Alma Salas and her daughter, Marisol Perez.
Courtesy: Alma Salas
As Marisol Perez fought for her life in a Texas hospital in autumn 2021, her mother, Alma Salas, sat together with her daily praying. Perez, then 42, had such a virulent case of Covid and pneumonia that doctors at St. David’s North Austin Medical Center, an HCA Healthcare facility, had put her on a ventilator and right into a coma to try to avoid wasting her.
Salas said she believed her daughter would pull through, but doctors and nurses on the hospital kept telling her otherwise. Over 10 days in October, lower than a month after Perez entered St. David’s, Salas received repeated visits from a palliative care nurse, her hospital record shows. Every other day, Salas said, the nurse urged her to initiate end-of-life look after her daughter. Several of Perez’s doctors also pressed Salas to remove her daughter from the ventilator, she said, in visits confirmed by details from Perez’s chart.
On one occasion, six or seven doctors and nurses gathered around Perez’s bed, Salas said. “We actually feel it’s in the very best interests of your daughter to let her go,” she recalled one doctor telling her.
Salas held firm. “I haven’t got the authority to take anyone’s life,” she said she told them.
A month later, St. David’s discharged Perez, her chart shows. She went on to make a full recovery.
St. David’s is considered one of 182 hospitals within the U.S. and the U.K. operated by HCA Healthcare, the nation’s largest hospital chain. HCA is extremely profitable — last yr it earned $5.6 billion — and its stock is a Wall Street darling.
As an industry leader, HCA’s practices are followed closely by competitors. But HCA’s profits come at a price to patients and staff, a few of its doctors and employees contend. They’ve cited severe understaffing and insufficient investment in facilities as having caused harm to patients.
Now, recent criticisms are arising related to HCA’s palliative and end-of-life look after patients, in response to some physicians and nurses who’ve worked in its facilities. They are saying HCA officials press staff to steer families of ailing patients to initiate such care, as Salas says she experienced together with her daughter. Although this could harm patients by withdrawing lifesaving treatments, the push can profit HCA two ways, the doctors and nurses said, and an internal hospital document confirms. It reduces in-hospital mortality rates, a closely watched quality measure, and might unlock a hospital bed more quickly for HCA, potentially generating more insurance reimbursements from a recent patient.
This text is predicated on interviews with six nurses and 27 doctors who currently practice at 16 HCA hospitals in seven states or did so previously. All said their HCA hospitals pushed palliative and end-of-life care in pursuit of higher performance metrics. Internal HCA hospital documents and texts between hospital staffers provided to NBC News support these health care professionals’ views.
Ed Fishbough, an HCA spokesman, denied the contentions. “Suggesting that medical care in HCA Healthcare hospitals is predicated on anything apart from a physician’s independent medical judgment of what’s within the patient’s best interest is unfaithful and incorrect,” he said in an announcement.
Two weeks after NBC News began raising questions with HCA about its hospice referrals, one physician at an organization hospital reported what he believes is a precipitous decline in the variety of referrals at the power.
Regarding Perez’s care at St. David’s, Fishbough said, “Severe, life-threatening illnesses are gut-wrenching experiences, and St. David’s HealthCare physicians, nurses and staff are dedicated to guiding patients and their families throughout the means of managing a severe illness.”
He said he couldn’t discuss details of Perez’s experience due to privacy laws. NBC News provided HCA with a waiver signed by Perez allowing St. David’s Hospital to provide details about her medical care and discuss it with NBC News. HCA said it could only speak about her care if Perez signed two HCA waivers. One was “Authorization for Use and Disclosure of Protected Health Information for Marketing and/or Promotional Purposes” and one other was “Consent for Use and Disclosures of Image, Voice and/or Written Testimonials,” giving HCA the precise to videotape Perez and record her voice. Perez declined.
Although few patients likely realize it, transfers to hospice care reduce a hospital’s inpatient mortality rate. Here’s why: If a patient passes away in a hospital, that death adds to the power’s inpatient mortality figures. But when that person dies after a transfer to hospice care — even when the patient stays at the identical hospital in the identical bed — the death doesn’t count toward the power’s inpatient mortality rate since the patient was technically discharged from the hospital.
A discount in lengthy patient stays is a second profit to the push to palliative after which end-of-life care, an HCA hospital document shows. Under end-of-life care, patients don’t typically live long, so the practice can allow HCA to interchange patients that could also be costing the power money because their insurance has run out with those that generate fresh revenues.
