58

Source (one of many).

At a rally in Michigan on Friday (Oct 30th, 2020), President Trump repeated an extraordinary and unfounded claim that American doctors were profiteering from coronavirus deaths.

“You know our doctors get more money if somebody dies from Covid."

Can anyone explain what Mr. Trump is claiming here, and whether it is factual?

  • 12
    No pseudo answers in the comments, please. – Oddthinking Oct 31 at 23:27
101

Can anyone explain what trump is claiming here ...

What Trump was claiming is something that has been claimed multiple times since the onset of the novel coronavirus pandemic: That doctors and hospitals are inflating the number of coronavirus hospital admissions and deaths because Medicare pays more if coronavirus is listed as one of the causes of the hospitalization or death.

... and whether it is factual?

This is true. Medicare does indeed pay hospitals more if coronavirus is listed as a cause for hospitalization or as a cause of death. The Centers for Medicare & Medicaid Services authorized a Medicare add-on payment of 20% for both rural and urban inpatient hospital COVID-19 patients.

The rationale for this 20% add-on payment is simple. COVID-19 can be significantly more difficult to treat than are other diseases, and this costs money. Another reason is that COVID-19 is pandemic. At some point, the trade-off between false positives and false negatives (it is impossible to reduce both) favors false positives.

The question then is whether physicians are inflating numbers regarding COVID-19 infections so as to profit from this add-on. The American Medical Association is very clear on this:

At a time when physicians and other health care providers are providing care to a record number of COVID-19 patients amidst a third wave, there is misinformation about how patients are counted. Let's be clear physicians are not inflating the number of COVID-19 patients. Research published in JAMA and in CDC reports indicate that the US had significantly more deaths in 2020 than in previous years (excess deaths). Physicians and patients are making remarkable sacrifices and we continue urging all to wear a mask, physically distance and wash your hands to reduce suffering, illness and death.

If anything, the number of COVID-19 deaths is undercounted rather than overcounted. There have been a significant number of excess deaths in the US since January 26, 2020. This is an undeniable fact. About two thirds of this excess mortality rate has been attributed to COVID-19. The other third includes people who may not have had COVID-19 but were afraid of going to a hospital for fear of contracting COVID-19. It almost certainly also includes people who had contracted COVID-19 but who died from one of the many comorbidities that in conjunction with COVID-19 infection make the disease so deadly.

Addendum, from comments

One of my specialties is failure detection, isolation, and recovery (FDIR), but on rockets rather than people. The problem of false negatives versus false positives is first nature to me. It apparently is not to others. As comments tend to disappear at this site, I'll quote two of @Accumulation's comments, verbatim:

Suppose, for each case, we assign a number from 0 to 100. A larger number means we're more sure that it's COVID. At what number should we classify it as COVID? If we classify everything with score of 10 or greater as COVID, then we'll catch most COVID cases, (i.e. low false negative) although occasionally there will be a case that has a score lower than 10 even though it actually is COVID. However, there will be a lot of cases that aren't COVID that are being classified as COVID (i.e. high false positive).

If we require a case to have a score of at least 90, then there are going to be a lot of cases that actually are COVID that aren't classified as COVID (high false negative), but most cases that are classified as COVID are going to actually be COVID (low false positive). Raising the threshold decreases false positive, but increases false negative. It's impossible to eliminate false positives without having a lot of false negatives, and vice versa. Since the consequences of a false negative are worse than a false positive, we should err on the side of the latter.

| improve this answer | |
  • Comments are not for extended discussion; this conversation has been moved to chat. – fredsbend Nov 4 at 22:25
  • 1
    Given that the question appears to be of the form "are doctors committing fraud?", why should we take the AMA at their word on this? There are any number of things that can explain excess deaths during a pandemic, aside from the virus itself (for just one example, suicides can reasonably be anticipated as a result of increased social isolation pushing vulnerable people over the edge). – Karl Knechtel Nov 9 at 3:59
26

Conflation. And oversimplification.
But not completely untrue. Exact phrase is unfortunate and could be treated as 'no evidence for that'.

  • "Doctors" paid directly for "cause of death is Covid" seems to be untrue.
  • In the health care system paid more for a diagnosis of Covid instead of other diagnosis (that is when a patient should be still alive) – seems to be true.
  • Death toll caused by Corona virus is distorted, in both ways, up and down. How much each is unfortunately not easily calculated
  • Death toll related to Corona virus is communicated intransparently

Our ruling: True
We rate the claim that hospitals get paid more if patients are listed as COVID-19 and on ventilators as TRUE.
— Michelle Rogers: "Fact check: Hospitals get paid more if patients listed as COVID-19, on ventilators" Usa Today Network, 24 Apr 2020

Or in other words:

“The way the [congressional] language is written, is if it’s a COVID-19 admission — whether or not the patient recovers — hospitals get the add-on payment,” Badger told InsideSources. “If you have a COVID-19 diagnosis in your submission to Medicare, you get a 20 percent bump up.”

