Dartmouth Atlas report shows little improvement in readmissions

In the National Journal, Maggie Fox explains a new Dartmouth Atlas Project report (PDF) which demonstrates that, despite the looming implementation of penalties included in the Affordable Care Act and the existence of a simple, proven road map to improvement, most hospitals haven’t significantly cut down their readmission rates over the better part of the past decade.

“Only seven of the 94 academic medical centers we studied had statistically significant changes in 30-day readmission rates following medical discharge from 2004 to 2009,” [Dr. David Goodman's] team wrote.

According to Goodman, improving readmission rates is a simple matter of actively scheduling follow-up visits and implementing a team approach to care delivery. Unfortunately, he told Fox, making that work in a busy hospital appears to be easier said than done, even with significant federal penalties lurking just over the horizon.

The 2010 health-care reform law begins using a stick in one year, penalizing hospitals with higher-than-expected readmission rates for Medicare patients treated for heart failure, heart attack or pneumonia. Medicare payments could be cut by up to 1 percent in October 2012, 2 percent in 2013 and 3 percent in 2014.

In addition to the overall message of the report, it’s interesting to note that readmission rates were affected by the same regional variation which has provided such fertile ground for reporters covering other Dartmouth Atlas Project research.

The percent of patients landing back in the emergency room within 30 days of discharge after surgery varied from less than 12 percent in 2009 in Rapid City, South Dakota, to 19 percent in Kingsport, Tennessee and 18 percent in Newport, Rhode Island.

For an example of how to localize the information in the report, see this article by Stacey Singer in The Palm Beach Post. To learn more about readmission data from CMS, see this article by Charles Ornstein, AHCJ president and ProPublica senior reporter.

AHCJ stresses priorities in reviewing government media policies

The newly drafted media policy of the Department of Health and Human Services has generated some discussion concerning one aspect of the guidelines – the requirement that federal employees notify media officials before talking with reporters.

The Association of Health Care Journalists has not yet taken an overall position on the HHS media policy, which includes many provisions. The organization had encouraged the department to develop such a policy so that reporters and public information officers would have a common understanding about how requests for information would be handled.

AHCJ fundamentally believes that anyone who wants to talk to a reporter should be free to do so. We object to anything that obstructs such interactions. We also have confidence that motivated sources and diligent reporters will continue to find each other regardless of any policy.

AHCJ acknowledges that the requirement for media-office clearance of interviews is an unwelcome, although longstanding, practice. But our priorities at this time are making sure reporters can speak with subject-matter experts by deadline, timely responses from media officers to reporters’ questions, and access to public data.

The vast majority of AHCJ members work outside the Beltway. When they call Washington, they want to be quickly connected with a source who can answer their questions – and they rely on public affairs officers to make that connection.

AHCJ has been pushing for more responsiveness and fairness from those officers. We insist that AHCJ members get an answer – from a quotable source – before their deadline, regardless of the size or prestige of the outlet they work for. Our members also want access to publicly available datasets about the quality of care delivered by local health care institutions and problems identified by inspectors.

AHCJ will continue to focus on working for the changes that make the most difference for most of our members.

Related

• Media policy of the Department of Health and Human Services
• HHS news media contacts
• AHCJ’s right to know activities

Investigation finds chart falsification endemic in Calif. nursing homes

In a two-part series (one | two) in The Sacramento Bee, Marjie Lundstrom reveals the results into the widespread falsification of patient records in California nursing homes.

While regulators have dogged facilities for years over fraudulent Medicare documentation, the issue of bogus records is more than a money matter. In California and elsewhere, nursing homes have been caught altering entries and outright lying on residents’ medical charts – sometimes with disastrous human consequences, according to a Bee investigation.

Medications and treatments are documented as being given when they are not. Inaccurate entries have masked serious conditions in some patients, who ultimately died after not receiving proper care, The Bee found.

Lundstrom writes that while chart falsification is a misdemeanor, nursing home workers are rarely prosecuted, because it’s difficult to prove and time consuming to track down. Instead, she found, sources say its become a pervasive part of the culture in such workplaces. Based on a review of 150 incidents that occurred over the course of two decades, Lundstrom spells out the most common reasons for such mistakes – reasons that will be immediately familiar to anyone with experience in a checklist-driven workplace.

