Project follows the race to make bagged salad safer

The latest investigation by California HealthCare Foundation Center for Health Reporting’s Deborah Schoch will make you think twice before ripping into a sack of spring mix, but her work about the myriad food safety challenges posed by bagged salads examines the industry’s struggle to develop technology powerful enough to overcome the existential threat posed by E. coli and friends.

The industry has made great strides since a 2006 outbreak linked to tainted spinach, she writes, but “It’s impossible to stop all pathogens from landing on lettuce and spinach leaves.” And once they’re on the leaves, it seems as if their spread is almost inevitable. They hide in gooey biofilms and resist powerful washes.

Thousands upon thousands of salad leaves are taken to a central plant, washed together, bagged and shipped. Even if only a few leaves are tainted, harmful pathogens can spread in the wash water — the modern salad version of the old adage that one bad apple spoils the whole barrel.

“I would think of it as swimming in a swimming pool in Las Vegas with a thousand people I didn’t know,” said William Marler, a prominent Seattle-based food safety attorney.

Plenty of public and industry money has been aimed at the problem, Schoch writes. “The Center for Produce Safety at UC Davis, founded in response to the spinach outbreak as an industry-public partnership, has pumped more than $9 million into 54 research projects at 18 universities.”

Even the best research can’t reduce the risk of contaminated greens by 100%, scientists said. At Earthbound, Daniels says the ultimate goal is to achieve what scientists call a “5 log reduction,” the equivalent of pasteurizing milk. In short, if an unwashed lettuce contained 100,000 pathogens, the perfect wash system would knock off five “0s” and reduce the pathogen count to 1.

An added bonus? Schoch’s column on whether she (and the experts she talked to) feel like it’s important, or even salutary, to wash their bagged greens.

Experts offer story ideas for covering health reform

More than 30 attendees heard local experts sketch the particular challenges and issues presented by the Affordable Care Act in California in the latest “Implementing health reform in the states” panel, hosted by AHCJ’s San Francisco Bay Area chapter on Wednesday night at the San Francisco Chronicle.

The panel, one of a series sponsored by AHCJ, the Alliance for Health Reform and the Robert Wood Johnson Foundation, began with an explanation of exchanges and what’s happening with their implementation (or lack thereof) around the country by Larry Levitt of the Kaiser Family Foundation.

He posed some story ideas, such as: How vigorously will the states promote enrollment through the exchanges? What sort of variations to the ACA might emerge once states have the ability to ask for waivers in 2017?

Kim Belshe, a board member of the California exchange, and Marian Mulkey of the California HealthCare Foundation discussed the California scene, with lots of detail, touching on the state’s large undocumented immigrant population, the challenge of getting people enrolled (since the law of the land is now “performance” –  which means maximum participation), new opportunities for medical professions, such as nurses, to fill gaps in care delivery, and how to ensure coordinated care during the transition period to exchanges so no patient is harmed. This is the accountability part of the ACA, and needs thought and new procedures, Belshe stressed.

Belshe noted that Medicaid (Medi-Cal) is the foundation of reform, a subject which reporters sometimes overlook. Both she and Mulkey noted that California is a national pacesetter when it comes to reform implementation - a story idea in itself.

The session was moderated by Ed Howard, executive vice president of the Alliance for Health Reform.

On Tuesday night, a similar briefing was held at the University of Southern California, featuring Walter Zelman, Ph.D., a professor and director of health science at California State University-Los Angeles; Daniel Zingale, senior vice president of the Healthy California program at The California Endowment; Anthony Wright, executive director for Health Access, a California health care consumer advocacy coalition; and Deborah Crowe, the health care and biotechnology industry reporter for the Los Angeles Business Journal. Howard, of the Alliance for Health Reform, moderated the session.

Zelman posed a number of questions about reform, mostly about exchanges. To a reporter from Orange County, he suggested a story about the origin of the individual mandate – an idea championed by Republicans early on, he noted, and opposed by Obama and many Democrats. To a question about accountable care organizations and bundling, he suggested stories about how fee-for-service medicine is anything but dead.

