The OIG’s findings echo those of previous studies that found that more than a quarter of patients in hospitals and a third in skilled nursing facilities suffer harm related to their care. Almost a quarter of the harmed patients had to be admitted to an acute care hospital, the study shows.
This story first appeared July 22, 2016 on the ProPublica website.
Patients may go to rehabilitation hospitals to recover from a stroke, injury, or recent surgery. But sometimes the care makes things worse. In a government report published Thursday, 29 percent of patients in rehab facilities suffered a medication error, bedsore, infection or some other type of harm as a result of the care they received.
Doctors who reviewed cases from a broad sampling of rehab facilities say that almost half of the 158 incidents they spotted among 417 patients were clearly or likely preventable.
"This is the latest study over a long time period now that says we still have high rates of harm," saysDr. David Classen, an infectious disease specialist at the University of Utah School of Medicine who developed the analytic tool used in the report to identify the harm to patients.
"We're fooling ourselves if we say we have made improvement," Classen says. "If the first rule of health care is 'Do no harm,' then we're failing."
The oversight study, from the office of the inspector generalof the U.S. Department of Health and Human Services, focused on rehabilitation facilities that were not associated with hospitals. Rehab facilities generally require that patients be able to undergo at least three hours of physical and occupational therapy per day, five days a week. Patients at these facilities are presumed to be healthier than patients in a more typical hospital or a nursing home.
Still, the findings echoed those of previous studies that found that more than a quarter of patients in hospitals and a third in skilled nursing facilitiessuffered harm related to their care.
"It's important to acknowledge that harm can occur in any type of inpatient setting," says Amy Ashcraft, a team leader for the rehabilitation hospital study. "This is one of the settings that's most likely to be underestimated in terms of what type of harm can occur."
For the purposes of the study, doctors and nurses identified harm by reviewing the medical records of 417 randomly selected Medicare patients who stayed in U.S. rehabilitation facilities in March 2012. The events they identified varied in severity, ranging from a temporary injury to something that required a longer stay at the facility or that led to permanent disability or death.
Almost a quarter of the harmed patients had to be admitted to an acute care hospital, at a cost of about $7.7 million for the month analyzed, the study shows.
The physicians who reviewed the cases for the OIG say substandard treatment, inadequate monitoring, and failure to provide needed care caused most of the harm. Almost half the cases, 46 percent, were related to medication errors, and included bleeding from gastric ulcers due to blood thinners and a loss of consciousness linked to narcotic painkillers.
That high number indicates there's lots of room for improvement, says Dr. Eric Thomas, director of the UT Houston-Memorial Hermann Center for Healthcare Quality and Safety.
"We know a lot about preventing medication errors," Thomas says.
Another 40 percent of the cases in which patients were harmed were traced to lapses in routine monitoring that led to bedsores, constipation or falls. These problems almost never contributed to a patient's death, but could mean extra days or weeks of recovery, a loss of independence or permanent disability, says Lisa McGiffert, director of the Consumers Union Safe Patient Project.
"It is a domino effect for any person who has had an adverse event," says McGiffert, who was not involved in the study.
The inspector general is recommending that Medicare and the Agency for Healthcare Research and Quality work together to reduce harm to patients by creating a list of adverse events that occur in rehab hospitals. In their responses to the report, the agencies have pledged to follow that suggestion.
Officials from the American Medical Rehabilitation Providers Association, the trade group that represents rehab facilities, say they have not yet seen the report and decline to comment for now.
Where a hospital is located and who owns it make a big difference in how many of its doctors take meals, consulting and promotional payments from pharmaceutical and medical device companies, a new ProPublica analysis shows.
A higher percentage of doctors affiliated with hospitals in the South have received such payments than doctors in other regions of the country, our analysis found. And a greater share of doctors at for-profit hospitals have taken them than at nonprofit and government facilities.
Doctors in New Jersey, home to many of the largest drug companies, led the country in industry interactions: Nearly eight in 10 doctors working at New Jersey hospitals took payments in 2014, the most recent year for which data is available. Nationally, the rate was 66 percent. (Look up your hospital using our new tool.)
