Hospitals, Aviation and Business

Boeing’s recent troubles remind us that in many ways, healthcare is like aviation:

1. They are both highly technical endeavors, guided by highly educated and trained personnel such as physicians and pilots.
2. Even small mistakes can be devastating.
3. Operating margins (operating income/revenue) are very low.
4. Both are led by businessmen not trained in the industry.
5. Some have put profit ahead of safety.

The cockpit of the typical airliner or the multitude of instruments in the typical intensive care unit demonstrates that aviation and medicine are both highly technical. Airline pilots have a minimum of 1,500 hours of flight time. This includes time spent obtaining a private pilot’s license, commercial license, instrument rating, multiengine rating, and airline transport pilot (ATP) certificate. Pilots often have additional in type ratings for turboprop or jet engines. Many have spent time as flight instructors and normally have at least 5 years of experience. A pilot must be over the age of 23 and be able to pass a 1st class medical exam. The military also trains pilots and brings them along faster, usually requiring some time commitment for the training they receive. In addition, they have recurring requirements to train in simulators to practice emergency procedures or when they begin flying new aircraft.

Physicians have four years of medical school after college. After medical school they become residents, a term from the past when the young physician resided in the hospitals. Residency lasts 3-5 years and is often followed by additional training called fellowship. For example, the typical cardiologist spends 3 years in an internal medicine resident, then an additional 3 years as a cardiology fellow. After fellowship, additional training may occur. For example, in cardiology this could be in interventional cardiology, nuclear cardiology, electrophysiology, etc. which are 1-2 years in length. In many cases additional time is spent doing research to become competitive for grants. Many have PhD’s and some have administrative or business degrees such as master of public health (MPH) or business (MBA). Like pilots, recertification is required. Nurses and physician’s assistants are also highly educated. Some have PhD’s and many have master’s degrees. Like physicians, administrative or business degrees are becoming increasingly common. 

Small mistakes can be devastating. Overshooting or undershooting a runway leading to a crash can kill not only the pilot but passengers on board. Poor handling of an emergency such as an engine failure, a door plug dislodging in flight or poor programming of the complex flight computers, such as occurred with the Boeing 737 Max, can be lethal. Similarly, mistakes in care for a sick patient can be deadly. The popular literature is rife with reports of physicians or nurses overlooking a laboratory or x-ray abnormality, giving the wrong medication, falls, or the wrong surgery on the wrong patient.

Although the high education and need for care are well appreciated, what is not so well known is that profit margins are narrow for both aviation and medicine.  Airlines are expected to have a 2.7% net profit margin in 2024 which is a slight improvement from the 2.6% in 2023 (1). Boeing’s net profit margin as of September 30, 2023 was -2.86%. (2). Hospitals began 2023 with a median operating margin of -0.9% and currently have a margin of -10.6% to 11.1% (3). For the three months ending Sept 30, the Mayo Clinic (Rochester, MN) had a relatively healthy 6.7% profit margin. In contrast, Banner Health was only 1.5%. Hospitals and health systems are estimated to finally break even after several years of losses secondary to the COVID-19 pandemic and higher than expected contract labor costs. The recent median margin data show that essentially half of hospitals and health systems are still operating at a financial loss, with many more just barely covering their costs (3). This means little to no discretionary money. Hospital executives who receive high compensation packages can consume much of this discretionary money. Many would argue that it could be better spent on patient care. 

Both aviation and hospitals are usually led by businessmen. This was not always so. Early airlines and hospitals were usually led by pilots and doctors. Only in the past 50 years have businessmen become involved. The rationale has nearly always been financial. Early aviators cared a great deal about demonstrating that aviation was safe. For example, Boeing Aircraft, founded in 1916 by William Boeing, was considered first and foremost an engineering firm where production of reliable aircraft was most important (4). The emphasis on quality and safety spawned the quote, “If it isn’t Boeing, we aren’t going”. In 1997 Boeing merged with its longtime rival McDonnell Douglas. The new CEO of the merged companies from McDonnell Douglas, Harry Stonecipher, brought a different attitude to the merged companies.

Figure 1. Harry Stonecipher. CEO of Boeing 2001-2, 2003-5.