Wright offered a look at what’s happening in Sacramento, including a hearing held just a few hours before the briefing.

Zingale mentioned the importance of prevention, and how the ACA encourages prevention. He too pointed out how nonprofits in the state can team up with reporters to educate people about the ACA. He said that the more people know about the law, the better they like it.

From a reporter’s perspective, Crowe offered several practical story ideas that reporters can start writing about today.

John Gonzales  of the California HealthCare Foundation Center for Health Reporting wrote about the panel and Michelle Levander of the California Endowment Health Journalism Fellowships program offers some of the story ideas mentioned by the panelists.

Special thanks to Colleen Paretty, chair of the Bay Area chapter, and Bill Erwin, of the Alliance for Health Reform, for contributing details about the panel discussions for this post.

Web outlet pumps out dozens of stories on prescription drug abuse

In partnership with USC’s Annenberg School for Communication & Journalism and a number of other organizations, Santa Barbara online news outfit Noozhawk (about), put together “Prescription for Abuse,” an exploration of the misuse and abuse of prescription drugs in the Santa Barbara area. In the extensive, online-only series, the reporters take a look at the problem and its underlying causes, then go a step further by exploring possible solutions as well.

In a uniquely meta twist, the series even looks at how journalism such is advancing public health goals and explains how the project came together. The series features at least 36 individual articles, by my count, and every health journalist who takes the time to browse the full catalog will come across at least a few easily localizable ideas, but in this space I’ll just highlight those stories that deal directly with the series itself:

• USC, California Endowment Unite to Support Health Journalism at the Source
• Bill Macfadyen: Prescription for Abuse Project Is a Series of Opportunities
• Santa Barbara Teen News Network Adds Another Dimension to Prescription Drug Abuse Series
• Annenberg Fellowships Take a Diverse Approach to Community Health Journalism
• Bill Macfadyen: Noozhawk Earns a USC Annenberg Health Journalism Fellowship
• Noozhawk Journalists Recount Lessons Learned from Prescription Drug Abuse Series

Calif. center, ethnic outlets partner to examine elderly day care’s demise

The California HealthCare Foundation’s Center for Health Reporting partnered with no fewer than nine different organizations to produce a sprawling story package examining the impact of the looming closure of many of California’s adult day health care centers. (Since the project launched, California reached a legal settlement that will allow adults most at risk of institutionalization to continue to receive services previously provided by adult day health centers. Existing centers will be able to provide services through the end of Feb. 2012. See this write-up in California Healthline.)

Jocelyn Wiener’s centerpiece stands alone, but the package really gains steam when you take the time to consider its full breadth and depth.

For those new to the issue, here’s Wiener’s primer and a hint as to why the package grew out of a collaboration with a kaleidoscope of ethnic media organizations.

Los Angeles County – especially its many ethnic minority communities –will be hit hardest by the closures. According to state data, the county is home to more than 60 percent of the program’s 38,000 enrollees statewide. One quarter have dementia. Forty percent are incontinent. Nearly half have a psychiatric diagnosis. More than 70 percent do not speak English.

The centers provide them with transportation, meals, exercise, medication management, physical and occupational therapy, as well as robust social programs that many participants say have renewed their will to live.

Health journalists will find Richard Kipling’s “how we did it” piece to be a natural entry point. Kipling unspools the narrative of how a brief suggestion became an anything-but-brief compendium of multilingual, multicultural, multigenerational reporting. Kipling’s blog also serves as a useful roadmap to the project.

Watch the AHCJ website for more about how this project was reported.

If the video doesn’t appear on your page, please click through to :Bibiana Viernes: Her Center, Her Life” from CAhealthReport on Vimeo.

