Exactly How Many People Have Covid-19, Anyway?
The numbers in Erath County are (predictably) climbing. This last weekend, some good news… a few *official* recoveries reported. But I have been asked, “Can we really trust the numbers published? Or are they artificially inflated so 1.) hospitals can bilk Medicare for some Cares Act cash or 2.) local, state and federal governments can use artificially elevated numbers to oppress us with evil doctrines such as mask wearing and preventing good clean American fun? (I kid… sort of.) This really boils down to two issues that I’ll address in turn.
First, the numbers. If anything, they are lower than reported. Yes, we have had increased testing. Yes, more people are aware of the dangers of the virus and are presenting to us for evaluation. But not everyone who gets Covid gets tested. This is good news and bad news. The good news is that the actual infection rate is actually higher than is reported and so, the death percentages and hospitalization percentages are, by definition, actually lower than reported. In order to precisely know the death rate, we would have to have population wide testing and at this point that is not feasible.
I have heard this statistical conundrum used to minimize the severity of this pandemic. Doing so is a mistake and is dangerous. In the worst flu season in the last 10 years, millions more Americans contracted influenza than have had Covid in the last 5 months and 80,000 died from that particularly harsh strain of flu. Many less people have had covid and – to date – over 134,000 of those identified to have been infected have died. The reported Covid-19 death rate in the US is just over 4%. (Side note: Get a flu shot this fall, please.)
The bad news about not everyone who has Covid-19 being tested is that they are likely spreading the virus unwittingly to people who may become one of the statistics I mentioned above. This is why masks (which do help decrease disease burden in an environment – many independent scientifically sound groups have proven so) and social distancing are so important. Countless graduation parties, birthday parties, “Covid” parties (ARE YOU KIDDING ME?) and other gatherings have resulted in entire families presenting to medical offices and ERs for testing, lost days at work for quarantine, hospitalizations, intubations and deaths. (Those Erath County residents intubated are in Fort Worth – fortunately, to date, our sickest patients have been able to find beds there.)
In Erath County, and in truth, all over the country, there is little incentive to fabricate cases of Covid-19. Personally there is no financial benefit for me to report extra (fake) cases. But what, you are surely asking, about the hospitals? Don’t they get extra money if they put covid as the cause of death in a motor vehicle crash victim?
That’s the second issue I need to discuss, and I’m happy too, though I must admit I’m no expert when it comes to hospital finance. But I think I can provide some insight. To begin, yes, absolutely, hospitals are paid more by Medicare if the patient who is treated there is diagnosed with Covid-19. They are also paid more if the patient has heart failure, or renal failure, or an aortic aneurysm. And they should be. It stands to reason that hospitals should be paid more for caring for sicker patients than they should for not so sick patients. I have sat through countless meetings during which hospital administrators have pleaded with us physicians to be sure and correctly document every co-morbidity (that’s other complicating medical problems) on the chart because the more complex a patient is, the more they’ll get paid for a stay. If we don’t document appropriately, the hospital will not likely be paid enough to cover the cost of the hospital stay. (But I have never been asked to fabricate diagnoses or even skew the truth in favor of making a patient appear sicker than they are. That would be Medicare fraud.) You see, Medicare pays hospitals bundled payments. They may pay X dollars for a pneumonia stay and if the hospital spends more than X, too bad. The hospital should have made it clear that the patient was more complicated and would cost more to treat (more medicine, studies, treatments, more hospital days).
Medicare has risk adjustment tables they use to predict how sick a patient is and what it ought to cost to treat them. The more sick the patient, the more Medicare pays for a hospitalization. And if you have Covid-19 and get admitted to the hospital, most of the time you are sicker than the patient in the room next door with run-of-the-mill pneumonia. Covid-19 makes everything worse. If you have two fictitious patients suffering from heart failure exacerbations and all other problems being equal, give one of them Covid-19 and that one is more likely to spend more time in the hospital, be ventilated, and require a great deal more resources than the other. People have to be quite sick to be admitted to the hospital, usually, unless it is for an elective surgery and if you have Covid-19, you are not being admitted for elective procedures. So I don’t buy the concept that people who are admitted but also have Covid-19 often aren’t very sick from having Covid-19. Like I said, if you are sick enough to be admitted for any reason, even including a fall and hip fracture, having Covid-19 is likely to complicate your hospitalization. In addition, a good ballpark cost to a hospital for treating a patient in an icu on a vent is about $10,000 per day. Add in some fancy new (well, new to Covid) Remdesivir to try and treat Covid-19, and it’s easy to see the Medicare Covid bonus may not even cover the hospital’s cost to treat the patient. And oh, by the way, if the hospital is in Dallas County and has missed out on elective surgeries for 3 out of 7 months so far this year, they are hemorrhaging money and trying to figure out where to make up the shortfall so they don’t have massive layoffs and close service lines.