Stonecipher said, “When people say I changed the culture of Boeing, that was the intent, so that it’s run like a business rather than a great engineering firm. It is a great engineering firm but people invest in a company because they want to make money” (5).  The company became fixated on stock market value and lost sight of the core value of manufacturing reliable, safe airplanes. Boeing is now reaping the decline in quality that was sown by Stonecipher years ago. The Federal Aviation Administration (FAA) which is supposed to  oversee airplane manufactures has also apparently become slack, allowing Boeing to have major declines in quality (6).

In hospitals we have seen a similar progression. Doctors or nurses were replaced as hospital heads in the later part of the twentieth century by businessmen who often did not understand, and in some instances did not care to understand, the core value of quality patient care. Recently, private equity firms have been acquiring hospitals or portions of hospitals such as emergency rooms or radiology practices. Data on the quality of care has been scant but there have been a multitude of complaints from doctors and nurses. Now, a recent systematic review that included 55 studies from 8 countries concluded that not only has private equity ownership increased over time across many health care sectors, but it has also been linked with higher costs to patients or payers (7). Although results for the 27 studies that looked at health care quality were mixed, the researchers found evidence that private equity ownership was tied to worse quality in 21 (7). This suggests a poorer quality of care. The lack of oversight by a variety of healthcare organizations such as the Joint Commission, Centers for Medicare and Medicaid Services (CMS), state departments of health, etc. may be following the FAA example in becoming lax at their jobs.

Hospitals and aviation companies do have one major difference. Hospitals are generally not-for-profit entities that should operate for the public good. Profit is secondary which does not mean that losses can be long tolerated. Aviation companies are for-profit entities where revenue is primary. However, as demonstrated by Boeing, quality is still very important. As more hospitals are acquired by private equity companies, many remain concerned that quality will suffer for the sake of profit. Perhaps in 20 years we will be shaking our heads and lamenting about the decline in the quality of US healthcare the way many are viewing Boeing today.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. https://www.iata.org/en/pressroom/2023-releases/2023-12-06-01/#:~:text=Airline%20industry%20net%20profits%20are,2.6%25%20net%20profit%20margin)
2. Boeing Profit Margin 2010-2023. Macrotrends. Available at: https://www.macrotrends.net/stocks/charts/BA/boeing/profit-margins#:~:text=Current%20and%20historical%20gross%20margin,%2C%202023%20is%20%2D2.86%25 (accessed 2/9/24).
3. Condon A, Ashley M. From -10.6% to 11.1%: 34 systems ranked by operating margins. Becker’s Hospital Review. December 29, 2023. Available at: https://www.beckershospitalreview.com/finance/from-10-6-to-11-1-34-systems-ranked-by-operating-margins.html (accessed 2/9/24).
4. Boeing. Wikipedia. Available at: https://en.wikipedia.org/wiki/Boeing (accessed 2/9/24).
5. Surowiecki J. What’s Gone Wrong at Boeing. The Atlantic. January 15, 2024. Available at:  https://www.theatlantic.com/ideas/archive/2024/01/boeing-737-max-corporate-culture/677120/ (accessed 2/9/24).
6. Rose J. The FAA is tightening oversight of Boeing and will audit production of the 737 Max 9. January 12, 2024. NPR. Available at: https://www.npr.org/2024/01/12/1224444590/boeing-faa-737-max-9-alaska-airlines-door-plug (accessed 2/9/24).
7. Harris E. Private Equity Ownership in Health Care Linked to Higher Costs, Worse Quality. JAMA. 2023 Aug 22;330(8):685-686. [CrossRef] [PubMed]

Cite as: Robbins RA. Hospitals, Aviation and Business. Southwest J Pulm Crit Care Sleep. 2024;28:20-23. doi: https://doi.org/10.13175/swjpccs009-24 PDF

Healthcare Labor Unions-Has the Time Come?