Offering palliative care to significantly unwell patients has gained traction industry-wide lately as a treatment for symptoms in addition to providing comfort and pain management and support for his or her families.
Palliative care differs from hospice care. Based on the National Institutes of Health, patients in palliative care can receive treatments for symptoms together 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, many doctors say, to be cautious when suggesting hospice to members of the family. Depending on the situation, Medicare, Medicaid and personal insurers cover some costs of palliative in addition to hospice care.
While palliative care and hospice care differ, the HCA spokesman confirmed that the 2 treatments work in tandem at its facilities. Palliative care acts as a gateway to hospice look after some patients; if palliative care is advisable, a consultation typically takes place to make sure the patient and family agree. A advice to maneuver forward from there to hospice care also requires physician and patient or family sign-off.
For instance, one internal HCA document describes palliative care consultations as step one to hospice care, and one other explains how the palliative care coordinator recommends hospice options to members of the family. In the event that they agree, “the patient will likely be discharged from an inpatient status and rolled over” into what’s often known as General Inpatient Hospice, or GIP, the document says.
An internal HCA hospital evaluation from about three years ago shows that just about 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’s inpatient mortality rate.
One other document recommends palliative care be considered for “patients with prolonged length of stay,” indicating that the services could also be seen as a strategy to reduce patient stays.
At HCA, the push to palliative care after which hospice is constant, in response 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 discover patients who’re almost definitely to die soon. This can also be known as a vulnerability index, texts shared with NBC News show.
Patients rating high on the vulnerability index turn into candidates for palliative care, the texts show. In a single, a palliative care team member at an HCA hospital identified such a patient; “Algorithm = 97% risk of mortality today,” it said.
The HCA spokesman declined to comment on the algorithm.
One HCA hospital document lists seven ways palliative care helps the facility; topping the list is “Reduction of re-admissions and hospital mortalities that reflect negatively on our hospital.” One other profit, the document says: “Decrease in hospital length of stay.”
Entities rating the standard of care at hospitals track inpatient mortality rates — the popular IBM Watson Health Top Hospitals rating is an example. HCA’s in-hospital mortality rate is essential in one other way — it’s considered one of 10 “quality of care” metrics used since 2021 to calculate the inducement pay received by top company executives, its financial filings show. In other words, higher mortality results at HCA contributed to higher company performance for executive pay purposes.
There isn’t a direct evidence that HCA’s palliative and hospice care push was intended to extend its executives’ pay.
HCA says in its filings that it calculates its mortality rate for pay purposes “internally” using a model devised by IBM Watson Health that excludes patients who die after discharge, similar to those in hospice. HCA uses the model “since it includes all patients fairly than being limited to Medicare patients, includes more conditions, and has a shorter lag time in the information,” the spokesman said.
On this April 14, 2020 file photo, Sam Hazen, CEO of HCA Healthcare, speaks concerning the coronavirus within the Rose Garden of the White House, in Washington. HCA Healthcare’s second-quarter profit jumped past analyst expectations as patients returned to operating tables and hospital rooms after staying away last yr at the beginning of the COVID-19 pandemic.
Alex Brandon | AP
Over the 2 years that HCA’s board has used mortality rates to calculate incentive pay, Samuel N. Hazen, HCA’s 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.
The three major publicly traded hospital corporations that HCA considers competitors don’t cite the use of mortality rates of their pay calculations, securities filings show. They’re Community Health Systems Inc., Tenet Healthcare Corp., and Universal Health Services Inc.
HCA administrators overseeing individual hospitals also receive compensation based on mortality rates, the corporate said. “We consider all hospital executives must have quality metrics — including mortality — as a part of their incentive compensation,” the spokesman said.
Ghasan Tabel, a health care provider who practices at Riverside Community Hospital, an HCA facility in Riverside, California, is troubled by HCA’s palliative care and hospice push. He said he has seen many situations where patients’ families were pressured by staff and told NBC News that the palliative care team doesn’t at all times seek the advice of the attending physician when encouraging a patient’s family to decide on this system.
“Sometimes it is cheap to speak about comfort care, but often it is completed prematurely,” said Tabel, who was involved in a lawsuit against Riverside that the hospital settled. ”What could be very alarming to me is in the event that they mislead the patient’s family concerning the prognosis, paint the worst-case scenario, sometimes graphically, to persuade the family to go to palliative care and withdrawal of care.”
The HCA spokesman said: “The choice to start out palliative look after a patient is predicated on discussions among the many patient, family and physician. Patient care at Riverside Community Hospital is predicated solely on a physician’s independent medical judgment. Any claims on the contrary are irresponsible and unfaithful.”
