HCA Healthcare accused of pushing patients toward end-of-life care to boost performance metrics

A pair of new reports released this week allege that HCA Healthcare policies are encouraging staff to transition more patients to palliative and end-of-life care, thereby increasing churn and boosting hospital quality scores.

The first report from NBC News cites dozens of anonymous doctors and nurses who work or worked at 16 HCA hospitals, patient stories and internal documents reviewed by the publication. Some of these sources outlined an algorithm used at certain HCA hospitals that quantifies the risk of mortality and identifies patients who score high and become candidates for transfer to palliative care.

The second (PDF), from the Service Employees International Union (SEIU), highlights transfer rate changes as recorded in Medicare claims data, citations for unsafe patient discharges and a physician’s allegations from an unsealed 2018 whistleblower lawsuit that was later dismissed voluntarily. Of note, SEIU often negotiates with HCA on behalf of its healthcare worker members and has previously released reports critical of the for-profit system’s practices.

Both reports outline how hospital mortality rates are directly linked to the incentive payment calculations of top executives and hospital administrators. Though such mortality-based incentives are not disclosed by other major for-profit health systems, NBC wrote, there is “no direct evidence” that programs in place to transfer patients to palliative and hospice care were designed with executive pay increases in mind.

Representatives for HCA have broadly denied claims that the organization is pressuring clinicians to recommend palliative and hospice care to NBC and to Fierce Healthcare.

HCA, which runs 182 hospitals and reported over $5.6 billion in net profit across 2022, would benefit financially from transferring more severely ill patients to end-of-life care.

Deaths that occur after transfer do not count among the inpatient mortality rates measured by care quality organizations and the Centers for Medicare & Medicaid Services (CMS), which uses such measures to determine reimbursement rates. Additionally, prompt transfers reduce length of stay metrics while opening up more hospital beds for additional inpatients and, subsequently, revenue.

Twenty-six doctors and six nurses interviewed by NBC spoke about the palliative and end-of-life processes at their HCA facilities under the condition of anonymity. Only one additional doctor, Ghasan Tabel, M.D., an internal medicine physician at HCA’s Riverside Community Hospital who was previously involved in a settled lawsuit against the hospital, went on the record to tell NBC what he saw.

“Sometimes it is reasonable to talk about comfort care, but usually it is done prematurely,” he told the news outlet. “What is very alarming to me is if they mislead the patient’s family about the prognosis, paint the worst-case scenario, sometimes graphically, to convince the family to go to palliative care and withdrawal of care.”

An analysis of Medicare fee-for-service claims among 140 HCA hospitals at the heart of SEIU’s report, meanwhile, found a consistent increase in HCA hospital transfer to hospice rates from 3.4% in 2017 to 5.2% in 2021, the latter of which was almost 40% above the national average for that year.

In-hospital mortality rates at the HCA hospitals were lower for each analyzed year than the national average, the union wrote, while HCA’s percent of hospital transfers to hospice care where a patient died on the day of their transfer was more than twice the national average during 2021, the group found.

“In short, our findings from this data analysis lead us to worry that the potentially perverse financial incentives to transfer hospital inpatients to hospice may be affecting the related care decisions at HCA hospitals,” the union wrote. “These data trends are especially concerning since HCA has been rapidly expanding in the hospice/home health space in recent years.”

SEIU’s report also included instances of CMS citations for improper patient discharges from HCA hospitals as well as critiques of HCA’s incentive pay structure, corporate strategy, and executive incentive plans. It concludes with calls for federal and state regulators “to begin their own inquiries into the system’s hospice transfer behavior as soon as possible.”

Speaking to NBC, HCA Healthcare Assistant Vice President of Communications Ed Fishbough said that “suggesting that medical care in HCA Healthcare hospitals is based on anything other than a physician’s independent medical judgment of what is in the patient’s best interest is untrue and wrong,” a representative told NBC.

Another representative of HCA, Director of Media Relations Harlow Sumerford, reiterated this position to Fierce Healthcare in an emailed statement and added that the “suggestion” that the organization influenced physician judgment “is irresponsible.”

Fishbough told NBC and Sumerford also told Fierce Healthcare that a patient whose experience was highlighted in the NBC article was unwilling to sign all of the privacy consent documents HCA requested before reviewing and commenting on their medical record. Sumerford added that “it would be misleading and dishonest to ignore the medical record when reporting on care provided to any patient.”

Sumerford described SEIU’s report, which was also included in NBC’s article, as a “propaganda document,” “not a serious report” and part of “SEIU’s smear campaign against our organization.” He criticized SEIU’s use of the voluntarily dismissed whistleblower report and said that decisions to align executive incentives with length of stay and mortality rates measured by CMS and others “is not only the right thing to do but also supports our focus on continuous quality improvement.”

In a statement, SEIU said that the referenced lawsuit was dismissed without prejudice but that the allegations involved were troubling regardless of the case's status. The union also stressed that the whistleblower case was just one of several sources that contributed to its report.