Labor unions in America look like they are making a comeback. Employees at  Starbucks stores, Amazon warehouses, Trader Joe's, and REI, grad students, Uber and Lyft drivers and employees at the Medieval Times have voted to unionize. Hollywood actors and writers, the United Auto Workers, and Kaiser Permanente employees have been on strike (1). Headline writers began declaring things like, "Employees everywhere are organizing" and that the United States was seeing a "union boom” (2). In September, the White House asserted "Organized labor appears to be having a moment" (2). However, the Bureau of Labor Statistics recently released its union data for 2022 and the data shows that the share of American workers in a union has continued to decline (2). Last year, the union membership rate fell by 0.2 percentage points to 10.1% — the lowest on record.

Despite an increase in union efforts since the pandemic, healthcare workers — particularly doctors — have been slow to join unions. Doctors Council bills itself as the largest physician union in the country with 3500 members according to Joe Crane, national organizing director. However, Crane estimated that only about 3% of US physicians are currently union members. A minority of advanced practice registered nurses (APRNs) (9%) report union membership, according to Medscape's APRN compensation report last year. In a rare alliance, more than 500 physicians, NPs, and PAs at Allina Health primary care and urgent care clinics in Minneapolis, Minnesota, recently filed a petition with the National Labor Relations Board to hold a union election. If successful, the Allina group will join the Doctors Council SEIU, Local 10MD. The Allina healthcare providers share concerns about their working conditions, such as understaffing and inadequate resources, limited decision-making authority, and health systems valuing productivity and profit over patient care.

The economist, Suresh Naidu, and his colleagues have found influential evidence showing that unions played a critical role in boosting wages for American workers and reducing income inequality in the early-to-mid 20th century (3). However, "American labor law just puts an enormous barrier in the way of workers joining a union," Naidu says. "So you need to convince 50% plus one of your coworkers to join a union if you want a union.” That alone can entail a difficult and time-intensive campaign process. Our labor laws make it relatively easy for employers to short-circuit organizing efforts (3). Even when some of their tactics are technically illegal, companies are given wide latitude to thwart unionizing with minimal legal sanctions (3). Union organizers are forced to strategize and organize outside their workplace and figure out how to convince coworkers to join the fight without getting penalized or fired.

The obstacles to forming a union have only grown in recent decades. Around 27 states have passed "Right to Work" laws, which make forming a union more difficult in states with those laws and provide a refuge for companies looking to escape unions in states without those laws (2). Globalization has given companies the option to close-up shop and move overseas. Automation has given companies the option to replace workers with machines. Deregulation has increased industry competition and weakened unions' ability to extract concessions from monopolistic companies. Various changes to labor law, by the U.S. Congress, by state legislatures, and by the federal courts, have made it harder for unions to grow and thrive. Corporations now spend millions and millions on highly paid consultants, developing effective tactics to suppress unionizing efforts and pressure their workers into submission. Once workers form a union, it now takes an average of 465 days for the union to sign a contract with their employer.

Doctors, nurses and healthcare workers tend to underestimate their potential to influence healthcare. If doctors formed a union, many of my colleagues, myself included, would be opposed to an all-out strike since this would likely harm patients. However, the present healthcare system depends on the flow of paperwork with business interests relying on doctors and nurses to generate. Refusing to fill out billing sheets, discharge patients, participate in non-patient care hospital activities are just some of the ways doctors and nurses could impact the system without denying care to patients. A recent strike against Kaiser drove a settlement in 3 days with an increase in wages and an agreement to improve staffing levels (1). The threat of another pandemic and the need for healthcare workers to care for these patients despite chronic understaffing, leaves management backed into a corner.

