Senate Finance Committee begins investigation of patient deaths at long-term care facilities

From The NY Times:

The Senate Finance Committee has opened an investigation into patient deaths and allegations of substandard treatment at long-term care hospitals, small specialty medical centers that treat chronically ill patients.

The investigation focuses on the Select Medical Corporation (pictured), a for-profit corporation that runs 89 long-term care hospitals, more than any other company. In a letter sent on March 8 to Select’s chief executive, Robert Ortenzio, the committee’s top two senators demanded that Select provide records about staffing levels and quality at its hospitals.

The committee has substantial power over long-term care hospitals because it oversees Medicare. The federal program spends almost $5 billion annually on the hospitals, providing about 60 percent of their total revenue.

An article in The New York Times last month detailed poor treatment and patient deaths at long-term care hospitals, which treat 200,000 seriously ill patients a year nationwide, but rarely have full-time physicians on staff. In one incident at a Select hospital in Kansas, a dying patient’s heart alarm sounded for 77 minutes before nurses responded. Select has said that it conducted an appropriate clinical review in the case and terminated a clinician involved in the patient’s care.

The article prompted the investigation, according to the letter, which was sent by Senator Max Baucus, Democrat of Montana, the committee’s chairman, and Senator Charles E. Grassley of Iowa, the panel’s senior Republican. The letter is not a subpoena, but companies usually respond voluntarily to such requests for information.

Select Medical said that it would cooperate fully with the inquiry. Through a spokeswoman, Carolyn Curnane, the company referred to the Times article as misleading and inaccurate and said it looked forward to providing the committee with accurate facts about the quality of care in its long-term care hospitals.

Mr. Baucus and Mr. Grassley asked Select to disclose its policies for patient monitoring, emergency situations and staffing, including physician involvement at its hospitals and staff turnover. Former employees of Select have said that the company’s hospitals are understaffed and rely heavily on temporary nurses.

The letter also requests that Select disclose information about its discharge policies. Former employees have also said that the company presses to keep patients for 25 days and then discharge them almost immediately, because patients are most profitable if they stay exactly 25 days under government reimbursement rules. At some Select hospitals, the 25th day is called the “magic day,” ex-employees say.

The company says it has a demonstrated record of providing quality care and that patients are seen daily by doctors, while facilities without doctors have doctors on call for emergencies. It added that it did not discharge or hold patients for financial reasons. In a separate letter, the senators asked that the Government Accountability Office, Congress’s investigative agency, examine federal and state oversight of all long-term care hospitals, saying that they worried the facilities might expose patients “to an unreasonable risk of harm.”

Only a few long-term care hospitals existed in the early 1980s. But more than 400 have opened nationally in the last 25 years. Experts on the treatment of critically ill patients say that growth has been driven mostly by Medicare rules that offer high payments to hospitals that treat patients for an average of 25 days or more.

Unlike other specialized hospitals, including psychiatric or children’s hospitals, long-term care hospitals do not treat specific types of patients or offer services unavailable in regular medical centers. They are defined solely by the fact that they keep patients longer than other hospitals. They are also smaller than a typical hospital, averaging about 60 beds, and do not have emergency rooms.

If their patients need surgery or suffer medical emergencies, they are usually transferred back to general hospitals.

Supporters of the hospitals say that even without staff physicians, they provide quality care and play an important role by treating patients who are too sick for nursing homes but are not improving at traditional hospitals.

The questions about long-term care hospitals center on the for-profit side of the industry, led by Select and Kindred Healthcare, another publicly traded company.

Run by Robert Ortenzio and his father, Rocco, who collectively have made $400 million since founding the company in 1996, Select tells investors that it increases its profits by monitoring staffing levels. At a presentation last week, the company said it had raised profit margins at its hospitals to 19 percent in 2009, from 16 percent in 2008, increasing cash flow by $54 million.

But former employees, state inspection reports and lawsuits paint a disquieting picture of the care that Select provides.

In 2007 and 2008, Select’s hospitals were cited at a rate four times that of regular hospitals for serious violations of Medicare rules, according to an analysis by The Times. Other long-term care hospitals were cited at a rate about twice that of regular hospitals.

Medicare has few levers against long-term care hospitals — or any hospitals. Medicare and Medicaid account for almost half of all hospital spending nationally, but Medicare cannot fine hospitals if it finds low-quality care, or force them to make staff changes. Its only remedy is to bar hospitals from the program entirely, a penalty so draconian the government rarely uses it.

Select has criticized the original article, calling its analysis faulty and noting that it treats many severely ill patients.

Since the article ran, physicians, patients and their families have contacted The Times about other disturbing incidents at Select hospitals.

According to a doctor’s deposition in a lawsuit, nurses at a Select hospital in Tulsa, Okla., injected a relatively healthy 79-year-old woman with 10 times the amount of insulin she was supposed to receive back in January 2009. They then failed to notify her doctor for at least 90 minutes after they discovered that she had fallen into a coma. The woman, Ruth Tanner, died a month later without fully regaining consciousness, according to medical records and the lawsuit.

Select Medical generally does not comment on pending lawsuits, so out of respect for the legal process and the parties involved, it will not do so in the Tanner case, the company spokeswoman, Ms. Curnane, said.

Dan Graves, an attorney for Ms. Tanner’s family, said that family members agonized after the overdose. “Now their grief and loss has been multiplied by the knowledge that other families have suffered similar tragedies because of Select’s practices.”