Counterpoint

Three weeks ago, the American Hospital Association (the AHA) announced the following: 

“A new report from the American Hospital Association using data analyzed by Vizient finds that hospital performance on key patient safety and quality measures is better in the first quarter of 2024 than it was before the COVID-19 pandemic, and that hospitals made these improvements while caring for patients with more significant health care needs.”¹ 

The AHA “partnered with Vizient” to analyze data from “a cohort of 715 general, acute care hospitals” that “routinely report clinical information to Vizient.” The analysis, “which uses Vizient’s risk-adjustment methodology, shows that since 2022, hospital mortality rates have been better than expected and that the difference between expected and observed continues to grow.”² 

I don’t know which hospitals report to Vizient, nor do I know what they report, so I cannot judge their analysis of “expected” mortality. I also don’t know whether a study extrapolating the clinical performance of a subset of Vizient’s Clinical Data Base customers to the hospital industry at large is free from selection bias. 

In contrast, I do know something about “actual” mortality as measured by the Centers for Medicare & Medicaid Services (CMS) because that data is public. 

CMS requires hospitals to report “condition-specific mortality measures” that are “used to calculate hospital-level 30-day risk-standardized mortality rates (RSMRs) following acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), heart failure (HF), pneumonia, and stroke admissions.”³ “In June 2007, CMS began publicly reporting 30-day RSMRs for AMI and HF for the nation’s non-federal short-term acute care hospitals… and critical access hospitals (CAHs), and added the pneumonia mortality measure in August 2008… In 2014, CMS began publicly reporting two additional hospital 30-day mortality measures: COPD and ischemic stroke.”⁴ “In 2015, CMS began publicly reporting 30-day RSMRs for CABG surgery for the nation’s nonfederal short-term acute care hospitals” and CAHs.⁵ 

Yesterday, we released the fourth installment of our annual report, Trends Shaping the Health Economy, which includes this analysis of post-discharge mortality. 

Whether “expected” mortality is better than expected pales in comparison to the fact that, since the pandemic, average “actual” mortality has increased for every medical condition except for AMI. Shockingly, at least to me, is that average post-discharge mortality rates for pneumonia and COPD are up by 18% and 10%, respectively. 

I would make a substantial wager that most of you immediately concluded this: “Well, of course, mortality increased because of the pandemic and hasn’t returned to normal.” As Waylon Jennings sings, “Wrong.”

CMS measures RSMRs based upon “index admissions” and significantly modified that definition because of the pandemic. To wit: 

“Changes Due to COVID-19  

The following modifications were made to the AMI, COPD, HF, and stroke measures publicly reported on Care Compare, in response to the COVID-19 PHE [NOTE: Pneumonia mortality measure specifications for 2022 have been delayed by CMS.]: 

• Claims data for January 1, 2020 – June 30, 2020 continue to be excluded from use in the measures under CMS’s Extraordinary Circumstances Exception (ECE) policy, similar to 2021 public reporting.
  ...
• A new ‘History of COVID-19’ risk variable has been added to the risk-adjustment models.
• COVID-19 index admissions are excluded from the cohorts. COVID-19 index admissions are defined by a principal diagnosis code of COVID-19 or a secondary diagnosis code of COVID-19 coded as POA on the index admission claim. [Of note, patients with a COVID-19 principal diagnosis code are inherently not included in the measures, by definition.]”⁶

I know what “expected” mortality is, though I doubt most Americans do. On the other hand, I expect that most Americans would understand the words of the famed British epidemiologist William Farr: “Death is a fact; all else is inference.” 

Not only has non-Covid post-discharge mortality significantly increased since the pandemic, so has excess mortality in Americans between the ages of 18-64: 

The question that every American should demand health economy stakeholders to answer is this: why is actual post-discharge mortality significantly higher in the aftermath of the pandemic? Understanding whether this data signal is a short-term anomaly is perhaps the most important health question of all.