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