Update: Right here.
Parkland is far from perfect. No question that organization needs to make some changes in how it does business. But is Parkland as horribly mismanaged and dangerous to its patients as the Dallas Morning News would lead you to believe? More specifically, is the ongoing Centers for Medicare and Medicaid Services (CMS) review of the hospital as monumental and unprecedented as the paper has made it out to be? I don’t think so.
Surely by now you’ve heard about the survey of the facilities conducted by the Texas Department of State Health Services, which led CMS (no idea why it’s not called CMMS) to issue a report saying the hospital was putting the health of its patients in “immediate jeopardy.” Fix the problems, said CMS, or we’ll withdraw your funding. Effectively, the hospital would be shuttered.
“It appears safety was routinely relegated to a lower priority by other pressures,” said Vanderbilt University professor Ranga Ramanujam, a national expert in health care safety. “The CMS action is extraordinary. I am hard-pressed to think of an example of a similarly high-profile hospital facing the very real possibility of losing their CMS funding as a result of safety violations.”
Ramanujam was the sole expert quoted in the story as to the singularity of the CMS report. You read his quote, and you think, “Parkland is the most awful hospital in America. It’s extraordinarily awful. I mean, a national expert can’t even think of another hospital that’s as awful as Parkland. That’s pretty awful.”
But hang on just a second. How rare are these “immediate jeopardy” CMS reports that a national expert can’t think of a single example that resembles what’s happening at Parkland? I called and emailed the regional headquarters of CMS and called the national HQ to ask them how many “immediate jeopardy” reports they issue. I got no response (that I’m aware of). Doesn’t much matter. According to this HealthLeaders report, CMS doesn’t have the information I’m after:
“These are serious citations, but incomprehensibly, neither the Centers for Medicare & Medicaid Services which issues them, nor the states whose survey teams investigate these incidents, will say which hospitals have received them, for what kinds of harm, nor will they say how many occur in a given year or in a given region.Â A spokesman for CMS says the agency doesn’t know because it just doesn’t track them.”
CMS literally can’t say — not by citing numbers, anyway — whether the “immediate jeopardy” report that Parkland got is extraordinary or not. Does CMS hand out 120 of these things a year? 1,120? They don’t know. But I get the impression that the number is higher than, say, 1.
In fact, an executive (who asked not to be named) at a large national hospital organization asked his company’s top CMS compliance officer, at my behest, how rare the CMS reports are that Parkland got. The CMS compliance guy said that every year 5 to 10 percent of all the hospitals in the country receive “immediate jeopardy” reports from CMS. In other words, on the high side, CMS finds that 1 in every 10 hospitals puts its patients in “immediate jeopardy,” just like Parkland. (I’ll leave it for another time to discuss how screwy the CMS hospital inspection process sounds, owing to the fact that various state agencies conduct the inspections, not CMS itself. Read that HealthLeaders report, if you want to learn more.)
In light of all this, I sent an email to Ramanujam, the Vanderbilt expert, asking him why he thought the Parkland “immediate jeopardy” CMS report was “extraordinary.” Ramanujam said he’d be happy to talk to me the following day about the matter. But as a prelude to that conversation, he wrote, “You are right that I said ‘extraordinary’ rather than ‘rare,’ the term that the former CMS official interviewed used.”
Ramanujam was being a little defensive, I believe, with that remark. We agreed to talk at 11 a.m. the following day. At 8:30 he sent an email saying, “Something just came up and I will not be able to talk with you.” He didn’t offer to reschedule. Did he change his mind about talking to me after he googled my name and saw what I’ve written previously on this blog about Parkland and the Morning News? Did he change his mind after calling the reporter he’s been working with at the Morning News? I’m sure it was neither. Ramanujam is a busy guy. Something came up. It happens.
I said Ramanujam was the sole expert quoted in the story as to the singularity of the CMS report. But alongside the story there ran a sidebar (sub. req.) headlined “National Health Experts Say Critical Report on Parkland Is Rare and Significant.” In a Q&A format, a fellow named Mark McClellan, the director of the Engelberg Center for Health Care Reform at the Brookings Institution, was quoted. McClellan is the former CMS official that Ramanujam was referring to. Ramanujam essentially said, “Okay, yeah, I used the word ‘extraordinary.’ But McClellan used to work at CMS. He said the Parkland report is ‘rare.’ Bam. Print that.”
I want you to look very closely at how Mark McClellan’s quote was presented by the Morning News. Here’s how they did it:
Q: How often do government regulators issue a highly critical evaluation and raise the threat of cutting off funding to a medical facility like Parkland?
A: Cutting a hospital’s Medicare and Medicaid funding is rare, according to CMS. Only two Texas hospitals have lost certification since 2005 — one in Houston and the other in San Benito. Both had fewer than 100 beds. Parkland has 735 beds. McClellan said: “These corrective action plans linked to immediate jeopardy, meaning ‘fix it now or funding will be cut off,’ are rare — maybe a couple a year.”
Do you see what happened there? The question is “How often does CMS issue an ‘immediate jeopardy’ report?” The answer is “CMS cuts off funding rarely.” But that wasn’t the question. Remember, perhaps as many as 1 in 10 American hospitals every year receives an “immediate jeopardy” report. But a report is not the same thing as cutting funding. After a hospital receives an “immediate jeopardy” report, it tells CMS how it plans to fix the problems. It executes that plan. CMS sends the investigators back in to see if the problems are fixed. If the problems aren’t fixed, then CMS can withdraw funding. THAT is rare.
Given that confusion, I didn’t know how to read McClellan’s quote. I wondered if it had been taken out of context. So I called his office. His assistant said that I could talk to him, but she asked me to email my question in advance so that McClellan could be prepared. I laid out my confusion about the Q&A in the Morning News and said I wanted some guidance in how to read McClellan’s quote. I never got to talk to McClellan, but his assistant sent me the following direct quote from him. I have highlighted in red the parts that I want you to read carefully.
“Corrective action plans are not rare and all essentially threaten sanctions if corrections don’t result in compliance. Cutting off funding or enrollment or program exclusion are the ultimate sanctions that are usually listed among the possibilities. Again, CAPs aren’t rare, but reaching the ultimate sanction is rare because most institutions or program participants will try to comply (immediate jeopardy usually indications that patients are at risk, which CMS takes very seriously).”
Unless I’m missing something, here’s the way I see this: the CMS report that Parkland got was not extraordinary. It wasn’t even rare.
Forget the experts. As we learned today (sub. req.) from the Morning News, about 5 miles down the road from Parkland, Methodist Dallas got its very own “immediate jeopardy” CMS report on Friday. Rare indeed.