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Calif. Hospital Doctors Medicare Bills for a Healthy Bottom Line

piggy bank with stethoscopeA Los Angeles medical center is now under scrutiny after reporting some of California’s highest rates of acute heart failure. Over the course of three years, the Chino Valley Medical Center diagnosed more than one-third of their Medicare patients with acute heart failure.

Acute heart failure is a condition in which one of the heart’s ventricles malfunctions, potentially disrupting blood flow. Estimates have shown that as many as 5 million Americans are affected by acute heart failure, with half a million cases reported annually.

National averages suggest about 5-6% of Medicare patients have this cardiac condition as opposed to 35.2% at Chino Valley, which raised a red flag with California Watch, an investigative reporting group.

When a reporter for California Watch contacted Dr. Steven Shayani for a review of the data by an expert cardiologist, it was clear that something suspicious was taking place.

“Acute heart failure is very prevalent, as you know,” Dr. Shayani told California Watch. “However, there is no way of explaining” Chino Valley’s high rate, he said. “It doesn’t make any sense.”

In an effort to bring more clarity to this situation, California Watch undertook its own investigation of the medical center in question to find the true motivation for their diagnoses. Before 2006, no cases of acute heart failure were reported at the hospital. However, following a change in Medicare rules which authorized additional funds for treating this condition, the diagnosis became common practice.

Between 2008 and 2010, under the new Medicare policy, Chino Valley reported 1,971 Medicare patients with acute heart failure. For the medical center, owned by Prime Healthcare Services, these diagnoses meant a healthy bottom line.

New Medicare standards treated acute heart failure as a “major complication” which entitled treating physicians to additional reimbursements worth anywhere from $2,000 to $20,000 or more. But monetary gains might not have been the only incentive for the faulty diagnoses.

A padded acute heart failure rate can boost a hospital’s ratings, said Dr. Shayani.

“If you put heart failure as the diagnosis and the patient survives, that’s how you would statistically lower your mortality rate,” he said. “And so your ratings are better.”

Indeed, Chino Valley has enjoyed a HealthGrades excellence award for the past two years in addition to a five-star rating for heart failure treatment. These accolades are based primarily on the survival rate of patients treated for cardiac conditions.

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