{"id":14267,"date":"2023-06-22T03:19:41","date_gmt":"2023-06-22T08:19:41","guid":{"rendered":"https:\/\/ustower.net\/?p=14267"},"modified":"2023-06-22T03:19:45","modified_gmt":"2023-06-22T08:19:45","slug":"youre-not-god-doctors-and-patient-families-say-hca-hospitals-push-hospice-care","status":"publish","type":"post","link":"https:\/\/ustower.net\/?p=14267","title":{"rendered":"‘You’re not God’: Doctors and patient families say HCA hospitals push hospice care"},"content":{"rendered":"\n

As Marisol Perez fought for her life in a Texas hospital in autumn 2021, her mother, Alma Salas, sat with her every day praying. Perez, then 42, had such a virulent case of Covid and pneumonia that doctors at St. David\u2019s North Austin Medical Center, an HCA Healthcare<\/a> facility, had put her\u202fon a ventilator and\u202finto a coma\u202fto try to save her.<\/p>\n\n\n\n

Salas said she believed her daughter would pull through, but doctors and nurses at the hospital kept telling her otherwise. Over 10 days in October, less than a month after Perez entered St. David\u2019s, Salas received repeated visits from a palliative care nurse,\u202fher hospital record shows. Every other day,\u202fSalas said,\u202fthe nurse urged\u202fher to initiate end-of-life care for her daughter. Several of Perez\u2019s doctors also pressed Salas to remove her daughter from the ventilator, she said, in visits confirmed by details from Perez\u2019s chart.<\/p>\n\n\n\n

On one occasion, six or seven doctors and nurses gathered around Perez\u2019s bed, Salas said. “We really feel it is in the best interests of your daughter to let her go,”\u202fshe recalled one doctor telling her.<\/p>\n\n\n\n

Salas held firm. \u201cI don\u2019t have the authority to take anyone\u2019s life,\u201d she said she told them.<\/p>\n\n\n\n

A month later, St. David\u2019s discharged Perez, her chart shows. She went on to make a full recovery.<\/p>\n\n\n\n

St. David\u2019s is one of\u202f182 hospitals in the U.S. and the U.K. operated by HCA Healthcare,\u202fthe nation\u2019s largest hospital chain.\u202fHCA<\/a> is highly profitable\u202f\u2014 last year it earned $5.6 billion\u202f\u2014\u202fand its stock is a Wall Street darling.<\/p>\n\n\n\n

As an industry leader, HCA\u2019s practices are followed closely by competitors. But HCA\u2019s profits come at a cost to patients and workers, some of its doctors and employees contend. They have cited severe understaffing<\/a> and insufficient investment in facilities<\/a> as having caused harm to patients. <\/p>\n\n\n\n

Now, new criticisms are arising related to HCA\u2019s palliative and end-of-life care for patients, according to some physicians and nurses who have worked in its facilities. They say\u202fHCA officials\u202fpress\u202fstaff to persuade families of ailing\u202fpatients to\u202finitiate such care, as Salas says she experienced with her daughter. Although\u202fthis can harm patients by withdrawing lifesaving treatments, the push can benefit HCA two ways, the doctors and nurses said, and an internal hospital document confirms.\u202fIt reduces in-hospital mortality rates, a closely watched quality measure, and can free up a hospital bed more quickly for HCA, potentially generating more insurance reimbursements from a new patient. <\/p>\n\n\n\n

This article is based on\u202finterviews with six nurses and 27 doctors who currently practice at <\/strong>16 <\/strong>HCA hospitals in seven states or did so previously. All said their HCA hospitals pushed palliative and end-of-life care in pursuit of better performance metrics. Internal HCA hospital documents and texts between hospital staffers provided to NBC News support these health care professionals\u2019 views.<\/p>\n\n\n\n

Ed Fishbough, an HCA spokesman, denied the contentions. \u201cSuggesting that medical care in HCA Healthcare hospitals is based on anything other than a physician\u2019s independent medical judgment of what is in the patient\u2019s best interest is untrue and wrong,\u201d he said in a statement.<\/p>\n\n\n\n

Two weeks after NBC News began raising questions with HCA about its hospice referrals, one physician at a company hospital reported what he believes is a precipitous decline in the number of referrals at the facility.<\/p>\n\n\n\n

Regarding Perez\u2019s care at St. David\u2019s, Fishbough said, \u201cSevere, life-threatening illnesses are gut-wrenching experiences, and St. David\u2019s HealthCare physicians, nurses and staff are dedicated to guiding patients and their families throughout the process of managing a severe illness.\u201d <\/p>\n\n\n\n

He said he could not discuss details of Perez\u2019s experience because of privacy laws. NBC News provided HCA with a waiver signed by Perez allowing St. David\u2019s Hospital to provide information about her medical care and discuss it with NBC News. HCA said it would only talk about her care if Perez signed two HCA waivers. One was \u201cAuthorization for Use and Disclosure of Protected Health Information for Marketing and\/or Promotional Purposes\u201d and another was \u201cConsent for Use and Disclosures of Image, Voice and\/or Written Testimonials,\u201d giving HCA the right to videotape Perez and record her voice. Perez declined.<\/p>\n\n\n\n