“Nobody can tell me after 35 years in the world of medicine that sometimes those kinds of things impact on what we do.”

Doug Badger, a visiting fellow for domestic policy studies at The Heritage Foundation, sees the potential problem.

The Foundation for Economic Education says simply that “the economic incentive to add COVID-19 to diagnostic lists and death certificates is clear and does not require any conspiracy.”

In Colorado, when officials stopped reporting all deaths of infected people as COVID-19 fatalities and instead only included those who died from the virus’s impact, their death toll fell from 1,150 to 878 — a 24 percent decrease.

“We recognize that there certainly has been confusion around this topic,” Dr. Rachel Herlihy, the state epidemiologist, said during a media call.

Jensen insists he never insinuated that hospitalswere listing coronavirus admissions — or “presumptive cases” — as a cause for increased funding, but “facilities are incentivized to raise the index of severity.”
— Hiram Reisner: "Politics: Are Hospitals Over-Reporting COVID-19 Cases Because of Financial Incentives?", InsideSources, May 20, 2020.

The flaw in this construction seems obvious: instead of giving just more money to hospitals in time of crisis, not tied to any specifics because the entire health care system is now under increased stress — they get this money bound to a specific diagnosis, which then increases to a certain extent by that effect alone.
By how much seems unclear, and it certainly not the only effect and not as large as perhaps insinuated in that speech we look at. The fun thing to ask about this flaw is of course: "Who constructed that in this 'attractive way'?" The answer to that is not very flattering to the speech giver:
— American Society of Clinical Oncology (ASCO): "COVID-19 Government, Reimbursement & Regulatory Updates", last updated on 10/15/2020.

But the other part seems very dubious:

Donald Trump claimed doctors get paid more if they put Covid-19 down as a patient's cause of death.

There's no evidence the claim is true […]

Donald Trump claimed doctors get paid more if they put Covid-19 down as a patient's cause of death.

He told a rally in Waterford Township, Michigan: "Our doctors get more money if someone dies from Covid. You know that, right?

"Our doctors are very smart.

"So what they do is, they say, "I’m sorry, but, you know, everybody dies of Covid.""

He added: "But in Germany and other places, if you have a heart attack, or you have cancer, you’re terminally ill, you catch Covid, they say you died of cancer, you died of heart attack. With us, when in doubt, choose Covid.”
— Mikey Smith: "Donald Trump claims doctors inflate Covid-19 death figures to get paid more money. The President claimed doctors get paid $2,000 more if they put coronavirus down as the cause of death. There's no evidence this is true", Mirror, 20:47, 30 OCT 2020 20:48, 30 OCT 2020

Quoted here in that length as the description of 'other places' is the outlandishly untrue part. For Germany: Wie ist die Evidenzlage zu Krebs und COVID-19?, COVID-19 bei Mehrzahl der Betroffenen auch die Todesursache.


It is unfortunate that he phrased it in this way. The monetary incentive to diagnose someone 'with Covid' is there, and the way Covid deaths are counted is systematically distorted by that alone.
The numbers of 'Covid deaths' reported then by other authorities is intransparent as well, creating an impression of inflated numbers. Many people died, but not all Covid deaths are really exclusively caused by that one virus.

Whether anyone dies with Covid or of Covid, they show up in the count of 'Covid deaths' in most media, when in reality and in the official reports we see 'Covid related deaths'.

This is not "downplaying the virus":

While at the same time people dying from Covid without ever being diagnosed as "Corona positive test" do not show up in the stats is the other side of that medal. The numbers we have are simply less exact than we wish they should be, and such distortions go in both directions:

The reality is that assigning a cause of death is not always straightforward, even pre-pandemic, and a patchwork of local rules and regulations makes getting valid national data challenging. However, data on excess deaths in the United States over the past several months suggest that COVID-19 deaths are probably being undercounted rather than overcounted.
— Stephanie Pappas: "How COVID-19 Deaths Are Counted. Assigning a cause of death is never straightforward, but data on excess deaths suggest coronavirus death tolls are likely an underestimate", Scientific American, LiveScience on May 19, 2020.

Raw numbers as an aggregate of this 'situation' can be very misleading.

It should be noteworthy that the CDC also describes other distortions in this process:

Understanding the Numbers: Provisional Death Counts and COVID-19

Provisional death counts deliver the most complete and accurate picture of lives lost to COVID-19. They are based on death certificates, which are the most reliable source of data and contain information not available anywhere else, including comorbid conditions, race and ethnicity, and place of death.

