How many of California’s Medicare patients are malnourished?
Do some hospitals report more malnutrition among seniors than others?
California Watch used public records to compare how frequently California hospitals diagnose malnutrition among older patients when their care is paid for by the federal Medicare system.
Our findings are based on a computer-assisted analysis of public data from a state agency, the Office of Statewide Health Planning and Development. The data contains information about every patient who was discharged from a state-licensed hospital in 2009, the most recent data available. It details each patient’s health problems – reporting as many as 25 different diagnoses, coded according to the World Health Organization’s ICD-9 system.
The data also provides some demographic information, while concealing personal identifiers. The 2009 data set contained 3,985,166 records. We zeroed in on patients age 65 or older whose care was billed to Medicare and who were treated at a major acute care, or general, hospital. We also focused on cases where patients sought care for serious medical conditions, rather than substance abuse treatment, psychiatric care or physical rehabilitation.
Excluded were hospitals that treated fewer than 500 patients per year, because their rates might be distorted. Also excluded were long-term acute-care facilities, because their patients’ health problems differ from those encountered at acute care hospitals. Finally, the analysis excluded managed-care hospitals, including those of the Kaiser Permanente system, because of fundamental differences in the way they are reimbursed for treating Medicare patients.
In the end, our analysis included a subset of 769,202 patients at 254 hospitals.
Using SAS data analysis software, California Watch examined the records of every patient fitting the criteria we identified. The ICD-9 system lists 38 different codes for malnutrition diagnoses – everything from kwashiorkor, a Third World nutritional disorder, to vitamin A deficiency.
A patient with one or more of these 38 codes entered by the hospital was counted as a malnutrition case.
The analysis then calculated the percentage of malnutrition cases among the total number of cases at each hospital, as well as the percentage of cases that had different degrees of malnutrition, including a separate count of cases coded as kwashiorkor.
The analysis found that hospitals in the Prime Healthcare Services chain reported that 25 percent of their Medicare patients age 65 and older were malnourished. The state average for hospitalized seniors was 7.5 percent. Two Prime hospitals also reported high rates of kwashiorkor.
Our results were similar to those reported in two other studies.
In October, the Service Employees International Union, which has clashed with Prime over pay and staffing issues, provided authorities with a private statistical study of federal Medicare data, a spokesman said. It showed high malnutrition and kwashiorkor rates at Prime hospitals. Later, the union said it paid the state health department to do a custom computer study of state health data. That study also showed high malnutrition and kwashiorkor rates at Prime, the union said. But California Watch relied on its own statistical analysis for this report.
In December, California Watch provided Prime officials with a description of our methodology and a copy of the entire state data set in computer form, inviting a critique of our findings.
Hospitals are eligible to receive bonus payments for treating patients with certain ailments or diseases. There are hundreds of medical complications that qualify for enhanced payments from Medicare. Three types of severe malnutrition, including kwashiorkor, are classified as “major complications,” and get the biggest boost, while 35 other forms of malnutrition are termed “complications” and get a more modest payment enhancement.
In e-mails, Prime officials insisted that their malnutrition diagnoses were accurate and that the chain was not assigning the diagnosis to obtain enhanced payments from Medicare.
Prime officials also accused the union of manipulating data to wrongly implicate the company in Medicare fraud. That’s part of a “campaign of misinformation and extortion” to leverage labor contracts, the company has charged.
The officials otherwise didn’t comment on California Watch’s methodology, study or findings.
Prime provided California Watch with letters from the Health Services Advisory Group, a Medicare contractor that monitors billing. The letters challenge Prime’s decision to bill for two cases of kwashiorkor, noting that the condition “is extremely rare if seen at all” in the American adult. Both cases, on re-review, say the bill is acceptable but cite no explanation. Prime did not provide information about hundreds of other kwashiorkor cases, and the Health Services Advisory Group did not return calls from California Watch. Its letter to Prime says the information about billing disputes is confidential.