Although few patients likely realize it, transfers to hospice care reduce a\u202fhospital\u2019s\u202finpatient mortality rate.\u202fHere\u2019s why: If a patient passes away in a hospital, that death adds to the facility\u2019s inpatient mortality figures. But if that person dies after a transfer to hospice care \u2014 even if the patient stays at the same hospital in the same bed \u2014 the death doesn\u2019t count toward the facility\u2019s inpatient mortality rate because the patient was technically discharged from the hospital.\u202f<\/p>\n\n\n\n

A reduction in lengthy patient stays is a second benefit to the push to palliative and then end-of-life care,\u202fan HCA hospital document shows.\u202fUnder end-of-life care,\u202fpatients don\u2019t typically live long,\u202fso the practice can\u202fallow\u202fHCA\u202fto replace\u202fpatients\u202fthat\u202fmay be\u202fcosting the facility money\u202fbecause their insurance has run out\u202fwith\u202fthose who generate fresh\u202frevenues.\u202f<\/p>\n\n\n\n

Offering palliative care to seriously ill patients has gained traction\u202findustry-wide\u202f<\/strong>in recent years as a treatment for symptoms as well as providing comfort and pain management and support for their families.<\/p>\n\n\n\n

Palliative care differs from hospice care. According to the National Institutes of Health<\/a>, patients in palliative care can receive treatments for symptoms along with those intended to cure their illnesses, while hospice care focuses on comfort and quality of life for a patient approaching death. Patients in hospice typically receive only pain medication, making it crucial, <\/strong>many\u202fdoctors say, to be cautious when suggesting hospice to family members.\u202fDepending on the situation, Medicare, Medicaid and private insurers cover some costs of palliative as well as hospice care.<\/p>\n\n\n\n

While palliative care and hospice care differ, the HCA spokesman confirmed that the two treatments work in tandem at its facilities. Palliative care acts as a gateway to hospice care for some patients; if palliative care is recommended, a consultation typically takes place to ensure the patient and family agree. A recommendation to move forward from there to hospice care also requires physician and patient or family sign-off. <\/p>\n\n\n\n

For example, one internal HCA document describes palliative care consultations as the first step to hospice care, and another explains how the palliative care coordinator recommends hospice options to family members. If they agree, \u201cthe patient will be discharged from an inpatient status and rolled over\u201d into what\u2019s known as General Inpatient Hospice, or GIP, the document says. <\/p>\n\n\n\n

An internal HCA hospital analysis from about three years ago shows that almost one-third of its palliative care consultations resulted in admission to inpatient hospice or a hospice discharge plan. Deaths in those plans were excluded from the hospital\u2019s inpatient mortality rate.<\/p>\n\n\n\n

Another document recommends palliative care be considered for \u201cpatients with prolonged length of stay,\u201d indicating that the services may be seen as a way to reduce patient stays.<\/p>\n\n\n\n

At HCA, the push to palliative care and then hospice is constant, according to the doctors and nurses who spoke with NBC News. At two HCA hospitals, the practice appears to be mechanized, with staff citing an algorithm used to identify patients who are most likely to die soon. This is also known as a vulnerability index, texts shared with NBC News show.<\/p>\n\n\n\n

Patients ranking high on the vulnerability index become candidates for palliative care,\u202fthe texts show. In one, a palliative care team member at an HCA hospital identified such a patient; \u201cAlgorithm = 97% risk of mortality today,\u201d it said.<\/p>\n\n\n\n

The HCA spokesman declined to comment on the algorithm. <\/p>\n\n\n\n

One\u202fHCA hospital document\u202flists seven ways palliative care helps the\u202ffacility; topping the list is \u201cReduction of re-admissions and hospital mortalities that reflect negatively on our hospital.\u201d Another benefit, the document says: \u201cDecrease in hospital length of stay.\u201d<\/p>\n\n\n\n

Entities rating the quality of care at hospitals track inpatient mortality rates \u2014 the\u202fpopular\u202fIBM Watson Health Top Hospitals\u202franking\u202fis an\u202fexample. HCA\u2019s in-hospital mortality rate is important in another way \u2014 it is one of 10 \u201cquality of care\u201d metrics used since 2021 to calculate the incentive pay received by top company executives, its financial filings show. In other words, better mortality results at HCA contributed to better company performance for executive pay purposes.<\/p>\n\n\n\n

There is no direct evidence that HCA\u2019s palliative and hospice care push was intended to increase its executives\u2019 pay.<\/p>\n\n\n\n

