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Rare Malnutrition, Sepsis Cases Dog Hospital Group

 |  By cclark@healthleadersmedia.com  
   May 12, 2011

A California chain of 14 hospitals has some explaining to do after results of state inspections released this week found three facilities had miscoded patient diagnoses and a fourth failed to adequately monitor central venous catheters for infections.

The documents follow accusations in February that the hospital system has been coding an astonishingly large number of patients with a rare wasting syndrome called kwashiorkor, a serious form of malnutrition that generates thousands of dollars more in federal reimbursement. The chain also faces allegations filed by a labor union with which it is in dispute that the entire system is coding large numbers of patients with septicemia they don't actually have.

After unannounced inspections, licensing officials said in their reports that Prime Healthcare Services' San Dimas Community Hospital had inaccurately coded principal diagnoses of 17 of 29 patients in 2008 and 2009 whose charts were randomly reviewed.

The state concluded that a diagnosis of septicemia, sepsis, or septic shock could be supported by only 7 of the 29 records, and the diagnosis was "marginal" for another 19 because of the absence of positive blood culture and criteria for systemic inflammatory response syndrome. For the remaining three patients, a diagnosis other than septicemia, sepsis or septic shock was found, the report said.

Coding problems were also found at Prime's West Anaheim Medical Center and Chino Valley Medical Center.

A fourth, Desert Valley Hospital in Victorville, failed to adequately monitor central venous catheter insertions for bloodstream infections.

Prior accusations against Prime have provoked influential state and federal lawmakers to call for investigations of the facilities' billing and safety practices and for health officials to hold up any Prime facility license reviews.

"The extreme infection rates may reflect a pattern of up-coding by Prime," wrote State Sen. Elaine Alquist, chairwoman of the influential Senate Health Committee, in a letter last fall requesting an investigation by the California Department of Public Health. "This theory is bolstered by the exceptionally low mortality rate among Prime's reported septicemia patients, indicating that diagnoses of septicemia may not have been warranted in many of the cases. … Prime may have been overpaid around $18 million by Medicare in 2008 alone." 

She postulated that if Prime Healthcare was not up-coding, there might be high infection rates in the system's surrounding communities, "or poor quality of care at the hospitals," and thus such events should be reportable under legislation she introduced.

A series of stories by the investigative news group, California Watch, and major California dailies fueled the issue.

In February, California Watch drew from its review of 2009 Medicare billing data to reveal Prime had coded 25% of its Medicare patients as being malnourished and 2.3% as having kwashiorkor, reflected as ICD-9 260. By comparison, according to the California Watch report, hospitals statewide reported 7.5% of their patients as being malnourished and .2% as having kwashiorkor.

Kwashiorkor, a form of malnutrition that results when there is insufficient protein in the diet, is rare in the U.S. Yet California Watch reported that 36% of the kwashiorkor codes in the state were for patients at Prime hospitals, a rate 70 times higher and which can result in several thousands of dollars more per episode of care.

Prime officials did not return phone calls or e-mails Tuesday or Wednesday requesting a response to the state findings. A statement on its website says it is the victim of an extortion campaign by the Service Employees International Union – United Healthcare Workers West (SEIU) over the past year because "PHS rejected SEIU's demands for a 'quick' deal for SEIU members at PHS' Centinela Hospital Medical Center so that SEIU could avoid a challenge from NUHW, an upstart union formed by disgruntled SEIU members."

"SEIU initially threatened to expose "dirt" on PHS, disseminate reports based on Medicare data, and claim that these reports showed that Medicare patients were acquiring serious blood infections like septicemia at PHS' hospitals even though SEIU knew that the Medicare data identified conditions present on admission; not hospital acquired conditions," the website reads.

This week, investors in a company that leases to Prime also posed questions about "federal and state investigations into Prime over possible Medicare fraud and to evaluate options for better monitoring of potentially fraudulent billing activities within the portfolio facilities."