Under these pressures and given the attitude of many doctors and nurses that they are healthcare professionals, not blue-collar workers, it is not surprising that the majority of doctors and nurses are not unionized. However, among my own social group of retired physicians the reluctance to join unions may be waning. One of my most conservative colleagues put it this way, “What choice do we have? Doctors have lost control of medicine and business interests have exploited their control over medicine to take advantage of us and our patients.” Many healthcare workers felt betrayed after the recent COVID-19 pandemic (5). They sacrificed much but received no rewards or even thanks for their sacrifices. Regardless, complaining about the situation is unlikely to change anything. Business interests are unlikely to relinquish control since they are making money, in some cases huge amounts of money. Unions may be one way to reverse the “hyperfinancialization” of medicine and return to a not-for-profit service for patients.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. Selena Simmons-Duffin S. After historic strike, Kaiser Permanente workers win 21% raise over 4 years. NPR. October 14, 2023. Available at: https://www.npr.org/sections/health-shots/2023/10/13/1205788228/kaiser-permanente-strike-contract-deal-reached (accessed 10/23/23).
2. Rosalsky G. You may have heard of the 'union boom.' The numbers tell a different story. NPR. February 28, 2023. Available at: https://www.npr.org/sections/money/2023/02/28/1159663461/you-may-have-heard-of-the-union-boom-the-numbers-tell-a-different-story#:~:text=Headline%20writers%20began%20declaring%20things,its%20union%20data%20for%202022. (accessed 9/30/23).
3. Farber HS, Herbst D, Kuzimenko I, Naidu S. Unions and Inequality over the Twentieth Century: New Evidence from Survey Data. The Quarterly Journal of Economics. 2021; 136 (3):1325–1385. [CrossRef]
4. Associated Press. Kaiser Permanente Reaches a Tentative Deal with Health Care Worker Unions After a Recent Strike. October 13, 2023. Available at: https://apnews.com/article/kaiser-permanente-health-care-workers-strike-411aa1f084c19725f29ff87766e99704 (accessed 10/14/23).
5. Griffin M, Hamilton P, Harness O, Credland N, McMurray R. ‘Running Towards the Bullets’: Moral Injury in Critical Care Nursing in the COVID-19 Pandemic. J Manag Inq. 2023 Jun 26:10564926231182566. [CrossRef] [PubMed]

Cite as: Robbins RA. Healthcare Labor Unions-Has the Time Come? Southwest J Pulm Crit Care Sleep. 2023;27(5):59-61. doi: https://doi.org/10.13175/swjpccs047-23 PDF 

Who Should Control Healthcare?

The American Academy of Emergency Medicine (AAEM) is urging stiffer enforcement of decades-old statutes that prohibit the ownership of medical practices by corporations not owned by licensed doctors (1). These century-old laws and regulations were meant to fight the commercialization of medicine, maintain the independence of physicians, and prioritize the doctor-patient relationship over the interests of investors and shareholders (2). Thirty-three states (click to see list of states that prohibit corporate ownership) plus the District of Columbia have rules on their books against the so-called corporate practice of medicine. In Arizona ownership by nonprofit entities is permitted, however as most of us know, nonprofit healthcare organizations are nonprofit in name only. Furthermore, over the years, companies have successfully sidestepped bans on owning medical practices by buying or establishing local staffing groups that are nominally owned by doctors and restricting the physicians so they have no direct control.

Those campaigning for stiffer enforcement of the laws say that physician-staffing firms owned by private equity investors are the guiltiest offenders. Private equity-backed staffing companies manage a quarter of the nation’s emergency rooms (2). The two largest are Nashville-based Envision Healthcare, owned by investment giant KKR & Co., and Knoxville-based TeamHealth, owned by Blackstone. Court filings in multiple states, including California, Missouri, Texas, and Tennessee, have called out Envision and TeamHealth for allegedly using doctor groups as straw men to sidestep corporate practice laws (2).

Physicians and consumer advocates around the country are anticipating a California lawsuit against Envision. The trial is scheduled to start in January 2024 in Federal court. The case involves Placentia-Linda Hospital in northern Orange County, where the plaintiff physician group lost its ER management contract to Envision. The complaint  by Milwaukee-based American Academy of Emergency Medicine Physician Group alleges that Envision uses the same business model at numerous hospitals around the Nation. Furthermore, the complaint alleges that Envision uses shell business structures to retain de facto ownership of ER staffing groups, and it is asking the court to declare them illegal. “We’re not asking them to pay money, and we will not accept being paid to drop the case,” said David Millstein, lead attorney for the plaintiff. “We are simply asking the court to ban this practice model.” Although Envision filed for Chapter 11 bankruptcy, AAEM has vowed to pursue the lawsuit (3,4).