• Covering up bad outcomes. A patient dies or is injured, and the nursing home staff or administrators rewrite the records to minimize blame or liability.
• Fill-in-the-blank charting. Overworked or lazy staff members take massive shortcuts, filling out charts en masse, not knowing whether treatments took place or if the information is accurate.
• Missing medicines. Medications are checked off as being given, but investigators later find unopened boxes or discrepancies with pharmacy records.

She explores each of these bullet points and ideas in subsequent headings and, in the process, lays out a blueprint for other reporters interested in looking for similar issues in their neck of the woods. The first story includes a number of heavy-hitting anecdotes, but Lundstrom doesn’t fully dig into one of the most affecting cases until the second installment of the series.

In two key paragraphs, Lundstrom lays out all you need to know about the significance of the story, one that began with the falsification of medical records. The whole story is well worth a read, and you’ll emerge with a deeper understanding of what makes records falsifications such a unique and tricky subset of nursing home infractions.

Johnnie Esco’s death on March 7, 2008, led to a contentious civil lawsuit, investigations by California’s Department of Justice and Department of Public Health – and the exhumation of her body from Arlington National Cemetery.

Last week, amid inquiries from The Bee, the state Department of Justice reopened its criminal investigation into Johnnie Esco’s treatment at the facility.

In a response published in The Bee, an industry representative took issue with significance of Lundstrom’s findings, accusing her of sounding the alarm “on behalf of trial lawyers” and not putting the problem in perspective.

…in a single day in California there are 30 million entries made on medical charts. The Bee examined 20 years of charting history from 1990 to 2010 – or 219 trillion entries – and found that during that period, regulators issued 209 citations for willful material falsification.

Project offers road map to local health care innovations

A new, but time-limited – looks like the emails may just be going out for just for 30 days – resource has been pouring into my inbox faster than I can read it. It’s called Care about your  Care, and it’s sponsored by the Robert Wood Johnson Foundation and a bunch of other groups (about 30 in fact: find the list here).

Part of the “Care” material is very consumer oriented- learning some of the basics about health care quality, such as “more is not always better” and how people can engage in their own care.  That may help those of you who are trying to communicate the basics to your audience. There’s also a link to an RWJF site that pulls together in one place a lot of publicly available information about both cost and quality of care (people often ask questions about tracking down such data on the AHCJ electronic discussion list.)

But what really caught my attention about Care about your Care is that it’s a terrific road map to a lot of the innovation going on across the country, much of which hasn’t registered in the national media or in some cases even in the policy conversation. Some of the sites mentioned are Beacon communities – pace setters in using health IT to improve care. Some are part of RWJF’s Aligning Forces for Quality.

Looking though these Care about your Care alerts, I found a few initiatives that were particularly interesting because they brought so many difference branches of the community together – health care powerbrokers and local neighborhood groups.

Healthy Memphis: The Common Table, for instance, has programs ranging from diabetes control to encouraging farmers markets to training neighborhood health advocates who can then spread the work about quality care, including in low-income and underserved areas.  Results can be  measured: More people with diabetes are getting their blood sugar screened appropriately, the adult smoking rate has dropped,  farmers markets are springing up,  mammograms … well, maybe we shouldn’t go there.

So explore the site. Find out what’s going on in your state. And if the answer is nothing, find out why. Maybe you’ll discover that these ideas about quality and change are slowly begin to percolate, not just to “early adopters” aligned with groups like RWJF but through ordinary cities and towns. “Health reform” can be seen as more than a piece of legislation to fight about in Washington.

It is,  potentially at least, a new way of thinking about, talking about, and doing something about both “health” and “care.”

Journalists turn to Sebelius for access to National Practitioner Data Bank file

The Association of Health Care Journalists and five other journalism groups appealed to Health and Human Services Secretary Kathleen Sebelius to intervene in the dispute over the Public Use File of the National Practitioner Data Bank and restore access to this important data tool.

AHCJ was joined in its letter to Sebelius by Investigative Reporters and Editors, the Society of Professional Journalists, the National Association of Science Writers, the Reporters Committee for Freedom of the Press and the National Freedom of Information Coalition. The groups have more than 15,000 members.

The U.S. Health Resources and Services Administration removed the Public Use File (PUF) from the data bank website earlier this month because officials believe it was used to identify physicians inappropriately.

The National Practitioner Data Bank is a confidential system that compiles malpractice payouts, hospital discipline and regulatory sanctions against doctors and other health professionals. For years, HRSA has made a public version of it available without identifying information about the health providers.

The groups took issue with a letter written last week by HRSA administrator Mary Wakefield, in which she defended the decision to remove the Public Use File from the agency’s website.