How it Works

The National Center for Health Statistics (NCHS) uses incoming data from death certificates to produce provisional COVID-19 death counts. These include deaths occurring within the 50 states and the District of Columbia.

NCHS also provides summaries that examine deaths in specific categories and in greater geographic detail, such as deaths by county and by race and Hispanic origin.

COVID-19 deaths are identified using a new ICD–10 code. When COVID-19 is reported as a cause of death – or when it is listed as a “probable” or “presumed” cause — the death is coded as U07.1. This can include cases with or without laboratory confirmation.

Why These Numbers are Different

Provisional death counts may not match counts from other sources, such as media reports or numbers from county health departments. Counts by NCHS often track 1–2 weeks behind other data.

  • Death certificates take time to be completed. There are many steps to filling out and submitting a death certificate. Waiting for test results can create additional delays.
  • States report at different rates. Currently, 63% of all U.S. deaths are reported within 10 days of the date of death, but there is significant variation between states.
  • It takes extra time to code COVID-19 deaths. While 80% of deaths are electronically processed and coded by NCHS within minutes, most deaths from COVID-19 must be coded by a person, which takes an average of 7 days. Other reporting systems use different definitions or methods for counting deaths.

Things to know about the data

  • Provisional counts are not final and are subject to change. Counts from previous weeks are continually revised as more records are received and processed.

  • Provisional data are not yet complete. Counts will not include all deaths that occurred during a given time period, especially for more recent periods. However, we can estimate how complete our numbers are by looking at the average number of deaths reported in previous years.

  • Death counts should not be compared across states. Some states report deaths on a daily basis, while other states report deaths weekly or monthly. State vital record reporting may also be affected or delayed by COVID-19 related response activities.

The possible range of this 'how do we count those that died and were diagnosed as positive?' is rather high:

The CDC reported in September less than 10% of all ("died with") Covid related deaths to have been solely caused by SARS-CoV2 ("died from"): Weekly Updates by Select Demographic and Geographic Characteristics, where we see that diagnosis code U07.1 as sole cause is only a fraction of total Covid related deaths.
Given the mentioned complications in determining one or multiple 'cause of death' in this scenario, we now only know that these numbers don't count some deaths from undetected Covid and overcount some deaths 'with' Covid. How much it goes in either direction is not known. While we could do somewhat better in increasing the exactness of these numbers, and communicating them more transparently, the ideal will remain unreachable.

The Victorian and Commonwealth governments are reportedly working to reconcile how COVID-19 deaths are counted and reported. But it may be months or years before detailed death data can be analysed.
— Marc Trabsky & Courtney Hempton: "‘Died from’ or ‘died with’ COVID-19? We need a transparent approach to counting coronavirus deaths", The Conversation, September 9, 2020 6.14am.

| improve this answer | |
  • 9
    A minor nitpick: The disease is COVID-19. The agent that causes this disease is the novel coronavirus (one word), or even more pedantically correct, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). You used "Corona virus" (two words) in multiple places. Corona, by the way, is a nice beer when served with a lime. – David Hammen Nov 1 at 14:21
  • 12
    Trying to determine a single cause of death is almost impossible. Just a couple of days ago, a (not yet peer-reviewed) study from the Imperial College of London found that even people who recovered from Covid-19 without any respiratory symptoms lost on average 4.5 IQ points, so clearly it seems that SARS-CoV-2 is doing something with people's brains. So, if one of those people 20 years from now in a bout of dementia walks out in the winter without a jacket and freezes to death, what did they die of? Cardiac arrest? Hypothermia? Dementia? Covid-19? All of the above? – Jörg W Mittag Nov 2 at 9:22
  • 3
    @JörgWMittag Yes, indeed a good question. What is criticised is the too often fulfilled desire to present a mono-causality in public communication when it is in most cases not quite as easy as to write down 'cause of death: decapitation' when applicable. If people are led to think that everyone 'with' (at some point) who then died (at some point) was inevitably always dying 'from': that is also an oversimplification we should try to avoid. But these probabilities and risk communication are apparently incompatible with news cycles and politics? Both seem to think we're too dumb to grasp that. – LangLаngС Nov 2 at 10:54
  • 8
    Most of this answer still conflates doctors with hospitals, which are very different things. USA Today said that it was true that hospitals get paid more, but that’s not what Trump claimed. He claimed that Doctors get paid more for their diagnoses which seems to be very untrue. – RBarryYoung Nov 2 at 18:43
  • 3
    I mean, depending on how reductionist you want to be and how you want to define death, it can be more or less reasonable to claim that there is only one true cause of death, which is "lack of Oxygen to the brain." But when you go that far, "cause of death" becomes a meaningless measure, so we don't define it that way. – Andrew Ray Nov 2 at 20:15

You must log in to answer this question.

Not the answer you're looking for? Browse other questions tagged .