The plaintiff — along with many doctors, nurses and consumer advocates, as well as some lawmakers — hopes that success in the case will spur regulators and prosecutors in other states to take corporate medicine prohibitions more seriously. The corporate practice of medicine has “a very interesting and not a very flattering history” said Barak Richman, a law professor at Duke University (2). This is a gross understatement in my opinion. The physicians, nurses, and technicians are not responsible for poorer care at higher prices that we now see. Businessmen are responsible by squeezing caregivers and patients for every penny, a practice some call “hyperfinancialization”(5). It is not surprising charging as much as possible while delivering minimal care has evolved. Businessmen in healthcare maximize profits in these situations, especially when they can avoid any responsibility for the healthcare delivered. Rather, a system of “quality assurance” has evolved which is more concerned with controlling caregivers than quality (6).

If not businessmen, then who should control healthcare? Doctors are alleged to be poor businessmen. If by this it is meant that physicians are more likely to try and deliver the best healthcare at the best price rather than bill the maximum for minimal care, I would hope most of physicians would plead guilty. Most physicians are concerned about delivering quality healthcare at reasonable prices. I suspect that the rumor that doctors are poor businessmen was started by business interests for their own financial gratification.

Not all doctors are qualified to lead healthcare. Some are straw managers which will do whatever their business supervisors tell them to do. Physician leaders practicing medical administration should be held to the same high standards that doctors are held in care of patients. Therefore, some degree of local control must be kept. Those of us who advocate for better healthcare can hope the courts enforce existing laws where applicable. We also need to take action in supporting each other for the good of medicine and the health of our patients. However, we also need to do a better job policing ourselves. Those ordering unnecessary or questionable diagnostic testing or treatments need to be called out. If successful, the Envision Case could prompt legislators, regulators and prosecutors in other states to focus attention on clinical practice of medicine prohibitions in their own states and take up arms against potential violations or reinvigorate prohibitions of clinical practice with new legislation and/or regulation.

Richard A. Robbins MD

Editor, SWJPCCS

References

1. American Academy of Emergency Medicine. Emergency Medicine and the Physician Practice Management Industry: History, Overview, and Current Problems. Available at: https://www.aaem.org/publications/key-issues/corporate-practice/emergency-medicine-and-the-physician-practice-management-industry-history-overview-and-current-problems/ (accessed 8/23/23).
2. Wolfson B. ER Doctors Call Private Equity Staffing Practices Illegal, Seek to Ban Them. Kaiser Health News. December 22, 2022. Available at: https://www.virginiamercury.com/author/kaiser-health-news/ (accessed 8/23/23).
3. Condon A, Thomas N. From private equity to bankruptcy: Envision's last 5 years. May 18, 2023. Available at: https://www.beckershospitalreview.com/finance/from-private-equity-to-bankruptcy-envisions-last-5-years.html (accessed 8/23/23).
4. Holland & Knight Law. Federal Bankruptcy Court Stays Envision Healthcare Litigation in California. August 3, 2023. Available at: https://www.hklaw.com/en/insights/publications/2023/08/federal-bankruptcy-court-stays-envision-healthcare-litigation (accessed 8/23/23).
5. Robbins RA. Who are the medically poor and who will care for them? Southwest J Pulm Crit Care. 2019;19(6):158-62. [CrossRef]
6. Robbins RA. The Potential Dangers of Quality Assurance, Physician Credentialing and Solutions for Their Improvement. Southwest J Pulm Crit Care Sleep. 2022;25(4):52-58. [CrossRef]

Cite as: Robbins RA. Who Should Control Healthcare? Southwest J Pulm Crit Care Sleep. 2023;27(3):33-35. doi: https://doi.org/10.13175/swjpccs039-23 PDF

Book Review: One Hundred Prayers: God's answer to prayer in a COVID ICU

By Anthony Eckshar MD

One Hundred Prayers: God's answer to prayer in a Covid ICU
amazon.com

The book is a very moving and spell-binding collection of the encounters between patients and physicians during the worst of the COVID-19 epidemic and Dr. Eckshar’s prayers for each of them. A devout person can read this as a prayer devotional; however, it is much more - an authentic account of what doctors and nurses go through working in the ICU. This book might help encourage people who are searching for faith, especially those who face severe illnesses in themselves or a loved one. It may also encourage doctors, nurses and other healthcare workers who might have been burned out working during the pandemic. Its main message is that faith, compassion, and the scientific method must co-exist. It is also a great review of the history of COVID pandemic from the trenches of patient care in the ICU. For nonmedical people it  should provide a clue to how doctors and nurses think. Hopefully, this book will lift everyone up and instill deep admiration and respect for the ICU doctors and nurses, and perhaps teach you a little something about faith.