As for Marisol Perez, she believes that if not for her mother, she could be dead and her 9-year-old daughter, Annaliese, orphaned. Of her experience with HCA, she said: ”People used as dollar signs and pushed off elsewhere to die — that shouldn’t be OK.”
‘You are not God’
Tabel is the rare doctor at an HCA hospital voicing public concerns concerning the company’s palliative care practices. The 26 other doctors NBC News interviewed spoke on the condition of anonymity out of fear of retaliation by the corporate.
All said, nonetheless, that the push for palliative and hospice care at their HCA facilities is insistent and aimed toward improving performance measures. Physicians that don’t promote the programs are told to toe the road, Tabel and a few of the opposite doctors told NBC News.
One doctor recalled attending meetings at which hospital administrators discussed the importance of transfers to hospice care before a patient dies. ”The first area of dialogue was, ‘Why didn’t this patient get moved to hospice 12 hours before?'” the doctor recalled. “‘What was the delay in getting them on hospice?'”
Failing to make a well-timed transfer, the doctor said, was considered a “missed hospice opportunity” by the hospital.
HCA declined to comment on this allegation. The corporate “doesn’t have an enterprise-wide palliative care program,” the spokesman said. “These programs are developed locally under the purview of independent medical staff organizations.”
While the programs could also be developed locally, the performance of any hospital deploying them is closely monitored by HCA, an organization known for applying performance metrics to all of its facilities and placing them in competition with each other. Speaking at a health care conference last month, Michael A. Marks, senior vice chairman of finance at HCA, detailed the corporate’s “internal benchmarking tool that takes 166 measures of cost and operating efficiency” at each facility. “Every hospital will know exactly how they perform against the remainder of HCA,” Marks said. “It helps our hospitals really find where their variability is.”
Although HCA doesn’t have an enterprise-wide palliative care program, transfers to hospice care have risen across most of its hospitals lately, Medicare claims data shows. Researchers on the Service Employees International Union (SEIU), which has labor agreements with some HCA facilities, found that from 2017 to 2021, the typical hospice transfer rate amongst HCA hospital discharges grew by greater than half — from 3.4% to 5.2%.
The national average of hospice transfers also grew throughout the period, but HCA’s growth rate was roughly double the national average, the research shows.
The research covered 140 hospitals, SEIU said, excluding acute care facilities, kid’s hospitals and people with too few claims in a given yr. Greater than half of those hospitals ranked above the eightieth percentile nationally for hospice transfer rates in 2021, the evaluation shows.
At the identical time, in-hospital deaths on the HCA facilities grew much more slowly than the national average, the Medicare data shows. In-hospital deaths on the HCA hospitals rose 17% from 2017 to 2021, while the typical rose 45%.
Fishbough, the HCA spokesman, said the corporate strongly disagrees with the report, calling it inaccurate and misleading. He didn’t dispute the Medicare data findings in his criticisms.
Maritza Tamarit said she felt pressured to position her disabled husband, Pedro, in hospice care after he’d spent months at HCA Florida Mercy Hospital, a 488-bed acute care facility in Miami, in the summertime of 2021.
Pedro Tamarit, 60, entered the hospital in May, with circulation problems in his leg, his wife said. After surgery, his condition worsened.
In September, the push for palliative care began, Tamarit said. “One doctor told me, ‘I feel your husband could be higher placed in hospice,'” she recalled. “I said, ‘Why?’ and he said, ‘Your husband is not going to be alive for greater than six months.'”
She refused, she said, telling the doctor: “You are not God to say how long that person can live.”
After Tamarit rejected hospice care for her husband, she took him home, she said. Soon she moved Pedro to a unique hospital not owned by HCA. He lived for one more yr.
“I just wanted my husband to have one other likelihood,” Tamarit said. She said she is telling her story in order that other people can avoid this experience.
HCA’s spokesman said Mercy Hospital “provides multi-disciplinary patient care, including palliative services, to assist patients manage pain and symptoms. As such, care goals are set independently by the treating physicians and care teams within the patient’s best interest.”
‘Deceiving changes in mortality reporting’
Academics have begun to note that transfers of critically unwell patients to hospice care can allow hospitals to enhance their mortality rates. A study published within the Journal of Healthcare Management in 2020 concluded: “Although appropriate in allowing the positive impact of hospice care,” transfers “may induce deceiving changes in mortality reporting in several high-volume hospital diagnoses.”
