5. Robbins RA. What does Shulkin's firing mean for the VA? Southwest J Pulm Crit Care. 2018;16(3):172-3. [CrossRef]

Cite as: Robbins RA. The VA mission act: Funding to fail? Southwest J Pulm Crit Care. 2018;16(6):334-5. doi: https://doi.org/10.13175/swjpcc074-18 PDF 

Kiss Up, Kick Down in Medicine

This past week the phrase “kiss up, kick down” was used to describe Ronny Jackson, then a nominee for the Secretary of Veterans Affairs (1). Wikipedia defines the phrase as “a neologism used to describe the situation where middle level employees in an organization are polite and flattering to superiors but abusive to subordinates” (2). Like most, I do not know Jackson and have no knowledge of the truth. However, the behavior attributed to Dr. Jackson is pervasive and harmful in medicine.

Kiss up, kick down is part of a blame culture. McLendon and Weinberg, see the flow of blame in an organization as one of the most important indicators of organization robustness and integrity (3). They argue that blame flowing upwards in a hierarchy proves that management can take responsibility for their orders and supply the resources required to do a job. However, blame flowing downwards, from management to staff, or laterally between professionals, indicate organizational failure. In a blame culture, problem-solving is replaced by blame-avoidance. Weinberg emphasizes that blame coming from the top generates "fear, malaise, errors, accidents, and passive-aggressive responses from the bottom", with those at the bottom feeling powerless and lacking emotional safety (4).

Calum Paton, Professor of Health Policy at Keele University, describes kiss up kick down as a prevalent feature of the UK National Health Service culture. He raised this point when giving evidence at the public inquiry into concerns of poor care and high mortality at Stafford Hospital in England (5). According to Paton, credit was centralized and blame devolved or transferred to a lower level. "Kiss up kick down means that your middle level people will kiss-up, they will please their masters, political or otherwise, and they will kick down to blame somebody else when things go wrong."

The VA scheduling scandal is a similar American example where management failed to provide the number of providers necessary to care for the patients. When caught, management attempted to blame the physicians (6). This is hardly surprising given that the physicians are often leaderless without anyone to speak for them. Too often physician leaders are not chosen from the best and brightest to protect the best interests of the patient and staff. Rather they are selected because they are the most compliant with management (kiss up).

Physicians near the top of a hierarchy are usually administrators peripherally involved in patient care. They may not always act with the best interests of the patient and staff but with what is best for their bosses and themselves as both the Stafford and VA examples illustrate. As such, they can be expected to “roll over on anyone” (kick down), a phrase used to describe Dr. Jackson (1). Furthermore, their practice skills may be weak or outdated making them particularly dangerous to the organization.

Physicians who put patient needs first often find themselves at odds with what is best for management. It may be time to reconsider how physician leaders are chosen. The medical staff is probably in the best position to judge which physicians are the best physician leaders rather than the obsequious leaders often chosen by management (7). If the medical staff chosen physician leader can work with management, the organization will have a dyad leadership. If not, then the physician leaders with the support of the staff can oppose those policies deemed harmful to patients or the organization.

Richard A. Robbins, MD

Editor, SWJPCC

References

1. Blake A. The lengthy list of allegations against Ronny Jackson, annotated. The Washington Post. April 25, 2018. Available at: https://www.washingtonpost.com/news/the-fix/wp/2018/04/25/the-list-of-allegations-against-ronny-jackson-annotated/?utm_term=.9ee75ad66c9b (accessed 4/28/18).
2. Kiss up kick down. Wikipedia. Available at: https://en.wikipedia.org/wiki/Kiss_up_kick_down (accessed 4/28/18).
3. McLendon J, Weinberg GM. Beyond blaming. Aye Conference Article Library. 1996. Available at: http://www.humansystemsinaction.com/beyondblaming/ (accessed 4/28/18).
4. Gerald M. Weinberg: Beyond Blaming, March 5, 2006, AYE Conference. Available at: http://www.ayeconference.com/beyondblaming/ (accessed 4/28/18).
5. Mid Staffordshire Public Inquiry Transcript - day 103. June 21, 2011. Available at: http://webarchive.nationalarchives.gov.uk/20150407092403/http://www.midstaffspublicinquiry.com/sites/default/files/transcripts/Tuesday_21_June_2011_-_transcript.pdf (accessed 4/28/18).
6. Robbins RA. Don't fire Sharon Helman-at least not yet. Southwest J Pulm Crit Care. 2014;8(5):275-7. [CrossRef]
7. Robbins RA. Beware the obsequious physician executive (OPIE) but embrace dyad leadership. Southwest J Pulm Crit Care. 2017;15(4):151-3. [CrossRef]

Cite as: Robbins RA. Kiss up, kick down in medicine. Southwest J Pulm Crit Care. 2018;16(4):230-1. doi: https://doi.org/10.13175/swjpcc060-18 PDF 

What Does Shulkin’s Firing Mean for the VA?