Richard A. Robbins MD

Editor, SWJPCCS

Cite as: Robbins RA. Book Review: One Hundred Prayers: God's answer to prayer in a Covid ICU. Sodsuthwest J Pulm Crit Care Sleep. 2023;27(1):14. doi: https://doi.org/10.13175/swjpccs032-23 PDF

One Example of Healthcare Misinformation

On June 21^st  NBC News aired an investigation into HCA Healthcare accusing HCA administration of pressuring doctors, nurses and family to have patients enter hospice care or be discharged (1). Patients entering hospice care can lower inpatient mortality rate and length of stay, increasing profits and bonuses for executives. It works this way — if a patient passes away in a hospital, that death adds to the facility’s inpatient mortality figures. But if that person dies after a transfer to hospice care — even if the patient stays at the same hospital in the same bed — the death doesn’t count toward the facility’s inpatient mortality rate because the patient was technically discharged from the hospital. A reduction in lengthy patient stays is a secondary benefit according to an internal HCA hospital document (1). Under end-of-life care, patients don’t typically live long, so the practice can allow HCA to replace patients that may be costing the facility money because their insurance has run out with those who generate fresh revenues.

These practices are not unique to HCA nor are they new. Manipulation of patient data such as mortality go back at least until the 1990’s. For example, at the Phoenix VA the floor inpatient mortality rate was low while the ICU mortality rate was high. This was apparently due to excess mortality in floor to ICU transfers (2). Reduction of inappropriate ICU transfers from the hospital floor corrected the high ICU mortality rate. Similar changes were seen for length of stay. There were also dramatic reductions in the incidence of ICU ventilator-associated pneumonias and central line-associated blood stream infections just by alternating the reported cause of pneumonia or sepsis. For example, ventilator-associated pneumonia was called “delayed onset community acquired pneumonia” and sepsis was blamed on a source other than the presence of a central line.

These data manipulations were not restricted to the inpatient mortality or length of stay. Outrageously exaggerated claims of improvement and lives saved became almost the norm. In 2003 Jonathan B. Perlin, then VA Undersecretary of Health, realized that outcome data was needed for interventions such as pneumococcal vaccination with the 23-polyvalent pneumococcal vaccine. On August 11, 2003 at the First Annual VA Preventive Medicine Training Conference in Albuquerque, NM, Perlin claimed that the increase in pneumococcal vaccination saved 3914 lives between 1996 and 1998 (3) (For a copy of the slides used by Perlin click here). Furthermore, Perlin claimed pneumococcal vaccination resulted in 8000 fewer admissions and 9500 fewer days of bed care between 1999 and 2001. However, these data were not measured but based on extrapolation from a single, non-randomized, observational study (4). Most studies have suggested that the 23-polyvalent vaccine is of little or no value in adults (5).

It raises the question of why bother to manipulate these data? The common denominator is money. Administrators demand that the numbers meet the requirements to receive their bonuses (1). At the VA the focus changed from meeting the needs of the patient to meeting the performance measures. HCA administration is accused of similar manipulations. Speculation is that many if not most healthcare administrators behave similarly. The rationale is that the performance measures represent good care which is not necessarily true (5).

Who can prevent this pressuring of care givers and patient families to make the numbers look better? One would expect that regulatory organizations such as the Joint Commission, Institute of Medicine, Centers for Medicare and Medicaid Services, Department of Health and Human Services, and Department of Veterans Affairs would require the data reported be accurate. However, to date they have shown little interest in questioning data which makes their administration look good. The Joint Commission is a National Regulatory group that is prominent in healthcare regulation. After leaving the VA in 2006, Perlin was named the President, Clinical Operations and Chief Medical Officer of Nashville, Tennessee-based HCA Healthcare prior to being named the President and subsequently CEO of the Joint Commission in 2022. When regulatory organizations get caught burying their heads in the sand, administrators usually respond by blaming the malfeasance on a few bad apples. An example is the VA wait scandal that led to the ouster of the Secretary of Veterans Affairs, Eric Shinseki, and the termination of multiple administrators at the Phoenix VA. It should be noted that although Phoenix was the focus of the VA Inspector General at least 70% of medical centers were misreporting the wait times similarly to Phoenix (6).