HCA says\u202fin its filings that\u202fit calculates its mortality rate for pay purposes \u201cinternally\u201d using a model devised by IBM Watson Health that excludes patients who die after discharge, such as those in hospice. HCA uses the model \u201cbecause it includes all patients rather than being limited to Medicare patients, includes more conditions, and has a shorter lag time in the data,\u201d the spokesman said.\u202f<\/p>\n\n\n\n

Over the two years that HCA\u2019s board has used mortality rates to calculate incentive pay, Samuel N. Hazen, HCA\u2019s chief executive, received $35.3 million in total compensation. Some $305,400 of that was incentive pay generated by the mortality rate calculation, HCA said. Through a spokesman, Hazen declined an interview.<\/p>\n\n\n\n

\u202fThe three major publicly traded hospital companies that HCA considers competitors do not cite the use of mortality rates in their pay calculations, securities filings show. They are Community Health Systems Inc., Tenet Healthcare Corp., and Universal Health Services Inc.<\/p>\n\n\n\n

HCA administrators overseeing individual hospitals also receive compensation based on mortality rates, the company said. \u201cWe believe all hospital executives should have quality metrics \u2014 including mortality \u2014 as part of their incentive compensation,\u201d the spokesman said.<\/p>\n\n\n\n

Ghasan Tabel, a doctor who practices at Riverside Community Hospital, an HCA facility in Riverside, California, is troubled by HCA\u2019s palliative care and hospice push. He said he has seen many situations where patients\u2019 families were pressured by staff and told NBC News that the palliative care team does not always consult the attending physician when encouraging a patient\u2019s family to choose the program.<\/p>\n\n\n\n

\u201cSometimes it is reasonable to talk about comfort care, but usually it is done prematurely,\u201d said Tabel, who was involved in a lawsuit against Riverside that the hospital settled.\u202f\u201cWhat is very alarming to me is if they mislead the patient\u2019s family about the prognosis, paint the worst-case scenario, sometimes graphically, to convince the family to go to palliative care and withdrawal of care.\u201d <\/p>\n\n\n\n

The HCA spokesman said: \u201cThe decision to start palliative care for a patient is based on discussions among the patient, family and physician. Patient care at Riverside Community Hospital is based solely on a physician\u2019s independent medical judgment. Any claims to the contrary are irresponsible and untrue.\u201d<\/p>\n\n\n\n

As for\u202fMarisol Perez, she believes that if not for her mother, she would be dead and her 9-year-old daughter, Annaliese, orphaned. Of her experience with HCA, she said:\u202f\u201cPeople used as dollar signs and pushed off somewhere else to die \u2014 that is not OK.\u201d <\/p>\n\n\n\n

‘You\u2019re not God’<\/p>\n\n\n\n

Tabel is the rare doctor at an HCA hospital voicing public concerns about the company\u2019s palliative care practices. The\u202f26\u202fother doctors NBC News interviewed spoke on the condition of anonymity out of fear of retaliation by the company.<\/p>\n\n\n\n

All said, however, that the push for palliative and hospice care at their HCA facilities is insistent and\u202faimed at improving performance measures.\u202fPhysicians that do not promote the programs are told to toe the line, Tabel and\u202fsome of\u202fthe other doctors told NBC News.<\/p>\n\n\n\n

One\u202fdoctor recalled attending meetings at which hospital administrators discussed the importance of transfers to hospice care before a patient dies.\u202f\u201cThe primary area of discussion was, \u2018Why didn\u2019t this patient get moved to hospice 12 hours before?\u2019\u201d the doctor recalled. \u201c’What was the delay in getting them on hospice?\u2019\u201d<\/p>\n\n\n\n

Failing to make a well-timed transfer, the doctor said,\u202fwas\u202fconsidered a \u201cmissed hospice opportunity\u201d by the hospital.<\/p>\n\n\n\n

Nbcnews<\/a><\/p>\n","protected":false},"excerpt":{"rendered":"

As Marisol Perez fought for her life in a Texas hospital in autumn 2021, her mother, Alma Salas, sat with her every day praying. Perez, then 42, had such a virulent case of Covid and pneumonia that doctors at St. David\u2019s North Austin Medical Center, an HCA Healthcare facility, had put her\u202fon a ventilator and\u202finto a coma\u202fto […]<\/p>\n","protected":false},"author":6,"featured_media":14268,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[5784],"tags":[3399,2258,4980,8928,8929,2259],"class_list":["post-14267","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-health","tag-doctor","tag-hospital","tag-hospitalization","tag-mortality-rate","tag-patient-family","tag-transfer"],"_links":{"self":[{"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/posts\/14267","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/users\/6"}],"replies":[{"embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=14267"}],"version-history":[{"count":1,"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/posts\/14267\/revisions"}],"predecessor-version":[{"id":14269,"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/posts\/14267\/revisions\/14269"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=\/wp\/v2\/media\/14268"}],"wp:attachment":[{"href":"https:\/\/ustower.net\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=14267"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=14267"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/ustower.net\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=14267"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}