This January 1, 2018 New York Times article outlines how the push for better  outcome scores puts patient care at risk.

The story recounts stories where a “nurse in charge of enforcing administration restrictions said the patient was not sick enough to qualify for admission to the hospital.”

Excerpts from the article include

The denial appeared to be part of an attempt by members of the Roseburg Veterans Administration Medical Center to limit the number of patients it admitted to the hospital in an effort to lift its quality-of-care ratings.

Fewer patients meant fewer chances of bad outcomes and better scores for a ranking system that grades all veterans hospitals on a scale of one to five stars. In 2016, administrators began cherry-picking cases against the advice of doctors — turning away complicated patients and admitting only the lowest-risk ones in order to improve metrics, according to multiple interviews with doctors and nurses at the hospital and a review of documents.

Those metrics helped determine both the Roseburg hospital’s rating and the leadership’s bonus checks. By denying veterans care, the ratings climbed rapidly from one star to two in 2016 and the director earned a bonus of $8,120.

The hospital’s director, Doug Paxton, acknowledged that being more selective had improved ratings, but denied that the hospital was turning patients away to improve scores. Tightening admissions, he said, benefited patients, not metrics, because Roseburg’s hospital lacks the resources for acute patients, so many need to be sent to larger hospitals in the community.

But five emergency room doctors strongly disagreed. In a letter in response to questions from The New York Times, they said they had warned about the arrangement at Roseburg, where physicians are repeatedly overruled by administrators. “When we voice concern that a process is dangerous and not good for patient care,” they wrote, “we are met with the response that ‘this is what the director wants.’”

The Department of Veterans Affairs began grading hospitals about four years ago based on 110 performance indicators such as wait times, infection rates and nurse turnover at its 1,200 hospitals and clinics.

And on the surface, the scrutiny appears to have paid off. In 2016, according to the department, 82 percent of facilities improved.

But as more patients were sent away in recent years, Roseburg was recognized by the Department of Veterans Affairs as one of the rising stars of its health care system.

However, interviews with staff at the hospital suggest that some improvements were pure manipulation. And in some cases efforts to improve the rating actually made care worse.

“For the few patients who are admitted to Roseburg, other tactics are used to further improve the ratings. The hospital is penalized when patients are hospitalized with congestive heart failure, because it counts as a sign of poor preventive care. So, doctors said, they are told to list it as hypervolemia, a condition that occurs when there is too much fluid in the blood, a diagnosis that isn’t tracked and hides the problem.

Another penalty is assessed for deaths in the hospital or within 30 days of discharge. To avoid counting these, doctors and nurses say, the administration regularly persuades veterans to be admitted only as hospice patients, signaling they are terminal and don’t want treatment. Often neither is true. Doctors said some veterans were switched to hospice without their knowledge.

“It’s extremely unethical, extremely,” Dr. Blum said. “I was asked to do it and so were the emergency department doctors. And we refused, so the administration just did it.”

In 2015, 17 of 23 primary care doctors left, according to Laura Follett, who oversaw scheduling for Roseburg’s primary care clinic.

“Teams would have no doctors, and we’d have to just cancel appointments,” Ms. Follett said. She resigned in 2016.

Roseburg’s decision to cloak deficiencies by manipulating metrics is part of a persistent problem that reaches beyond one rural hospital, said Dr. Michael Mann, a professor of surgery at the University of San Francisco who led the thoracic surgery program at the San Francisco veterans hospital for eight years.

Attempts to track performance in the veterans health care system have repeatedly created perverse outcomes, he said. He pointed out that the 2014 scandal exposing hidden wait times for veterans arose only after the department began tracking whether medical appointments were scheduled within 14 days, and veterans hospitals across the country that could not meet the goal began keeping off-the-books lists to hide actual wait times.

During Dr. Mann’s tenure, the veterans department began ranking hospitals on surgical complications. Remarkably, complications across the nationwide system dropped steadily, decreasing 47 percent between 1997 and 2007.

The medical center created an “exclusion list” of conditions deemed too severe for Roseburg and put in place a “utilization management team” of administrators to approve hospital admissions using a risk analysis score.

Doctors were required to call an off-site nurse to ask permission to admit a patient. Patients who had a high risk of death — usually because of advanced age — were routinely transferred to other hospitals or sent home. Even low-risk patients that Roseburg could easily have cared for, such as people with pneumonia, were denied, doctors said.

In a statement, the Department of Veterans Affairs said Roseburg was not manipulating data, adding: “All admission decisions are based on the hospital’s ability to provide the care patients require and are made by clinicians, including the facility chief of staff and her clinical chiefs of service — nonclinical administrators have nothing to do with these decisions.”

The hospital has no plans to change its admitting practices. In November, Roseburg was demoted to one star, because of what Mr. Beiring called “a death or two” but he said it was a temporary setback and the hospital had already “deployed counter measures” that would soon send its ratings up again.

One of those measures, doctors said, appears to be that admissions have become ever more strict.




Source: At Veterans Hospital in Oregon, a Push for Better Ratings Puts Patients at Risk, Doctors Say – The New York Times