Sudden Outbreak of Kwashiorkor (Severe Malnutrition) in Maryland, or Computer-Facilitated Upcoding?

At a Feb. 2011 post "Does EHR-Incited Upcoding Need Investigation by CMS, And Could it Explain HIT Irrational Exuberance?" I wrote about how EMR's can facilitate medically unjustified upcoding, a form of fraud.

Here's a peculiar upcoding story out of Baltimore. I am cited:

Malnutrition diagnoses at Kernan were fraud, feds say
Baltimore Sun
Jay Hancock
7:44 p.m. EST, November 7, 2011

It looked like a public health emergency. Hundreds of patients checking into Kernan Hospital were getting diagnosed with a severe form of malnutrition called kwashiorkor.

Taking its name from a Ghanian word, kwashiorkor (link) is typically seen in children and is marked by swollen feet, a swollen stomach and skin ulcers. It's common in Africa and developing nations elsewhere but is hardly heard of in the United States.

But by 2008, according to records obtained from state regulators, the West Baltimore orthopedic hospital was diagnosing one in every eight patients with the disease that helps define famines in Somalia or Bangladesh. A few years earlier no Kernan patients were diagnosed with kwashiorkor.

"That's very odd," said Dr. Scot Silverstein, an expert in electronic patient records and an adjunct professor at Drexel University in Philadelphia. "For an orthopedic hospital? In Maryland? That's a disease that's typically a disease of foreign countries."

I've never seen a case personally, despite having trained at places like Boston City Hospital in the 1970's, an extremely poor area at the time.

Perhaps the deteriorating economy was harming Marylanders a lot more than anybody suspected. Or perhaps the lucrative medical payment system was inducing Kernan employees and clinicians to report a disease that wasn't really there.

I tend to think the latter is more likely.

Last month the Justice Department accused Kernan of fraud, alleging in a civil complaint that it falsely labeled patients as kwashiorkor victims to inflate bills paid by government health programs and insurance companies.

Co-morbidities increase reimbursement.

"There are a variety of reasons why patients at Kernan may be classified with malnutrition," system spokeswoman Mary Lynn Carver said in the statement, including low weight and nutritional problems indicated by blood tests.

Another reason, government attorneys said, was to rip off Medicare, Medicaid and health insurers. Kernan's patients typically need new hips, ligament repairs and so forth. But labeling patients as simultaneously suffering from kwashiorkor or other malnutrition increased the amount Kernan was able to bill.

Malnutrition is one thing. Kwashiorkor is another entirely. It is a syndrome with multiple symptoms, signs and features.

Kwashiorkor is so rare I had trouble finding American experts to discuss it. The Centers for Disease Control and Prevention in Atlanta don't track it.

"One of our nutritionists is aware of a handful of cases in children whose parents are vegan and whose diets don't include animal protein," said CDC spokeswoman Kathryn Harben.

I wanted to interview Dr. Jaime Sepulveda, head of global health sciences at the University of California, San Francisco, and former head of Mexico's National Institutes of Health, about kwashiorkor.

"He said he didn't feel comfortable serving as an expert on it, since he's never seen a case in his life," a UCSF spokeswoman said.

But somehow Kernan experienced an apparent kwashiorkor outbreak starting in 2006, the only Maryland hospital to do so. Its cases of kwashiorkor as a secondary diagnosis grew a hundredfold, from three in 2005 to 358 in 2008, according to data from the state Health Services Cost Review Commission.

That was more than a third of all the diagnosed kwashiorkor cases statewide. At Kernan, 12.7 percent of all patients were diagnosed in 2008 with the rare ailment. At all Maryland hospitals, on the other hand, only 0.13 percent of that year's patients had kwashiorkor on their charts, according to the HSCRC data.

Stunning. Here's the catch:

Thanks to inappropriate diagnosis of kwashiorkor and other malnutrition, Kernan fraudulently collected $1.6 million from federal health programs, according to the complaint filed Oct. 17 by Rosenstein's office. The government seeks more than $8 million in damages and recompense.

Upcoding has been a problem before computers. As in the aforementioned post, computers can pose a "moral hazard" by making "suggestions" that can facilitate upcoding.

... the incidence of upcoding may be increasing.

"You might call it an institutionalized practice that is especially facilitated by electronic health records," which are used by more and more hospitals, said Drexel's Silverstein. The computer might prompt a clinician, he said: "If you just do this one little thing, you might generate a higher level of acuity" and more revenue.

When the upgrade is justified by patient symptoms, it's fine. But the government says Kernan crossed the line.

The Complaint, United States of America (on behalf of HHS and DoD) vs. Kernan Hospital can be found here (PDF).

It is quite a read, especially what appears to be, if true, an internal push for rendering the malnutrition and kwashiorkor diagnoses through 'creative' computing and internal pressures on clinicians. See, for example, pgs. 10-11.

I note that I could have easily advised the hospital not to use the diagnosis of kwashiorkor or do these things, had I been on staff there. I would have opined that it would stick out like a sore thumb via the algorithms payers use to detect fraud, e.g., via sudden, strange changes in claims. One wonders why nobody else gave that advice ... (fear?)

-- SS