For the past six years, ProPublica has tracked industry payments to doctors, finding that some earn hundreds of thousands of dollars or more each year working with drug and device companies. We've reported how the drugs most aggressively promoted to doctors typically aren't cures or even big medical breakthroughs.
And we recently found an association between payments and higher rates of brand-name prescribing, on average. Accepting even one inexpensive meal from a company was associated with a higher rate of prescribing the product to which the meal was linked, another study showed.
This analysis shows profound differences among hospitals, but it's uncertain why that is. It could be that hospitals play a role in shaping affiliated doctors' acceptance of payments or that like-minded physicians congregate at particular hospitals.
Those who support limits on such payments say patients may want to know how prevalent industry money is at a hospital before choosing it for care. "Maybe they're prescribing or treating you as a patient not based on evidence but rather based on markets or industry gain or personal gain," said Dr. Kelly Thibert, president of the American Medical Student Association, which grades medical schools and teaching hospitals on their conflict-of-interest policies. Patients, she said, "need to be aware that this could potentially be an issue and they need to speak up for themselves and their loved ones who may be in those hospitals."
ProPublica matched data on company payments to physicians in 2014 with data kept by Medicare on the hospitals with which physicians were affiliated at the time. We only looked at each doctor's primary hospital affiliation and only at doctors eligible to receive payments in the 100 most common medical specialties. The payments included speaking, consulting, meals, travel, gifts and royalties, but not research.
To be sure, the data is not perfect. Companies must report their payments to the federal government, and some doctors have found errors in what's been attributed to them. Companies can face fines for errors, and doctors have a chance each year to contest information reported about them. Also, Medicare's physician data may not capture doctors who do not participate in the program and it may not accurately reflect the status of doctors who have moved. (Read more about how we conducted our analysis.)
As might be expected, hospitals with tougher rules, such as banning industry reps from walking their halls and bringing lunch, tended to have lower payments rates. For example, at Kaiser Permanente, a giant California-based health insurer that runs 38 hospitals, fewer than three in 10 doctors took a payment in 2014. Since 2004, the system has banned staff from taking anything of value from a vendor.
"Our intent was to disrupt the strategy of using what industry calls 'food, friendship and flattery' to develop relationships with prescribers and influence the choice of drugs, the choice of devices, implants, things like that," said Dr. Sharon Levine, an executive vice president of the Permanente Federation, which represents the doctor arm of Kaiser Permanente. "Passing a policy alone doesn't make anything happen. There's a fair amount of surround-sound in the organization around reminding people about this and reminding them why we took this step."
Levine said she believes many of the payments attributed to Kaiser doctors were for meals and snacks at professional meetings, even if they didn't eat them.
ProPublica's analysis found distinct regional differences in comparing where industry payments were most concentrated.
After New Jersey, the states with the highest rates of hospital-affiliated doctors taking payments were all in the South: Louisiana, Mississippi, Florida, South Carolina and Alabama had rates above 76 percent. At the other end of the spectrum, Vermont had the lowest rate of industry interactions (19 percent), followed by Minnesota (30 percent). Maine, Wisconsin and Massachusetts had rates below 46 percent. Some of these states had laws requiring public disclosure of payments to doctors that predated the federal government's.
There were also major differences between hospitals based upon who owned them. For-profit hospitals had the highest rate of payments to doctors, 75 percent, followed by nonprofit hospitals at 66 percent. Federally owned hospitals had the lowest rates at 29 percent, followed by other government hospitals at 61 percent. Hospitals operated by the U.S. Department of Veterans Affairs were not included in our analysis.
Evidence is mounting that doctors who receive as little as one meal from a drug company tend to prescribe more expensive, brand-name medications for common ailments than those who don't.
A study published online Monday in JAMA Internal Medicine found significant evidence that doctors who received meals tied to specific drugs prescribed a higher proportion of those products than their peers. And the more meals they received, the greater share of those drugs they tended to prescribe relative to other medications in the same category.
