HCA Hospitals Accused of Pushing Patients Toward Hospice To Improve Mortality Metrics

Hospice and palliative care are growing aspects of the healthcare system, which is typically a good thing: It means that more people have come to recognize the importance of access to quality end-of-life care. Unfortunately, reports have come to light showing that one of the nation’s largest hospital chains, HCA Healthcare, is allegedly abusing the system to improve its mortality metrics.

NBC News interviewed six nurses and 27 doctors who currently practice at 16 HCA hospitals in seven states (or did so previously). All said that their HCA hospitals pushed palliative and end-of-life care in pursuit of better performance metrics. Upon further investigation, internal HCA hospital documents and texts between hospital staffers supported these claims. The conclusions drawn by the investigative report indicate that administrators pushed medical professionals to transfer critically ill patients to hospice care in order to improve their mortality metrics – a quality indication measure used by hospitals to show how many people die while receiving inpatient care.

The Importance of Mortality Metrics

Gretchen Morgenson, the Pulitzer Prize-winning journalist who wrote the investigative report for NBC News, explains that there are two key reasons why HCA would incentivize pushing patients to hospice care. For one:

“Although few patients realize it, transfers to hospice care reduce a hospital’s inpatient mortality rate. Here’s why: If a patient passes away in a hospital, that death adds to the facility’s inpatient mortality figures. But if that person dies after a transfer to hospice care — even if the patient stays at the same hospital in the same bed — the death doesn’t count toward the facility’s inpatient mortality rate because the patient was technically discharged from the hospital.”

Mortality rates are often used to rate the quality of care at hospitals, as can be seen with the popular IBM Watson Health Top Hospitals rankings. In particular to HCA, mortality rate is also one of the 10 “quality of care” metrics used since 2021 to calculate the incentive pay received by top company executives. (In other words, better mortality results at HCA contributed to higher incentive pay rates for high-ranking executives.) This is objectionable on its face, but even more so when you consider the fact that the three major publicly traded hospital companies in direct competition with HCA do not cite the use of mortality rates in their pay calculations.

The second way HCA benefits by pushing patients into palliative and then hospice care is that it allows the hospital to increase their turnover rate. A reduction in lengthy patient stays frees up beds for new patients, which generates more revenue from insurance compensations.

The Crucial Difference Between Hospice Care and Palliative Care is Not Often Made Clear to Patients and Their Families

Although the terms are often used interchangeably by those outside the healthcare industry, hospice care and palliative care mean different things. Patients in palliative care can receive treatments for symptoms along with those intended to cure their illnesses, while hospice care focuses on comfort and quality of life for a patient approaching death. In other words: palliative care includes options for helping the patient get better, and hospice care does not. 

This can be confusing for patients and their loved ones, because the two care models often work in tandem. In HCA hospitals, palliative care acts as a gateway to hospice care; for some patients, the palliative care coordinator would recommend hospice options for family members to sign off on. If a patient agrees to enter hospice care, they are discharged from inpatient status and “rolled over” into what’s known as “General Inpatient Hospice,” or GIP. 

One doctor, Dr. Ghasan Tabel, has publicly spoken against the way HCA goes about this practice:

“Sometimes it is reasonable to talk about comfort care, but usually it is done prematurely,” said Tabel, who was involved in a lawsuit against Riverside [an HCA facility] that the hospital settled. “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.”

Dr. Ghasan Tabel, a doctor who practices at Riverside Community Hospital, an HCA facility
Credit: NBC News

HCA’s Hospice Transfer Growth is Suspiciously High, and In-Hospital Mortality Rates Suspiciously Low

All of the doctors and nurses interviewed by Morgenson said that the push for palliative and hospice care at HCA facilities is insistent and aimed at improving performance measures – not, apparently, with concern for the quality of care received by their patients. One doctor (who asked to remain anonymous in fear of retaliation from HCA) recalled attending meetings at which hospital administrators admonished doctors for not moving patients to hospice sooner, thereby harming their performance metrics.

According to researchers at the Service Employees International Union, which has labor agreements with some HCA facilities, the average hospice transfer rate among HCA hospital discharges grew by more than half from 2017 to 2021. Even more impressively, HCA’s growth rate was roughly double that of the national average, while in-hospital deaths at HCA facilities grew far more slowly than the national average. (HCA’s in-hospital death average was 17% compared to the national average of 45%.)

Why More People Should Care

HCA’s alleged practices are highly concerning, as they set a dangerous precedent regarding the future of our country’s hospice system. 

Hospice care is a relatively new practice. Dame Cicely Saunders, a nurse, physician, and writer, founded the hospice movement in Britain in the mid-1960’s. The U.S. opened its first hospice center in Branford, Connecticut in 1974. Over a decade later, Medicare enacted a Hospice Benefit, and the practice has expanded exponentially ever since.

With the growing realization that hospice care is an essential part of providing quality end-of-life, there is too much room for abuse like that of the HCA. Hospice was designed to manage pain and symptoms while providing emotional support for the whole family. If it becomes relegated to a cost-saving algorithm that prematurely shunts critically ill people towards their deaths without concern for actual well-being, our nation will be much the worse for it.