"In its letters to the Medical Properties Trust Board, CtW (Investment Group) warned that if these incident(s) were proven to stem from systemic up-coding, Prime's potential liabilities could easily outstrip the operator's net income, posing considerable reimbursement risk to Medical Properties' shareholders," said a CtW press statement.

It's unclear why cases of kwashiorkor and malnutrition have spiraled at Prime Healthcare hospitals. But the trend appears to be a national one.

According to the federal Agency for Healthcare Research and Quality's H-Cup (Healthcare Cost and Utilization Project) data tables, secondary diagnoses of kwashiorkor, filed under ICD-9 260, cases grew from 13,591 in 2004 to 59,250 in 2009. California, the data tables show, has only 6.3% of those cases, in 2009, but Texas has 11.2% and Florida has 5.5%.

Two other categories of malnutrition have mushroomed as well. ICD-9 261 indicating care for a protein deficiency called marasmus, bloomed from 37,288 cases in 2007 to 103,132 in 2009. Moreover ICD-9 262 – other severe malnutrition cases – went from 22,680 to 114,417.

Asked why these cases are ballooning, Ann Elexhauser, an AHRQ senior research scientist, said in an interview Monday she was unaware of the phenomenon review is being launched.

Ted Mazer, MD, a physician on staff at Alvarado Hospital Medical Center in San Diego, which Prime purchased last fall, hypothesized that the upswing may be tied to better surveillance for disease at the time of admission. Or, he says, "it might be due to administrative policies that automatically require albumin levels in routine daily blood draws. The former is good care if it is followed by intervention directed to such malnutrition.

"Albumin below a certain level may be associated with malnutrition, such as at time of admission, but it may also be a transient and expected effect of medical or surgical care of a problem unrelated to malnutrition, from which the patient is expected to recover once regular nutrition is restarted," says Mazer, former president of the San Diego County Medical Society.

"Let's say you're randomly or routinely including albumin levels for certain patients in your blood draws. At some point, you may reach the critical level that meets the criteria for kwashiorkor, or malnutrition, even though it's iatrogenic. You can say, 'Oh, the patient now has a technical characteristic of possible kwashiorkor diagnosis, so we're going to use that as the diagnosis for their stay.' "

"Is that illegal or unethical?" Mazer asks.  "Or is it an administrative use of rules that pushes the envelope but doesn't fall outside the boundaries? That's the question CDPH and other regulators are going to have to answer." He adds that a similar situation may be taking place with respect to the bump in septicemia cases at Prime as well.

It should be pointed out that accusations against Prime surfaced after its labor dispute with United Healthcare Workers-West, which is part of the SEIU, the largest healthcare workers union in the west with more than 150,000 members.

Because of the labor dispute, SEIU-UHW said, it engaged healthcare data experts to dig into federal and state Medicare statistics. They prepared an extensive report ,"Care and Coding of Prime Healthcare Services," released in January. "Not surprisingly, we often find that the same corporate employers who fail to treat their employees with dignity, respect, and fairness are also failing to be responsible corporate citizens in other areas," the report says.

The SEIU-UHW report also notes that five of six hospitals with the highest septicemia rates in the U.S. were operated by Prime Healthcare in 2008, and seven of 12 hospitals with those rates were operated by Prime Healthcare in 2009. Prime Healthcare's septicemia rates were 70% higher and 50% higher, respectively, than the second highest comparable health systems in either of those years, the report states.

But now that the state reports are out, clearly something, as they say, is rotten somewhere. California Watch reported last fall that the Office of Inspector General was asked to look into Prime's coding and billing practices by U.S. Reps. Henry Waxman, D-Los Angeles and Fortney "Pete" Stark, D-Fremont.

Perhaps they may jump in and start examining the bolus of these unusual diagnoses to see if any are wrongly exploiting an opportunity at the taxpayer's expense.

 

 

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