The researchers did not determine if there was a cause-and-effect relationship between payments and prescribing, a far more difficult proposition, but their study adds to a growing pile of research documenting a link between the two.
A ProPublica story published in March found that doctors who took payments from the pharmaceutical and medical device industries prescribed a higher proportion of brand-name medications than those who didn't. It also found that the more money a doctor received, the higher the percentage of brand-name drugs he or she prescribed, on average.
Similarly, a Harvard Medical School study published in May found that Massachusetts physicians prescribed a larger proportion of brand-name statins — the category of drugs that treat high cholesterol — the more industry money they received. There was no significant increase in brand-name prescribing for those who received less than $2,000.
What makes the current study different is that it looked at specific drugs.
In an editor's note, Dr. Robert Steinbrook wrote that the recent analyses "raise a broader question. Is it necessary to prove a causal relationship between industry payments to physicians and the prescribing of brand-name medications?"
Other than for research and development, and related consulting, Steinbrook wrote, "it is already evident that there are few reasons for physicians to have financial associations with industry. Outright gifts, such as meals, may be legal, but why should physicians either expect or accept them?"
Holly Campbell, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, the industry trade group, said the latest study creates more confusion than clarity. In part, that's because the researchers acknowledge that they could not determine whether the drugs were prescribed before or after doctors received meals paid for by companies.
"This study cherry-picks physician prescribing data for a subset of medicines to advance a false narrative," Campbell wrote in an email. "Manufacturers routinely engage with physicians to share drug safety and efficacy information, new indications for approved medicines and potential side effects of medicines. As the study says, the exchange of this critical information could impact physicians' prescribing decisions in an effort to improve patient care."
Since 2013, the government has required all pharmaceutical and medical device makers to publicly report their payments to doctors. The government has released data on transactions from August 2013 to December 2014; data from 2015 is set to be made public next week. Those payments can be searched in ProPublica's Dollars for Docs tool.
In the study released today, a team led by Colette DeJong at the University of California San Francisco examined four classes of medications, including those that treat high cholesterol, heart rhythm disorders, high blood pressure and depression. The researchers identified one heavily marketed brand-name drug in each class – Crestor, Bystolic, Benicar and Pristiq – for which there are cheaper, equally effective options.
DeJong and her colleagues then looked at physicians who received meals specifically tied to those drugs (companies have to list the products associated with each of their payments) and their 2013 prescriptions in Medicare's drug program. The researchers excluded physicians who received other types of payments—such as for promotional speaking and consulting–in an effort to isolate any relationship to the meals alone.
Though only a relatively small percent of physicians who prescribed the drugs examined in the study received payments from their makers, those doctors prescribed the drugs more often than other doctors.
Physicians who received meals related to Crestor on four or more days prescribed the drug at almost twice the rate of doctors who received no meals. The difference was even more marked for the other drugs. Physicians who received meals prescribed Bystolic at more than 5 times the rate of their uncompensated peers, Benicar at a rate 4.5 times higher, and Pristiq at a rate 3.4 times higher.
Higher rates of prescribing were also observed when doctors received just a single meal, even after taking into account a physician's specialty and region of practice.
Dr. R. Adams Dudley, a professor of medicine and health policy at UCSF and one of the study's authors, said he and his colleagues expected to see "some evidence that doctors were responsive to incentives, what with their being humans and all."
Still, he said, "I think we were probably surprised that it took so little of a signal and such a low value meal…It has changed our thinking."
DeJong said the researchers don't think the meals themselves cause doctors to prescribe more of a drug, but rather the time they spend interacting with drug reps when they drop off those meals.
"There's really no way that a $10 bagel sandwich can influence a doctor in a gift way," she said. "We think it represents more reciprocity, the time spent with the drug rep and the fact that the doctor is listening to this 10-minute pitch."
Dudley suggested that patients talk to their doctors and ask "Is there a generic that's just as good?"
"Hopefully they can get the doctor off of the prescribing behaviors that we're observing."
