During a campaign rally in Wisconsin, President Donald Trump questioned the reported numbers of COVID-19 cases and deaths in the U.S. by describing a purported “incentive” to report cases and deaths, because “doctors get more money and hospitals get more money.”
Trump’s comments tapped into a months-old, baseless conspiracy theory for which there is no evidence: that COVID-19 deaths have been inflated by hospitals seeking to profit. Multiple experts previously told us that such claims were unfounded.
Trump’s remarks came during an Oct. 24 rally in Waukesha, Wisconsin.
Trump, Oct. 24: If somebody’s terminally ill with cancer, and they have COVID, we report them. And you know, doctors get more money and hospitals get more money. Think of this incentive. So some countries do it differently. If somebody is very sick with a bad heart, they die of COVID, they don’t get reported as COVID. So then you wonder, gee, I wonder why their cases are so low.
This country and their reporting systems are really not doing it right. If somebody has a really bad heart, and they’re close to death, even if they’re not, but they have a very bad heart and they get COVID, they put it down to COVID. Other countries put it down to a heart. So we have to be — we’re gonna to start looking at things because you know, they have things back — they have things a little bit backwards.
The supposed “incentive” referenced by Trump is likely a reference to the financial assistance for hospitals treating COVID-19 patients that was created by bipartisan legislation — and that Trump himself signed into law in March.
As we’ve explained, the Coronavirus Aid, Relief, and Economic Security Act, or CARES Act, created a 20% add-on to be paid to hospitals treating Medicare patients with COVID-19; Medicare is the federal health insurance program for those 65 years and older. The law also set aside some money to reimburse hospitals for treating uninsured patients.
That fact alone is not evidence of misreporting or fraud, though — especially at levels large enough to significantly affect the country’s current death toll of 227,000.
Medical associations rejected the president’s suggestion that deaths were being improperly counted for financial reasons.
The American College of Emergency Physicians said in a statement it was “appalled by President Trump’s reckless and false assertions that physicians are overcounting deaths related to COVID-19.”
The American Medical Association challenged the claims by pointing to this year’s excess mortality in the U.S. — meaning the actual number of deaths from all causes, minus a “normal” or expected number of deaths during a given time period. That metric is an alternative way of estimating the impact of the coronavirus that avoids issues of miscounting or underreporting COVID-19 deaths. It also captures the indirect effects of the pandemic, such as those who died from other causes because they avoided or were unable to access medical care.
From late January through Oct. 3, there were an estimated 299,028 excess deaths, according to the Centers for Disease Control and Prevention; about two-thirds were directly attributed to COVID-19. (The deaths in that report were based on death certificates from the National Vital Statistics System, which lags behind other measures because of the time it takes to complete and process certificates, the CDC told us.)
The U.S. does not have an especially good record on excess mortality compared to other countries, as we’ve reported.
According to a paper published in the Journal of the American Medical Association on Oct. 12 that compared the U.S. to 14 other countries, America had a higher rate of per capita excess mortality than all but two nations since the start of the pandemic through late July. And University of Oxford economists Janine Aron and John Muellbauer concluded in a report published last month that the U.S.’s excess mortality rate is “substantially worse” than Europe’s.
To be clear, there could be some cases that are misreported. But experts also have said the official death toll may be underestimated, in part because excess mortality figures are higher.
We asked the Centers for Medicare & Medicaid Services whether it could point to any specific cases of fraudulent reporting or billing for COVID-19 cases and it didn’t answer our question.
Instead, the agency noted the requirement of a positive COVID-19 test for the enhanced Medicare reimbursement — a requirement implemented in September — and said that if, upon review, the medical record lacks a positive test, that increased payment will be considered an overpayment and recouped by CMS.
Writing for Medscape, Ashish K. Jha, dean of Brown University’s School of Public Health, said the enhanced payments came about because “policymakers knew that hospitals would need the extra money in order to provide their staff with appropriate personal protective equipment (PPE). The federal government was not going to be able to provide all of the needed PPE. The funds were a way to help make hospitals whole. But it hasn’t. Most hospitals are bleeding money as a result of COVID.”
Jha said there have also been arguments about hospitals improperly reporting “car accident victims who tested positive for COVID” — which he called “nonsense.”
“There is no higher reimbursement that I can find for car accident victims who are COVID positive. And if you bill these patients as COVID pneumonia, that is fraud,” he said.
Karyn Schwartz, a senior fellow at the Kaiser Family Foundation, told us in a phone interview that hospitals have other incentives for testing and identifying COVID-19 cases — regardless of whether someone is covered by Medicare — including making clinical decisions and taking precautions to prevent spread.
Schwartz also pointed out that the enhanced payments only apply to cases of Medicare beneficiaries hospitalized with COVID-19 — which represent a small fraction of the total U.S. cases.
According to CMS, there were 284,316 total COVID-19 hospitalizations of Medicare beneficiaries through Aug. 15. That is only 5% of the 5.3 million confirmed or probable cases in the U.S. reported as of that point in time.
And, Schwartz said, those Medicare payments are based on the diagnosis and diagnosis-related groups — not on outcomes or a death certificate.
That said, it’s worth understanding how COVID-19 deaths are classified.
Death certificates, as we’ve written, can list multiple causes or conditions that contributed to a person’s death. So the disease often shows up alongside other comorbidities. Those ailments could be caused by COVID-19, such as acute respiratory distress syndrome, or they can be long-term conditions, such as diabetes. It is well-known that seniors and people with underlying medical conditions are at increased risk of severe illness from COVID-19.
But in 92% of death certificates in the U.S. citing COVID-19, the disease is listed as the underlying cause of death — meaning the condition that started the chain of events that led to a person’s death — according to the CDC.
The CDC says that its “mortality statistics are compiled in accordance with World Health Organization (WHO) regulations specifying that WHO member nations classify and code causes of death with the current revision of the International Statistical Classification of Diseases and Related Health Problems (ICD). ICD provides the basic guidance used in virtually all countries to code and classify causes of death” — including “the rules used to select the single underlying cause of death for tabulation from the several diagnoses that may be reported on a single death certificate.”
Bob Anderson, chief of mortality statistics at the CDC’s National Center for Health Statistics, told our colleagues at PolitiFact: “If a terminal patient still had, say 6 months to live, but was infected by the virus and died, the certifier might determine that COVID-19 was the underlying cause of death because of the timing.”
“In the same way, if that same terminal cancer patient was in a car accident and died from that trauma, the car accident would be the underlying cause,” Anderson said. “If, on the other hand, death from terminal cancer was imminent or COVID-19 symptoms were mild, COVID-19 might be viewed only as a contributing factor — not the underlying cause — or, if the patient was asymptomatic, it might not be viewed as a factor at all — and therefore, not reported on the death certificate.”
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