David Shulkin MD, Secretary for Veterans Affairs (VA), was finally fired by President Donald Trump ending long speculation (1). Trump nominated his personal physician, Ronny Jackson MD, to fill Shulkin’s post. The day after his firing, Shulkin criticized his firing in a NY Times op-ed claiming pro-privatization factions within the Trump administration led to his ouster (2). “They saw me as an obstacle to privatization who had to be removed,” Dr. Shulkin wrote. “That is because I am convinced that privatization is a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans.”

Former Secretary Shulkin’s tenure at the VA has had several controversies. First, as undersecretary of Veterans Healthcare and later as secretary money appropriated to the VA to obtain private care under the Veterans Access, Choice, and Accountability Acts of 2014 and the VA Choice and Quality Employment Act of 2017 appears to have been largely squandered on administrative salaries and expenses rather than hiring healthcare providers to shorten VA wait times (3). Second, Shulkin took a trip with his wife to Europe eventually ending up at Wimbledon to watch tennis (4). The purpose of his trip was ostensibly to attend a London Summit with senior officials from the United States, the United Kingdom, Canada, Australia, and New Zealand to discuss topical issues related to veterans. Although the summit occurred over 2 1/2 days, Shulkin and his wife traveled for 11 days at the taxpayer expense including a side trip to Denmark.

“The private sector, already struggling to provide adequate access to care in many communities, is ill-prepared to handle the number and complexity of patients that would come from closing or downsizing V.A. hospitals and clinics, particularly when it involves the mental health needs of people scarred by the horrors of war,” Dr. Shulkin wrote (2). “Working with community providers to adequately ensure that veterans’ needs are met is a good practice. But privatization leading to the dismantling of the department’s extensive health care system is a terrible idea.” Going on Shulkin states that, “Unfortunately, the department [VA] has become entangled in a brutal power struggle, with some political appointees choosing to promote their agendas instead of what’s best for veterans … These individuals, who seek to privatize veteran health care as an alternative to government-run VA care, unfortunately fail to engage in realistic plans regarding who will care for the more than 9 million veterans who rely on the department for life-sustaining care.”

However, the VA for many years has engaged in a relentless expansion of administration at the expense of healthcare. In the absence of sufficient oversight, Shulkin and VA Central Office did little to curb this trend (3).

Assuming he is confirmed, what will Ronny Jackson, Shulkin’s replacement, do? It seems likely that he will do exactly what Shulkin alleges and Trump apparently wants, i.e., privatize VA healthcare. Whether Jackson will be able to bend the large VA bureaucracy towards privatization is another matter given his lack of healthcare administrative experience. Shulkin may also be right that privatization may only reward select people and companies with profits rather than improving veterans’ care. Regardless, healthcare is more expensive than not delivering healthcare, so the price will probably rise. Time will tell, but something needs to be done. To paraphrase former VA undersecretary Ken Kizer, it is time for another “Prescription for Change” at the VA. 

Richard A. Robbins, MD*

Editor, SWJPCC

References

1. Rein L, Rucker P, Wax-Thibodeaux E, Dawsey J.  Trump taps his doctor to replace Shulkin at VA, choosing personal chemistry over traditional qualifications. Washington Post. March 29, 2018. Available at: https://www.washingtonpost.com/world/national-security/trump-ousts-veterans-affairs-chief-david-shulkin-in-administrations-latest-shake-up/2018/03/28/3c1da57e-2794-11e8-b79d-f3d931db7f68_story.html?utm_term=.7bcfe44b4ff6 (accessed 3-30-18).
2. Shulkin DA. Privatizing the V.A. will hurt veterans. NY Times. March 28, 2018. https://www.nytimes.com/2018/03/28/opinion/shulkin-veterans-affairs-privatization.html (accessed 3-30-18).
3. US Government Accountability Office. Better data and evaluation could help improve physician staffing, recruitment, and retention strategies. GAO-18-124. October 19, 2017. https://www.gao.gov/products/GAO-18-124 (accessed 3-30-18).
4. VA Office of Inspector General. Administrative investigation: VA secretary and delegation travel to Europe. Report No. 17-05909-106. February 14, 2018. Available at: https://www.va.gov/oig/pubs/VAOIG-17-05909-106.pdf (accessed 3-30-18).

*Dr. Robbins has received compensation for providing healthcare to veterans under the VA Choice Act.

Cite as: Robbins RA. What does Shulkin's firing mean for the VA? Southwest J Pulm Crit Care. 2018;16(3):172-3. doi: https://doi.org/10.13175/swjpcc052-18 PDF