Who should be the watchdogs and whistleblowers on these and other questionable practices – obviously, the hospital doctors and nurses. However, the hospitals have these employees so under their thumb that any complaint is often met with the harshest and most severe sanctions. Doctors or nurses who complain are often labeled “disruptive” or are accused of being substandard. The latter can be accomplished by a sham review of patient care and reporting to the physician or nurse to a regulatory authority such as the National Practitioner’s Databank or state boards of medicine or nursing (7). Financial data may be even easier to manipulate (8). A recent example comes from Kern County Hospital in Bakersville, CA (9). There the hospital’s employee union accuses the hospital of $23 million in overpayment to the hospital executives over 4 years. According to the union the hospital tried to cover up the overpayment. Now the executives have requested the hospital board to cover the overpayments.

The point is that hospital data can be manipulated. One should always look at self-reported data with healthy skepticism, especially if administrative bonuses are dependent on the data. Some regulatory authority needs to examine and certify that the reported data is correct. It seems unlikely that Dr. Perlin’s Joint Commission will carefully examine and report accurate hospital data. Hopefully, another regulator will accept the charge of ensuring that hospital data is accurate and reliable.

Richard A. Robbins, MD

Editor, SWJPCCS

References

1. NBC News. HCA Hospitals Urge Staff to Move Patients to Hospice to Improve Mortality Stats Doctors and Nurses Say. June 21, 2023. Available at: https://www.nbcnews.com/nightly-news/video/hca-hospitals-urge-staff-to-move-patients-to-hospice-to-improve-mortality-stats-doctors-and-nurses-say-183585349871 (accessed 6/28/23).
2. Robbins RA. Unpublished observations.
3. Perlin JB. Prevention in the 21^st Century: Using Advanced Technology and Care Models to Move from the Hospital and Clinic to the Community and Caring. Building the Prevention Workforce: August 11, 2003. First Annual VA Preventive Medicine Training Conference. Albuquerque, NM.   
4. Nichol KL, Baken L, Wuorenma J, Nelson A. The health and economic benefits associated with pneumococcal vaccination of elderly persons with chronic lung disease. Arch Intern Med. 1999;159(20):2437-42. [CrossRef] [PubMed]
5. Robbins RA. The unfulfilled promise of the quality movement. Southwest J Pulm Crit Care. 2014;8(1):50-63. [CrossRef]
6. Department of Veterans Affairs Office of Inspector General. Concerns with Consistency and Transparency in the Calculation and Disclosure of Patient Wait Time Data. April 7, 2022. Available at: https://www.va.gov/oig/pubs/VAOIG-21-02761-125.pdf (accessed 6/28/23).
7. Chalifoux R Jr. So, what is a sham peer review? MedGenMed. 2005 Nov 15;7(4):47; discussion 48. [PubMed].
8. Beattie A. Common Clues of Financial Statement Manipulation. Investopedia. April 29, 2022. Available at: https://www.investopedia.com/articles/07/statementmanipulation.asp (accessed 7/28/23).
9. Kayser A. California Hospital Accused of Overpaying for Executive Services. Becker’s Hospital Review. June 28, 2023. Available at: https://www.beckershospitalreview.com/compensation-issues/california-hospital-accused-of-overpaying-for-executive-services.html?origin=BHRE&utm_source=BHRE&utm_medium=email&utm_content=newsletter&oly_enc_id=6133H6750001J5K  (accessed 6/29/23).

Cite as: Robbins RA. One Example of Healthcare Misinformation. Southwest J Pulm Crit Care Sleep. 2023;27(1):8-10. doi: https://doi.org/10.13175/swjpccs029-23 PDF