“We believe the stance taken by administrator Wakefield and HRSA staff is overly restrictive based on the law governing the data bank. We do not dispute that federal law precludes the administration from sharing confidential information from data bank reports, including the person being reported and the institution filing the report. We disagree with HRSA that the Public Use File, removed from the web earlier this month, did this.”

The letter also criticized HRSA’s research protocol under which reporters can now request data from the data bank as intrusive and unfair. The agency’s new web page about the Public Use File and how to make requests for data says: “At this time, a researcher must provide a proposal (including table shells) for their need of data. DPDB will review the request and approve or deny the request for data. DPDB will provide only the variables needed to complete the research.”

“We find it troubling that a federal agency now wants to judge the quality of reporters’ stories and make individual decisions about which one is worthy –perhaps putting officials in the position of denying requests that may make HRSA or the data bank look poor,” the letter said. “We don’t see any provisions in the act governing the data bank that gives HRSA the authority to deny research data as long as it doesn’t identify individuals.”

The groups said they stood ready to meet with Sebelius and work with her on a solution that will provide continued access to the Public Use File.

“Reporters have exposed dangerous lapses in oversight by state medical boards, prompting legislation to increase transparency and improve patient protections,” the letter said. “We hope you will agree that this is a matter of public concern and that you will urge HRSA to change course and immediately restore the Public Use File of the data bank.”

The letter to Sebelius followed a request for assistance to members of Congress last week.

Health stories win at ONA for investigations, multimedia

The Online News Association has honored two of this year’s bumper crop of excellent health pieces with top honors in their respective categories at the 2011 Online Journalism Awards, with nods going to pioneering work by both ProPublica and The Washington Post.

For ProPublica, AHCJ member Robin Field’s examination of the nation’s Medicare-funded dialysis system and what this oft-overlooked federal budget item tells us about the implementation of “socialized medicine” in America earned the Gannett Foundation Award for Innovative Investigative Journalism in the Small Site category. Since its publication, Fields’ award-winning piece has continued to evolve, adding data and updates as they become available.

Also nominated in the category were ProPublica’s Dollars for Docs and Investigative West’s Livesaving Drugs, Deadly Consequences.

The other prominent health winner was The Washington Post’s video-heavy “Traumatic Brain Injury: Coming home a different person,” which beat out another multimedia piece, the Los Angeles Times‘ Dylan’s Brain, in the large site category of the Multimedia Feature Presentation award.

Earlier: Health journalists poised for strong showing at 2011 ONA Awards

Cash-strapped Ill. goes after hospitals’ nonprofit status

A New York Times article written by Bruce Japsen, an independent journalist writing for the Chicago News Co-Op, digs into Illinois’ recent challenges to the tax exemptions granted to a trio of prominent hospitals by virtue of their nonprofit status. The challenge, inspired in part by the state supreme court’s willingness to uphold the revocation of the nonprofit status of an Catholic hospital in Urbana last year, could expand to more than a dozen other institutions as the state scrambles to cover a looming revenue shortfall.

In its case, the state alleges that the hospitals aren’t providing a high enough proportion of charity care to fulfill the mission of a nonprofit.

All three of the hospitals the state is focusing on provided free and discounted medical care that ranged from 0.96 percent to 1.85 percent of patient-care revenue, according to the revenue department. The state also said that each one had been operating as a “for profit” business when the state’s Constitution says that “only charities are entitled to a tax exemption.”

The hospitals, for their part, point to the other benefits they provide the community, such as neonatal intensive care and burn units, that don’t always bolster their bottom lines. Advocates answer that paying taxes provides a community benefit as well, one that can readily be measured in dollars and cents. And Japsen found that paying those taxes doesn’t even seem to preclude the provision of charity care, especially at the parsimonious levels provided by the hospitals currently targeted by the state.

“The relative amounts of charity care provided by not-for-profit tax-exempts are not materially different from the amount provided by for-profit hospitals,” said Jim Unland, a longtime analyst of Illinois’ health care industry and president of the Health Capital Group, a consulting firm in Chicago. “This raises the issue of whether the tax-exempts are getting prejudicially favorable treatment.”

The three hospitals whose tax exemptions have been stripped by the state department of revenue plan to challenge the action in court, and state hospital organizations are gearing up for a lobbying push they hope will put their tax status on firmer ground.