MergerWatch, which analyzes the hospital industry and opposes faith-based health care restrictions, surveyed health care statutes and regulations in all 50 states and the District of Columbia. It found that only 10 states require government review before hospital facilities and services can be shut down.
Mergers have become commonplace as hospital mega-chains increasingly dominate the American health-care market. But these deals often go unscrutinized by state regulators, who fail to address potential risks to patients losing access to care, according to a new report released Thursdday.
MergerWatch, which analyzes the hospital industry and opposes faith-based health care restrictions, surveyed health care statutes and regulations in all 50 states and the District of Columbia. It found that only 10 states require government review before hospital facilities and services can be shut down. Only eight states and the District of Columbia mandate regulatory review when hospitals enter into more informal partnerships rather than full-scale mergers, closing a loophole that exists in other states for deals to pass with minimal state oversight.
Smaller, local hospitals often agree to merge with larger chains in order to survive. The goal is to cut overlapping services, negotiate better deals with insurance companies and share in the cost savings. But without state protections, local residents can see health services disappear, sometimes without a chance to weigh in.
"In a number of states, there is no oversight at all. So hospitals are just doing what makes business sense for them," said Lois Uttley, one of the report's co-authors and the director of MergerWatch. "Someone needs to be looking out for the patients and the community."
Sometimes the loss of services is ideological: As ProPublica and Mother Jones have reported, the expansion of Catholic hospitals in Washington State has led to restrictions on women's health services and end-of-life counseling. Other times it's just the bottom line: Expensive services such as pediatrics, obstetrics, emergency room and neo-natal intensive care may be downsized when a non-profit hospital is taken over by a for-profit one, according to the report.
Even when state regulatory programs exist, they often fail to protect consumers from reductions in health-care services. That's because state oversight programs were largely written in the 1960s and 70s when hospitals were expanding and the main fear was duplication of facilities and services. Today, however, the opposite is happening: According to MergerWatch's data, the number of hospitals that provide short-term acute-care has declined by about 240 over the past fifteen years in the United States. Meanwhile, the country's remaining hospitals are consolidating at a faster rate: 112 hospital deals were announced in 2015, which is a 70 percent increase from 2010, according to a recent analysis by Kaufman, Hall & Associates LLC, a management consulting firm.
Most state governments offer few avenues for consumers to express their concerns about proposed hospital deals. Just six states require a public hearing for every merger application under review, MergerWatch found. In the absence of state-mandated public forums, grassroots battles against hospital mergers have been taking place across the country, driven largely by local residents only after health services have been restricted.
Consider Arizona: In 2010, the Sierra Vista Regional Health Center partnered with the Carondelet Health Network, a Catholic system. Many residents of rural Sierra Vista only became aware of this after they discovered new limitations on birth control, including tubal ligations and vasectomies, as well as on end-of-life options for the elderly.
"It happened before anybody had any input from the community," Dotti Wellman, a longtime Sierra Vista resident who helped organize protests against the partnership, told ProPublica. "I was very angry to think that families were going to be denied care. Quite honestly, if something happened to me, I didn't want to go there."
Bruce Silva, an OB-GYN who was based at the health center, saw patients denied care, including a woman who needed an emergency abortion after miscarrying one of her 15-week-old twins. He describes the essential paradox of the situation: "What they felt was morally reprehensible was what I felt was the moral thing to do." He explained that the nearest non-Catholic hospital was about 100 miles away and some patients in this rural area could not even afford the gas. "It was denying access to people who were poor," he told ProPublica.
For several months, according to Wellman, she and a group of community residents — mostly patients over the age of 60 — picketed the hospital every weekday for around four hours. Some residents also provided the state attorney general's office sworn statements of their views. After a year, the health center decided to end its partnership with the Catholic system.
Two years after the failed affiliation with Carondelet, Sierra Vista partnered with a larger for-profit hospital system that built a new facility and renamed it Canyon Vista Medical Center. In April, the parent company finalized a merger with another regional health-care group, forming an even bigger entity called RCCH Healthcare Partners whose expanded reach covers 12 states.