Christa Schorr, professor of drugs at Cooper Medical School of Rowan University, in Camden, Latest Jersey, co-wrote the study. ”If you may have the potential of providing these services, are you being realistic about what your mortality rate is?” she asked in an interview. Calculating hospital executives’ incentive pay using a mortality rate that might be reduced by hospice transfers “doesn’t seem appropriate,” she added.
Tabel said the palliative and hospice care push at his HCA hospital began in 2019, a timeframe supported by documents provided to NBC News and interviews with doctors at other facilities. On Jan. 1 of that yr, Hazen became the chief executive of HCA after years in its management ranks. The HCA spokesman declined to say whether Hazen played a job within the heightened focus.
More moderen internal documents obtained by NBC News show that an HCA facility closely tracked deaths inside and out of doors of the palliative care and hospice programs and set goals for deaths in hospice to satisfy a certain level. When the hospital exceeded the goals — with more deaths occurring in hospice — the power’s mortality rate dropped.
“Healthcare professionals should present hospice as an choice to all patients and families when death inside a yr wouldn’t be surprising and may reintroduce the hospice option because the patient declines,” one other HCA hospital document states. It notes that this system was introduced to the hospital’s staff in 2019 and a weekly evaluation tracked its progress. Going forward, the document stated, the hospital planned to “offer goals for increased compliance with this standard.”
Along with being pushed to advertise hospice care at Riverside Community Hospital, Tabel says he’s pressured to scale back how long his patients remain in the power. HCA closely monitors a metric often known as length-of-stay, internal documents show, and Tabel said he’s pressed to discharge patients that he believes will not be able to go.
Limiting lengths of stay at any hospital reduces patients’ likelihood of infection and is a measure of health care efficiency used across the industry. Tabel agrees in concept but says the various elderly and infirm patients he treats require longer stays than the hospital prefers and infrequently have nowhere to go to receive the care they need. He says shorter stays can profit the hospital by removing a costly patient and freeing up a bed for higher reimbursements.
Tabel said hospital officials have told him they were under pressure from HCA higher-ups and he needed to bring his length-of-stay numbers down. Tabel said he told them he wouldn’t kick people out of the hospital to enhance its numbers.
In 2015 Tabel sued Riverside, alleging retaliation for refusing to satisfy the hospital’s length-of-stay metric. The hospital reduced patient referrals to him as punishment, he alleged. Riverside disputed his claim, but Tabel received an undisclosed settlement from the hospital within the case in 2019.
Now, Tabel says, the hospital is again pressuring him to scale back his patients’ stays, demanding that he comply with abide by recent rules in exchange for keeping his privileges at Riverside. He has refused and his status on the hospital is the topic of an internal hearing.
The HCA spokesman declined to comment, citing the dispute with Tabel, but said that “we hold our independent physicians to high standards on clinical outcomes set by the medical staff.”
Expanding hospice services
Under Medicare rules, when a hospital transfers a patient to hospice care in the identical facility, the patient enters what’s called General Inpatient Care, or GIP.
But determining whether a patient is appropriate for GIP requires ”careful assessment of pain and other symptoms” that can’t be managed in one other setting, the principles say. “GIP shouldn’t be an ‘automatic’ level of care when a patient is imminently dying,” the National Hospice and Palliative Care Organization says.
One doctor described a procedure at an HCA facility where staff targeted ICU patients for hospice transfers regardless that they were very near death. The physician said the moves didn’t profit the patients and seemed aimed toward reducing the hospital’s inpatient mortality rate. The doctor’s experience is supported by the previously cited HCA hospital document detailing the advantages of palliative care to the power. On the list: “Decrease in futile & high utilization of Emergency Department and ICU.”
HCA’s spokesman declined to comment on the doctor’s allegation. But Medicare data from the SEIU report buttresses the doctor’s concerns.
The researchers tracked what number of hospital patients died the identical day they were transferred to hospice, a measure of the form of imminent death cited by the National Hospice and Palliative Care group. On the HCA hospitals, same-day death rates in hospice greater than doubled from 2017 to 2021 — rising from 7% to 18%. HCA’s same-day death rates were nearly twice the national average in 2021, the research shows.
Meanwhile, HCA is expanding its hospice services; in 2021, it paid $400 million to acquire a majority stake in the house health and hospice provider Brookdale Healthcare Services. The acquisition added 80 locations and 4,000 staff.
“We consider this three way partnership will result in improved care coordination,” Hazen said in an announcement announcing the deal.