Reporters uncover Calif. chain’s systematic upcoding

In a follow-up to their lengthy California Watch investigation into sketchy billing practices at the state’s Prime Healthcare chain, Christina Jewett and Stephen Doig looked at newly released data and found that “Prime Healthcare Services bills Medicare for a variety of unusual ailments – among them a brain disease and a condition causing eyes to bleed – that can generate lucrative payments to the chain.”

For this piece, the reporters reviewed hundreds of pages from five related court cases and talked to a number of former Prime employees who protested the hospital’s billing practices — many of which they say were mandated directly by the company’s owner. Doig and Jewett then returned to the data and found that, as the 14-hospital chain’s leadership pushed providers to bill for a certain lucrative condition, instances of that condition just happened to rise in Prime hospitals.

Jewett and Doig even analyzed medical codes to estimate how much the alleged upcoding could have earned Prime hospitals.

It is not possible to pinpoint how much additional revenue Prime earned when documenting the unusual conditions, because each patient may have numerous diagnoses. But it is clear that conditions reported in outsized rates at Prime hospitals can bring in an additional $3,000 to $7,000, compared with similar but less serious conditions.

Taken together, the report stands out for its deft integration data, court records and interviews into a cohesive investigation.

Quake damage could cripple Calif. hospitals

In her series on earthquake preparedness at California hospitals, California HealthCare Foundation Center for Health Reporting senior reporter Deborah Schoch look at what she calls the “Achilles heel” of hospitals in earthquake territory: internal damage to pipes and equipment.

While much of the legislative focus has been on preventing structural damage, Schoch writes that recent seismic disasters in places such as Chile and Japan have demonstrated that a broken water pipe or sprinkler system can shut down a hospital every bit as effectively as a crumbled wall.

To better avoid internal damage, Schoch writes, hospitals need to bolt down equipment, anchor water tanks and set up back-up generators. According to Schoch, “Many facilities locally and statewide are still years or decades away from making those non-structural internal fixes, even though they are required under California law.” This is largely thanks to a variety of deadline extensions and loopholes requested by cash-strapped hospitals which refer to the law as the largest unfunded mandate in state history.

As of 2009, fully 1,357 hospital buildings statewide had not made fixes that should have been finished at the start of 2002, according to a December 2009 report from state regulators.

Another 1,233 buildings, or 95 percent of buildings statewide, had not yet done improvements that were due Jan. 1, 2013, according to the report. State officials caution that some hospitals may have completed upgrades, but they do not have up-to-date statistics.

In the second installment of the series, Schoch uses state records to show that more than 40 hospitals close to the fault are rated at high risk of collapse in a major earthquake.

California hospitals were supposed to have fixed hospitals by 2008 or the state would shut them down. But that deadline has been pushed back multiple times: “Championing the delays, the state Legislature repeatedly extended the 2008 deadline to 2013, 2015, even 2020, under pressure from hospitals that said they can’t afford the fixes.”

Rising medical debt spawns problems, fosters solutions

Kelley Weiss, of the California HealthCare Foundation’s Center for Health Reporting,  dug deep into the rising mountain of medical debt accumulating around American patients. Her package includes four pieces (one an extended forum, embedded below) on KQED as well as numerous companion stories online. Her stories consider both the causes of and solutions to medical debt, an issue which plagues hospitals as much as it does patients.

In her first piece, Weiss lays out the simple formula driving all that indebtedness: It’s “because health care costs continue to rise at the same time people are losing their jobs and health coverage.” She uses the story of an unfortunate, unemployed motorcyclist to show how the American billing, credit and insurance systems can quickly add debt to injury.

In the second piece, she looks at the debt from the other side, exploring the massive and largely ineffective lengths hospitals go to in order to collect what they’re owed. Since the recession began, even the most successful collections agencies have only been able to collect about 12 percent, one hospital official said. Confronted with this fact, Weiss asked the obvious question.

So why even bother, if you get such a low return? Maybe they could give those financially squeezed patients with no other options a break. Well, to a certain extent they can, and charity care is on the upswing.