HHS releases guidelines for handling media requests

The U.S. Department of Health and Human Services has adopted a set of guidelines on how it will provide information to the media. The guidelines reaffirm that employees’ contacts with the media must be cleared by a public affairs office, but call on media officials to respond promptly and accurately.

AHCJ had no part in writing the guidelines but had pushed for a media policy that would promote consistency among all HHS agencies and allow reporters to know the ground rules.

Although the guidelines are in force, Richard Sorian, HHS assistant secretary for public affairs, called them a “living document” and said he welcomed feedback.

AHCJ members are encouraged to read the six-page document and share their thoughts with Felice Freyer, Right to Know Committee chair at felice.freyer@cox.net.

Among the key features are:

• An emphasis on timely response and respect for reporters’ deadlines
• Putting bloggers on equal footing with mainstream journalists
• Encouraging, but not requiring, HHS employees to consent to interviews
• Requiring that employees arrange such interviews through media offices
• Allowing employees who speak at conferences or other public events to answer reporters’ questions at that time
• Specifying that “media interviews should be on-the-record and attributable to the person speaking to the media representative, unless an alternate attribution arrangement is mutually agreed upon in advance.”

Although employees are required to arrange their contacts with the media through the public affairs offices, they do not need to seek approval for scientific, technical or policy articles or commentaries written for peer-reviewed journals.

The guidelines also extend to all HHS agencies the policy on embargoes recently adopted by the Food and Drug Administration. That policy permits reporters to share embargoed materials with sources, provided the sources promise to honor the embargo.

The guidelines do not state whether a media representative must or should listen in on interviews with HHS employees. They also do not address whether reporters from large and small media outlets should be treated equally.

Sorian released the new guidelines Wednesday, after the second quarterly phone conversation between AHCJ and HHS public affairs officers. Freyer and AHCJ President Charles Ornstein spoke with Sorian and others as part of a continuing effort to improve HHS responsiveness to reporters’ requests for information.

Asked whether reporters would ever be allowed to contact and interview federal employees on their own, Sorian said that HHS has no plans to change the policy requiring interview requests to be cleared by a public affairs office. But he emphasized that public affairs officers are supposed to be helpful and should not “shape the interview.” If a reporter feels that press officer has been heavy handed, “we definitely want to hear about that,” he said. Sorian can be reached at Richard.Sorian@hhs.gov.

Agency declines to restore public data

The U.S. Health Resources and Services Administration resisted demands by three major journalism organizations for the immediate restoration of a Public Use File of the National Practitioner Data Bank, a tool that reporters have used to expose lapses in oversight of troubled physicians.

HRSA removed the Public Use File from the data bank website earlier this month because officials believe it was used to identify physicians inappropriately.

The National Practitioner Data Bank is a confidential system that compiles malpractice payouts, hospital discipline and regulatory sanctions against doctors and other health professionals. For years, HRSA has made a public version of it available without identifying information about the health providers.

In letters to the Association of Health Care Journalists, Investigative Reporters and Editors and the Society of Professional Journalists, HRSA Administrator Mary Wakefield said her agency regretted having to remove the Public Use File from its website and hopes to bring it back in some form “as quickly as is possible.” She did not provide a date.

“The statute that governs the NPDB clearly states that we are obligated to keep data about individual practitioners housed in the NPDB confidential,” Wakefield wrote. “We now know that the PUF in its current form can be manipulated to identify individual practitioners, and therefore were compelled to act.”

Wakefield said HRSA shared the groups’ interest in transparency and patient safety but was compelled to act in the way that it did.

Wakefield was responding to a Sept. 15 letter from the three groups, which called for the Public Use File to be returned online without delay.

AHCJ President Charles Ornstein took exception to Wakefield’s comments, noting that reporters have used the Public Use File responsibly for many years and that the agency only acted after a single complaint from one doctor’s lawyer. He said HRSA has been well aware of how reporters have used the database and even assisted them in their statistical analysis.

“It is not true that the Public Use File can be ‘manipulated’ to identify individuals,” Ornstein said. “Nothing in that data can be used to identify individuals if reporters or researchers don’t already know who the bad actors are. We remain troubled that it appears HRSA is more interested in protecting doctors accused of harming patients than protecting the patients themselves.”

Wakefield’s response came the same day the journalism groups – joined by the National Association of Science Writers, the Reporters Committee for Freedom of the Press, and the National Freedom of Information Coalition – wrote letters to members of Congress asking for their help in getting the old version of the Public Use File restored. The groups would like to see that file regularly updated.