Jeff Atwood, a spokesman for RCCH, declined to comment on the Sierra Vista-Carondelet partnership. Gary Hopkins, a spokesman for Tenet Healthcare Corporation, the majority owner of Carondelet since September, said he could not comment because the partnership predates Tenet's involvement.
Many states do allow the state attorney general to review transactions when they involve non-profit hospitals to ensure that their charitable status won't be compromised. Some hospital mergers might also trigger antitrust review at the state or federal level, which aims to protect consumers (and their wallets) by making sure a single hospital system doesn't gain monopoly-esque control over an entire area. Since November, the Federal Trade Commission has challenged proposed hospital mergers in Pennsylvania, West Virginia and Illinois.
Christine Khaikin, a co-author of the report, called MergerWatch's work "a jumping off point" to "open the eyes of legislators and policymakers that the regulation of hospital transactions is not inherently bad. It can be used to the consumers' advantage, and we're hoping to start really engaging healthcare advocates in the states."
A story by ProPublica and NPR and a Senate investigation prompt a Missouri nonprofit hospital to change its policies and forgive thousands of patients’ debts. But without similar scrutiny, it’s unclear if other hospitals that sue the poor will change.
by Paul Kiel, ProPublica, and Chris Arnold, NPR. This article first appeared on ProPublica June 1, 2016.
For years, Heartland Regional Medical Center, a nonprofit hospital in the small city of St. Joseph, Missouri, had quietly sued thousands of its low-income patients over their unpaid bills. But after an investigation by ProPublica and NPR prompted further scrutiny by Sen. Charles Grassley, the hospital overhauled its financial assistance policy late last year and forgave the debts of thousands of former patients.
The hospital "deserves credit for doing the right thing after its practices were scrutinized," Grassley, R-Iowa, wrote last week in a letter to his Senate colleagues, "but it should not take Congressional and press attention to ensure that tax-exempt, charitable organizations are focused on their mission of helping those in need."
While the changes at Heartland, which now goes by Mosaic Life Care, are a boon to its poorest patients, ProPublica has found numerous cases across the country of nonprofit hospitals, which pay no income tax, filing suits by the thousands.
Some have filed more suits than Mosaic ever did. In Evansville, Indiana, for example, Deaconess Hospital filed more than 20,000 lawsuits from 2010 through 2015. Like Mosaic, Deaconess reconsidered its financial assistance policies after questions from ProPublica last week and said it would be making changes.
Grassley, in a floor speech announcing the results of his investigation, said litigious nonprofits should take it upon themselves to change their ways. "Let me be clear, nonprofit hospitals should not be in the business of aggressively suing their patients," he said. "In essence, because of the favorable tax treatment these hospitals receive, they have a duty to help our nation's most vulnerable."
As part of Mosaic's revamped policies, it instituted a "medical debt grace period" late last year. Typically, patients who have been sued by the hospital are no longer eligible for financial assistance. But during the grace period, former patients with outstanding debts were allowed to be evaluated for assistance.
The program resulted in 3,342 people receiving a total of $17 million in debt relief, Mosaic said. The largest bill was $225,000, though the average was a more modest $5,000.
Despite those numbers, patients featured in our 2014 story had a mixed experience trying to get their bills resolved.
After Mosaic secured two court judgments against Keith Herie, a 53-year-old drill operator, it seized about $20,000 from his wages over the course of eight years. But Herie still owed the hospital more than $26,000 when we published our story, partly due to interest on the debt. During the grace period, Mosaic determined that Herie's income was too high for his debt to be completely forgiven, but offered to settle it for $8,300. He accepted, paying it with the proceeds from a worker's compensation settlement he received.
"It feels awesome to be able to close the books on it permanently," he said.
The story was different for Keith Berry, who is on disability, and his wife Tammy, who works at the fast food chain Taco John's. As we reported back in 2014, Tammy Berry earned just above $8 an hour, but the couple was faced with bills exceeding $11,000.
