Sometimes you think you're dreaming, sometimes you think it
just can't be, not even in Trump's America. But you'd be wrong.
As per the NY Times, "An 81-year-old veteran hobbled
into the emergency room [at the veterans hospital in Roseburg, Ore] . . . in December, malnourished and dehydrated,
his skin flecked with ulcers and his ribs broken from a fall at home."
After Walter Savage waited for nine hours — nine hours
— in the emergency room he was denied admission. Doctors said of course he
should have been admitted, as did nurses. But director Doug Paxton overruled
them. It wasn't that Savage was too healthy to merit admission; no, it was that
he was too unhealthy. The hospital earns no bonus points for trying to treat the
likes of Savage, and Paxton gets no bonus check.
This is not a dark episode from the Twilight Zone. It is
just an example of Trump care.
Maybe this piece of reporting from the "failing"
NY Times will help turn things around at the Roseburg, Ore veterans hospital. It
should certainly reinforce the notion that, though this is 2018, Trump merits
maximum resistance and derision as before.
NY
Times 1/1/18
https://www.nytimes.com/2018/01/01/us/at-veterans-hospital-in-oregon-a-push-for-better-ratings-puts-patients-at-risk-doctors-say.html?hp&action=click&pgtype=Homepage&clickSource=image&module=second-column-region®ion=top-news&WT.nav=top-news&_r=0
At
Veterans Hospital in Oregon, a Push for Better Ratings Puts Patients at Risk,
Doctors Say
ROSEBURG,
Ore. — An 81-year-old veteran hobbled into the emergency room at the rural
Veterans Affairs hospital here in December, malnourished and dehydrated, his
skin flecked with ulcers and his ribs broken from a fall at home.
A
doctor examining the veteran — a 20-year Air Force mechanic named Walter Savage
who had been living alone — decided he was in no shape to care for himself and
should be admitted to the hospital. A second doctor running the inpatient ward
agreed.
But
the hospital administration said no.
Though
there were plenty of empty beds, records show that a nurse in charge of
enforcing administration restrictions said Mr. Savage was not sick enough to
qualify for admission to the hospital. He waited nine hours in the emergency
room until, finally, he was sent home.
“The
doctors were mad; the nurses were mad,” said Mr. Savage’s son-in-law, Mark
Ridimann. “And my dad, he was mad, too. He kept saying, ‘I’ve laid my life on
the line, two years in Vietnam, and this is what I get?’”
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.
Current
and former staff members say the practice may reach well beyond Roseburg.
Recent government reports
also challenge the reliability of the department’s metrics, casting doubt on a
key tool that it says it relies on for reforming its beleaguered health care
system.
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.
“The
numbers are indicators of the quality of care for the veterans, so, sure, we’re
worried about the numbers,” he said. “But if you improve the care to veterans,
in turn your numbers are going to improve. That’s the bottom line.”
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.’”
“We
cannot express strongly enough how detrimental this process has been for
patient care and how unacceptable it would be anywhere else,” the letter noted.
The
day after Mr. Savage was turned away, he showed up again asking for help.
Again, he was denied. He waited for hours in the emergency room until a doctor
finally admitted him against the wishes of the administration, his son-in-law
said. The administration, ever mindful of metrics, moved him to a nursing home
in less than 24 hours.
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.
Even
Roseburg. For years, the hospital in this logging town, which had no intensive
care unit and limited surgery facilities, has struggled with the challenges
many rural hospitals face. It was hard to attract new doctors. A small staff
meant that just one open position could create a pileup of delays. Doctors
constantly left for higher-paying jobs outside the system.
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.
“It’s
a numbers game,” Dr. Steven Blum, a doctor at the veterans hospital in
Roseburg, said of the medical center’s approach. “The leadership has figured
out the hospital can actually do better by seeing less patients.”
Credit
Ruth
Fremson/The New York Times
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.
“It’s
a numbers game. The leadership has figured out the hospital can actually do
better by seeing less patients,” said Dr. Steven Blum, a hospitalist there who
said he has seen patients regularly turned away or transferred to private
hospitals. “These numbers show up on the director’s report card, so it is very
important they look good.”
On
average, more than half the hospital’s beds now sit empty, he said, while
patients are either sent home or transferred to private hospitals at government
expense. Costly transfers don’t come out of the Roseburg budget, but they do
protect the hospital by moving risk to other facilities’ books.
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.”
The
focus on improving scores overshadowed deep-seated problems, staff said,
including crippling turnover in primary care doctors.
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.
Photo
Laura
Follett, who oversaw scheduling for Roseburg’s primary care clinic, at home in
Springfield, Ore., this month. She resigned in 2016.
Dangerous
gaps appeared when doctors ordering critical tests were no longer around to
review the results and alert patients. Several nurses said they saw positive
cancer screening alerts and other critical lab results languish for weeks or
even months.
“Alerts
go into Neverland,” said Treva Moss, a nurse who works in the medical center’s
specialty clinic in Eugene, Ore.
This
fall, a number of employees complained to their Congressman, Peter DeFazio, who
blasted the hospital
management on the floor of the House of Representatives as “dysfunctional.” At
his request, the department is conducting an investigation.
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 veteran’s 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.
“Of
course quality had not really improved by that much,” Dr. Mann said. “People
had just learned to make it appear that it had.”
Many
hospitals simply stopped performing surgeries on high-risk patients, or cut
high risk procedures all together, Dr. Mann said. “I’m very ashamed. I
colluded. I was told not to operate and pulled back, and at least one of my
patients died because of it.”
The
vast health care system has little choice but to rely on metrics, said David J.
Shulkin, the veterans affairs secretary.
“Without
it we’re like an airport with no air traffic control,” he said in an interview.
“We don’t know where our hospitals are, we don’t know where they are headed.
All we can do is respond to the crashes. I’d rather be able to look ahead and
prevent them.”
The
department regularly audits hospitals, he said. But the Government
Accountability Office raised doubts in a report this fall noting
in many cases the data seems inaccurate but the central office “has not
determined the extent to which these problems exist.”
In
2014, when Mr. Paxton took over Roseburg, he vowed to turnaround a hospital
that had long ranked one of the worst in the system. He added staff, tried to
cut inefficiencies, and tapped his new chief of mental health, a social worker
by training named Paul Beiring, to figure out how to improve metrics.
In
an interview, Mr. Beiring said focusing on hospital admissions was strategic
because it accounted for a big slice of the rating.
“It
is weighted really high, so we knew we had to optimize that measure,” he said.
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.
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