Wakefield said HRSA is reconfiguring the Public Use File to prevent identification of a health care provider or patient, and that researchers and members of the media can request data in the interim on the agency’s website. She also said there would be a call at 1 p.m. Eastern on Oct. 13 to hear from the public about what they would like from the Public Use File.

But Ornstein said it remained unclear how useful the information would be if the agency removes unique identifiers for individuals, which had allowed reporters to see what type of follow-up action was taken against doctors who repeatedly made malpractice payouts or had been disciplined repeatedly by hospitals.

On Wednesday, AHCJ and its partner journalism groups released a report on how reporters and news organizations have used the Public Use File in the past to expose dangerous lapses in oversight by state medical boards. Several of those articles led to new laws and rules to increase transparency and implement patient protections.

“As result of our investigation – and the solid documentation provided by the NPDB, malpractice suits and patient records – Virginia passed a law giving its state medical board more authority to crack down on doctors … ,” wrote Liz Szabo, a USA Today reporter who used the data bank in 2002 while at the Virginian-Pilot. “Patients in Virginia are safer today due to our reporting, and due to the data provided by the NPDB.”

Wakefield noted in her letter that the amount of information in the databank has increased dramatically in the past 18 months. Journalism leaders say what she failed to state was that a huge number of reports came in only after journalists (including Ornstein) showed that state agencies were not reporting discipline to the data bank and that HRSA was not following up on glaring inconsistencies and irregularities.

Wakefield did not address a request by the journalism groups to seek legislation permitting the continued disclosure of the Public Use File in the same form as before it was pulled Sept. 1.

She also did not apologize, as requested, to Kansas City Star reporter Alan Bavley, who was threatened with sanctions if he wrote a story based on information from the data bank. She said Bavley will not be pursued but was reminded that the Public Use File was for “statistical analysis only.”

Ornstein said the issue is larger than Bavley. “The threat to Alan is not a moot point just because HRSA didn’t fine him. Such threats by the federal government could have a chilling effect based on a news’ organization’s ability – and willingness – to stand up to government fines and local lawsuits.”

“There needs to be an apology and a promise that reporters won’t be threatened by the federal government when they plan to report public information,” Ornstein added.

IRE has made available free on its website a copy of the Public Use File, downloaded last month, along with documentation and instructions.

More journalism groups join effort to restore access to National Practitioner Data Bank

Three additional journalism organizations have joined the campaign calling for the Obama administration to restore access to a public version of the National Practitioner Data Bank. And letters are going out to key members of Congress asking for their assistance.

The National Association of Science Writers, Reporters Committee for Freedom of the Press, and National Freedom of Information Coalition have signed the letter, along with the Association of Health Care Journalists, Investigative Reporters & Editors, and the Society of Professional Journalists.  The groups have more than 15,000 members.

The U.S. Health Resources and Services Administration removed the Public Use File (PUF) from the data bank website earlier this month because officials believe it was used to identify physicians inappropriately.

The National Practitioner Data Bank is a confidential system that compiles malpractice payouts, hospital discipline and regulatory sanctions against doctors and other health professionals. For years, HRSA has made a public version of it available without identifying information about the health providers.

“The Public Use File, while it didn’t identify doctors by name or address, provided invaluable information about the functioning of state medical boards and hospital disciplinary systems,” said the letter from the groups to members of Congress. “Reporters for years have used the data to identify holes in their states’ regulatory systems that have led to patient harm. As a result of these stories, states have enacted new legislation and medical boards have taken steps to investigate problem doctors.”

The groups also provided the representatives and senators with details of major stories written with the assistance of the Public Use File and descriptions of the changes that resulted.

Finally, the letter once again expressed concern that HRSA sent a threatening letter on Aug. 26 to Alan Bavley, a health reporter at the Kansas City Star. The letter, signed by Division of Professional Data Banks director Cynthia Grubbs, said that Bavley could be subject to a civil monetary penalty of up to $11,000 if he identified a physician based upon confidential information in the data bank. The threat came even though other reporters have done the same thing for years without penalty.

In news reports, HRSA acknowledged that the letter–and the agency’s subsequent decision to remove the Public Use File–was prompted by a single complaint: from the lawyer of a doctor who was the subject of Bavley’s story.

Although HRSA said in some news reports that it will not pursue sanctions against Bavley, he has not received an apology.

“Without stories written by our members, it’s fair to say that some unsafe doctors would continue to be practicing with clean licenses and patient protection legislation in several states likely would not have been enacted,” the letter said.

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