The couple has yet to find financial relief, although they appear to qualify for free care. In fact, during the grace period, the hospital seized a portion of Tammy Berry's pay, although she earns barely enough to be garnished under state law. Three months of garnishments extracted only about $300.
In December, ProPublica contacted Keith Berry to see if he had heard of Mosaic's forgiveness program. He had not, but said he would contact the hospital. In January, Berry told ProPublica that when he had called, he'd been told that he didn't qualify for help because the bill was "too old."
"They didn't seem to want to deal with me," he said.
In a statement, Mosaic said that it publicized the grace period by advertising on TV, on the radio, and in the newspaper, as well as sending about 100,000 postcards to households in the area, including the Berrys'. Mosaic said it had also attempted to call both Keith and Tammy Berry with no success. Additionally, the hospital had no record of Keith Berry inquiring about financial assistance, the statement said. Meanwhile, Tammy Berry's paycheck is currently being garnished.
One Missouri hospital sued thousands of uninsured patients who couldn't pay for their care, then grabbed a hefty portion of their paychecks to cover the bills. "We will be paying them off until we die," one debtor said.
In remarks late last year to the St. Joseph News-Press, the hospital's president and CEO Dr. Mark Laney said the primary lesson the hospital learned from the scrutiny of its collection practices was to be more "proactive" in identifying patients who qualified for aid. "We were doing the medically right thing for the person, but on the financial responsibility part, we were doing the wrong thing," he said.
Not being "proactive" is a widespread problem for hospitals, according to a national study of hospitals by the University of Michigan Institute for Healthcare Policy and Innovation last year. The institute found that fewer than half of the 1,800 hospitals they studied were notifying patients about their financial assistance policy before attempting to collect unpaid bills.
"It's an important problem," said IHPI director Dr. John Z. Ayanian. "Now we need a stronger system of oversight and monitoring to see how well [hospitals] are implementing those policies."
This year, new federal rules went into effect that set clearer guidelines for nonprofit hospitals on the steps they should take before suing a patient for failing to pay a bill. But a "big question" remains, said Chi Chi Wu, an attorney with the National Consumer Law Center: Who will enforce the rules?
The IRS is understaffed, experts say, and doesn't have a history of aggressive enforcement. The Mosaic case "demonstrates that noncompliance is a distinct possibility unless someone holds the hospital's feet to the fire," said Wu.
ProPublica has found nonprofit hospitals filing thousands of suits in several states, from Kansas to Alabama to New Jersey. Last April, ProPublica reported on the extremely high volume of suits over medical debt in Nebraska, and many of the suits stemmed from hospital bills.
Even as it files as many as 4,000 suits every year, Deaconess Hospital has — on paper — a somewhat generous financial assistance policy. Those with income below the federal poverty line are eligible for free care and those with income below three times the poverty line are eligible for reductions in their bills. But there's evidence that, as occurred with Mosaic, suits are nevertheless being filed against low-income patients.
Katherine Rybak of Indiana Legal Services said she has often seen low-income clients who clearly qualified for assistance under the hospital's policy that didn't know about it and had been sued anyway. She said, however, that the hospital often was cooperative in resolving these situations for her clients once she got involved.
The hospital's aggressiveness has come despite its very robust finances. In 2015, the last publicly available report, the hospital disclosed a profit of $150 million. The hospital's CEO Linda White was paid $1.74 million.
In a response to questions from ProPublica, the hospital said in a statement that it made a "proactive" effort to "work with patients to ensure that financial options are explored from the beginning."
But, it wrote, "we will enhance our processes to further benefit our patients by offering financial assistance through the life of the account" including after a patient has been sued.
And, in response to questions about its financial assistance policy, which is less generous than the other large nonprofit hospital in Evansville, St. Mary's, Deaconess said it would be changing that as well, allowing those with incomes at twice the poverty line to receive free care.
The hospital said the timing of these changes was prompted by ProPublica's questions, but that a review of its policies had already been underway.