But it turns out there are statutes in place that require hospitals to make collection efforts. Medicare is one of the biggest payers to hospitals and it says that hospitals must try to collect money from every patient. And if they don’t? Medicare won’t pay off its bills. Todd Nelson with the Healthcare Financial Management Association said that leaves hospitals in a tough spot.

As wallets remain tight and debt collection becomes increasingly difficult, both hospitals and patients are starting to take steps to become more up front about exactly how much their care is going to cost, Weiss writes in her third installment. Finally, when all else fails, Weiss finds in her fourth installment, patients can turn to California’s Hospital Fair Pricing Act, which “says hospitals must give patients who are at 350 percent of the Federal Poverty Level a discount on their bills if they’re uninsured or underinsured.”

String of errors made Stanford patient data public

In The New York Times, Kevin Sack traces the series of errors and lapses in judgement that led to a large-scale data breach at Stanford Hospital, one which went unnoticed for almost a year. Sack’s lead paragraph neatly encapsulates the whole story.

Private medical data for nearly 20,000 emergency room patients at California’s prestigious Stanford Hospital were exposed to public view for nearly a year because a billing contractor’s marketing agent sent the electronic spreadsheet to a job prospect as part of a skills test, the hospital and contractors confirmed this week. The applicant then sought help by unwittingly posting the confidential data on a tutoring Web site.

Since 2009, when federal law began requiring disclosure of medical data breaches involving more than 500 people, Sack reports that about 330 incidents have been reported on an HHS website. A CSV file of the data is available.

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.

Data analysis reveals wide variation in use of heart procedures

One town’s high rate of elective angioplasties has drawn the attention of the California HealthCare Foundation Center for Health Reporting and the San Francisco Chronicle.

Emily Bazar reports that people in Clearlake, Calif., have undergone the procedure at 15 times the rate of people in nearby Sonoma County and more than five times the rate of San Franciscans and Californians. Clearlake residents had elective angiography at nearly six times the state rate.

The project includes a downloadable spreadsheet of heart surgical procedures for 208 geographic areas in California.

The analysis was done by Stanford health research and policy Professor Laurence Baker and was commissioned by “the Campaign for Effective Patient Care, an interest group that promoted the involvement of patients in making medical decisions. Formed during the health reform debate, the group recently disbanded.”

The financial and health implications of extreme variation are enormous, raising the prospect that billions of dollars are wasted each year on unnecessary and potentially dangerous treatments. About 600,000 angioplasties alone are performed nationwide annually at a price tag of more than $12 billion, according to a recent study in the Journal of the American Medical Association.

The analysis finds the heart procedures were performed frequently in other parts of California as well. While one hospital says the disparity is because its rural community suffers from overlapping health situations, comparing it to the Third World, the research shows that above-average use of the procedures was found in urban areas as well.

Yet long-standing research suggests that something else usually causes large geographic variation in medical procedures: striking disparities in how doctors treat diseases.

“You just have a group of physicians that tend to order more angiograms or (angioplasties). That’s how they think and do things. They’ve never been told not to. They’ve never been told they’re the outliers,” said Eric Hammelman, a vice president at Avalere Health, a health care consulting firm in Washington, D.C.

The project includes a consumer’s guide to heart procedures, graphics and an explanation of Baker’s methodology.

Learn how to use this data

In a webinar next week, Hiding in plain sight: California hospital data, Charles Ornstein, senior reporter at ProPublica and president of AHCJ’s board of directors, will guide attendees through using the data from the California Office of Statewide Health Planning and Development to determine rates of variation for types of treatments.

Ornstein calls the data set a “gold mine” that can answer questions such as:

• Does your local hospital place more cardiac stents than others?
• Do more of its patients leave the emergency room without being seen?
• Does it have a high level of C-section births?

It doesn’t matter if your hospital is public, nonprofit or for-profit, data on its patients and services are available online. Join us on Sept. 13 to learn how to use this data. California journalists will find this particularly useful, but it also introduces data sets that journalists can request in other states.

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