How to make a silk purse from a sow's ear—a comprehensive review of strategies to optimise data for corrupt managers and incompetent clinicians

Manipulation of non-clinical performance targets

This is particularly important for managers when meeting so called P-45 targets—an expression used by Tony Wright MP while examining Sir Nigel Crisp for the House of Commons Select Committee on Public Administration2 and meaning targets for which failure to meet can result in redundancy (in Britain the P-45 is the tax form people receive when leaving employment). A House of Commons investigation in 2002 uncovered strategies to bring waiting times and numbers of patients waiting for treatment within national targets.3 Records were altered, patients were inappropriately suspended from waiting lists, and some hospitals did not report patients waiting longer than government targets. Though such techniques are readily exposed, one in 10 healthcare managers admitted to “fiddling figures” in a recent survey.4

Various gaming strategies can help to disguise less than perfect clinical performance

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More intelligent managers inquire when patients intend to go on holiday and then offer an appointment during this period. Few patients cancel their holiday for medical reasons, preferring to postpone their appointment. Since the patients initiate these delays, their wait is no longer recorded. A related strategy offers patients non-existent appointments at impossibly short notice to attend; cancellation shifts them to the back of another list whose waiting times are not officially recorded. If you identify patients waiting longer than the permitted limit, you could arrange admission when their consultant is on holiday; then apologise profusely for the cancellation of their operation and offer a new date for surgery in the distant future.5

In Scotland the waiting lists record only patients receiving inpatient care. To reduce the numbers of patients on published waiting lists you should ensure wherever possible that patients already offered inpatient treatment get treated as outpatients.6

If you cannot place a patient on an unpublished waiting list, use the date you periodically update the waiting list, rather than the date of referral, as the starting point. This can knock several weeks off apparent waiting time.6 Variations include not placing patients on the waiting list until the month of their appointment or failing to reinstate previously suspended patients.

We applaud advance warning of assessment, as this allows managers time to ensure that systems are in place to meet targets. We particularly commend the Department of Health for choosing one week each year to record waiting times in accident and emergency departments.7 Cancelling unnecessary operations and keeping extra beds open that week ensures your hospital meets the national target (90% of patients seen by a doctor within four hours of arrival) at least once a year. A BMA survey in 2003 found that 72% of accident and emergency departments introduced exceptional arrangements during the audit week, including hiring agency staff, introducing double shifts, and cancelling routine operations.8 This strategy proved highly effective at meeting government targets: during the audit week 85% of hospital trusts met the target, but the following week only 63% still met target waiting times.

Another way to shorten waiting times in accident and emergency departments is to refuse to book in ambulance patients until your clinical staff are ready to assess them.5 Although patients are on hospital premises, you choose when to “start the clock,” and until then the patients officially remain under the care of paramedics (jeopardising their performance targets instead of yours).

Remember to “stop the clock” once you have transferred patients from trolley to bed since they have now been admitted (even if they remain in the department for the next two days). Once patients have seen a doctor, discharge them from the computer rather than wait for their transport to arrive and take them home.5 If your hospital is full, simply remove the wheels of a trolley to transform it into a bed, and erect a partition in the corridor to create an “observation ward.”9

Academic units are not immune from the need to enhance reputations by undertaking and publishing trials. If you cannot be bothered to do the research in the first place you may be able to persuade a journal to publish a trial under your name that has been conducted elsewhere and published in another journal. For example, it is intriguing that two randomised clinical trials comparing surgical techniques should include the same number of patients and find identical results, despite obviously being carried out in different hospitals on different continents.10 11

Fraudulent reimbursement claims

You should be aware of the various types of fraud described and prohibited by law in the United States and elsewhere. The False Claims Act prohibits misrepresenting the level of care offered or billing for services not rendered. The Anti-Kickback statute prohibits inducements with the intent to influence the purchase of healthcare services. Self referrals, in which physicians refer patients to facilities where they have a financial interest, are outlawed.12

The prospective payment system in the United States, in which healthcare costs are paid prospectively, based on a standard sum for well defined medical conditions (the diagnosis-related group, DRG) has created a golden opportunity to maximise profits without extra work. When classifying your patient's illness, always “upcode” into the highest treatment category possible. For example, never dismiss a greenstick fracture as a simple fracture—inspect the x ray for tiny shards of bone. That way you can upgrade your patient's break from a simple to a compound fracture and claim more money from the insurance company. “DRG creep” is a well recognised means of boosting hospital income by obtaining more reimbursement than would otherwise be due.13

Another reason for upcoding your patients' illnesses is to manipulate reimbursement rules for your patients' benefit. A recent national survey of US doctors showed 39% had used such tactics—including exaggerating symptoms, changing billing diagnoses, or reporting signs or symptoms that patients did not have—to secure additional services felt to be clinically necessary.14 Medical fraud is estimated to account for 10% of total US spending on health care (some $120bn) in 2001.15

Reducing mortality figures—gaming and clinical performance data

Many clinicians worry about public release of clinical performance data, as above average mortality figures can unfairly damage your reputation. In reality half of all hospitals have above average (technically, above median) mortality, and various gaming strategies can help to disguise less than perfect clinical performance.

Selection of risk adjustment procedure

When calculating risk adjusted mortality, you can enter a bewildering number of risk factors into multivariate equations, and many proprietary risk adjustment formulas are available. Rankings of individual hospitals vary widely depending on how you adjust for disease severity, and in principle your hospital could “shop around” for whichever adjustment measure shows it in the best possible light.17

“Accurate hospital statistics are much more rare than is generally imagined” (Florence Nightingale, 1863)

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