Kwashiorkor in Surf City: 5 Tips from California Watch's Medicare billing investigation

Picture a honey sunrise glistening across the Pacific. A wave rises up, lifting a golden surfer, hair flapping in the wind like a flag as he negotiates a perfect turn and glides toward the beach. He steps onto the sand and his smile falls. Among the women in bikinis and men playing volleyball is a horrible scene of human suffering: a throng of senior citizens in wheel chairs, their bellies distended from malnutrition, flies landing on their eyelids, which are too sapped of any strength even to blink them away.

Sally Struthers suddenly appears to explain, "You may know this place as Surf City USA, but the senior citizens of Huntington Beach and other California cities are starving. They can't get enough to eat, and they struggle each day with the consequences of severe malnutrition disorders like kwashiorkor. Please help."

If the titans of the hospital chain Prime Healthcare Services are to be believed, we are on the verge of a humanitarian crisis here in the US. We all thought obesity was our greatest health challenge, but hospitals, Prime officials say, need to be more vigilant about malnutrition, including disorders heretofore seen only in the developing world. Reporters Lance Williams, Stephen K. Doig and Christina Jewett at California Watch uncovered that "the Prime chain treated 3.6 percent of Medicare patients in California, records show. But 12 percent of the state's malnutrition cases – and 36 percent of all kwashiorkor cases – were reported at Prime hospitals."

Kwashiorkor is a childhood malnutrition disorder that is most commonly seen in sub-Saharan African countries, such as Ghana, where the word originates. As Mercy Medical Center dietitian Rita Steffen told California Watch, "Kwashiorkor is more of a protein malnutrition that you find in other countries – you know the pictures you see of African children with big bellies."

The kwashiorkor story, published last month, is part of the incredible job California Watch has been doing covering suspicious billing at Prime. The story offers some great tips for health writers. Here are my favorite five:

Show what you don't know. The story says up high, "a diagnosis of kwashiorkor on a Medicare patient's bill can entitle a hospital to a bonus from the government worth thousands of dollars, according to federal records." The story later notes that California Watch was not able to find out which malnutrition cases triggered bonuses. It then lets a Prime official make the case that very few did: "Citing internal data, he said Prime obtained enhanced payment from Medicare in only 3.6 percent of its malnutrition cases. At other times, the company put the rate at 3.1 percent."

Look for distant cousins. The lead of the story makes this great side-by-side comparison. "Redding, near Mount Shasta, and Victorville, in the Mojave Desert, have little in common but an unusual statistic: In each city, a hospital has reported alarming rates of a Third World nutritional disorder among its Medicare patients." Health reporters know how the profiles of different areas differ. One of the chief responses hospitals usually have when reporters compare hospitals – even in the same city – is that all hospitals treat a different mix of patients. The fact that California Watch found high rates of malnutrition at so many different hospitals and that most of them were operated by Prime made the story newsworthy and made it easier for readers to understand.

Provide data in absolute and relative terms. The story says:

In 2009, Prime reported that 25 percent of its Medicare patients were malnourished, another medical complication that can entitle a hospital to a reimbursement bonus from the government. The state average for hospitalized seniors was 7.5 percent. Of the 10 California hospitals that reported the highest malnutrition rates among Medicare patients, eight – including the top four – are owned by Prime. ... Statewide, only 1.3 percent of Medicare patients were diagnosed with the types of severe malnutrition that pay the biggest treatment bonuses – nutritional wasting and severe protein calorie malnutrition, in addition to kwashiorkor. Prime's rate for these conditions was 10.1 percent.

Those are all great comparisons using the rates for different billings, but even more interesting were the hard numbers. "Last year, Prime reported treating more than 6,800 malnourished seniors, records show. More than 2,700 were diagnosed with severe forms of malnutrition, including kwashiorkor."

Prime says it is a leader in early diagnosis and treatment and that "there are patients going undiagnosed and untreated" and other hospitals. Let's extrapolate. If we take Prime's response at face value, then this means that other hospitals should be diagnosing seniors with severe malnutrition at similar rates. If 2,700 patients a year receive this diagnosis from just 3.6 percent of the Medicare population in California, we could be facing a true epidemic nationwide affecting hundreds of thousands of seniors. Or not.

Trust but verify. The billing problems at Prime were first highlighted by the Service Employee International Union, which has fought with Prime over worker pay and other issues. Unions bring stories to reporters all the time, and reporters often avoid these stories for fear of getting caught in the middle of a he said-she-said labor dispute with no way of sorting out the facts. California Watch decided that the allegations seemed interesting enough to prompt it to crunch its own numbers: "The union has provided authorities with a private statistical study of Medicare records that showed high malnutrition and kwashiorkor rates at Prime hospitals, a union spokesman said. California Watch obtained health data from the Office of Statewide Health Planning and Development and relied on its own statistical analysis for this report." Then California Watch went the extra step of providing a how-to guide on its site so other reporters could look for similar patterns in their local hospitals.

Go early. California Watch consistently amazes me with the level of transparency in its reporting. The reporters had to know they were on to something amazing when they saw these kwashiorkor cases pop up. But they didn't carefully construct a damning story and then call on a Friday for comment before publishing that Sunday. They went to Prime in December with their findings.

In December, California Watch provided Prime officials with a description of our methodology and a copy of the entire state data set in computer form, inviting a critique of our findings.

How did Prime respond? Well, not very persuasively:

In e-mails, Prime officials insisted that their malnutrition diagnoses were accurate and that the chain was not assigning the diagnosis to obtain enhanced payments from Medicare. Prime officials also accused the union of manipulating data to wrongly implicate the company in Medicare fraud. That's part of a "campaign of misinformation and extortion" to leverage labor contracts, the company has charged. The officials otherwise didn't comment on California Watch's methodology, study or findings.

Let's hope that either those poor seniors are given a proper feeding soon or that more reporters follow California Watch's lead. Anyone have a previously undetected Dracunculusmedinensis epidemic out there?