“Aha,” you say. “Those greedy hospitals are losing money! That’s where the fabricated Covid cases are coming from. The crooked hospital bean counters are labeling every patient who dies as a Covid death so they can get the money and they’re making everyone panic in the process by artificially driving up numbers.”
Not so fast. Bean counters don’t fill out the death certificates nor do they complete the medical records from which Medicare payment is determined. Doctors do. And doctors don’t have any financial incentive – zero – to lie on death certificates. In fact there is significant pressure not to. Doing so on a Medicare patient for the purpose of helping a hospital game the system is called Medicare fraud – a serious federal offense. And most doctors don’t want to trade in their white coats for orange jumpsuits.
I’m a hospice medical director so I fill out many death certificates. We are instructed to put the immediate cause of death first like cardiac arrest or respiratory failure and then put the sequence of events that lead to that cause of death such as pneumonia or acute coronary syndrome. We fill in a few details like recent pregnancy and if smoking contributed to the cause of death, etc. There is a space to put other factors that may have contributed like Alzheimer’s Disease or alcoholism etc. Regarding Covid-19, the following are instructions on the Texas death certificate website when we log in:
For deaths due to COVID-19, report COVID-19 in Cause of Death – Part I on the Medical 2 tab. Report other chronic conditions that may have contributed (e.g. COPD, asthma) in Cause of Death – Part II on the Medical 2 tab.
So, I interpret that to mean only put Covid-19 as a cause of death if the patient died directly as a result of contracting Covid-19. If they already had end stage colon cancer and happened to contract Covid-19 just before dying, and I felt the death was due to colon cancer, I would put that as the cause of death and list Covid-19 as a possibly contributing factor. “But,” you may ask, “are all doctors as scrupulous as you? Aren’t some doctors employed by the hospitals and so they write what they are told to write?” Perhaps. But if so, these instances represent only a pittance of the incorrectly reported cases and likely many other cases go unreported, so I maintain that the total number of cases and deaths from Covid-19 are under-reported as a whole.
I was asked specifically about a case in Florida, of which I have no personal knowledge, in which a patient who was in a motor vehicle crash was decapitated, and the death was listed as having been due to Covid-19. 1.) This is unlikely and probably is circulated as fabricated or misinterpreted internet fodder for consumption by conspiracy theorists who are looking for bits of “evidence” to bolster their theories. 2.) If that did happen, the physician who signed the death certificate, if falsified purposely, could face much more than the loss of their license – likely jail time and financial ruin. 3.) There is always more to the story – we can’t believe everything we read on the internet and quote it as gospel truth. It’s unprofessional, unseemly and unsafe. Are there people in this country who are in a position to game the Cares Act and might glean some financial benefit? Sure there are. Is it happening with reckless abandon and making a statistically significant impact on the reported numbers? Absolutely not.
Every government policy has unintended consequences. It’s like medicine. One of my favorite blood pressure medications is amlodipine. Depending on the study you read, up to 10 percent or so of people might have swelling in their lower extremities if they take amlodipine daily as prescribed. I know there are potential unintended consequences but I prescribe it anyway, because as I say to a patient almost monthly, “Swelling in the legs is a small price to pay for the benefit of not having a stroke or heart attack due to uncontrolled blood pressure.” (Please don’t stop taking your amlodipine, if you are taking it, without discussing it with your personal doctor, first.) The federal government has chosen to financially stabilize hospitals who are struggling to care for very sick patients while not having regular revenue streams such as elective surgeries, etc. Perhaps the benefit of stabilizing hospitals financially during a pandemic is worth the potential for a few unscrupulous people taking advantage of this government program. Every HHS Covid-19 stimulus payment received by clinics and hospitals has been accompanied with the promise of government audits – language serious enough to ensure those entities will do their best to report truthfully.
We have to guard against splitting hairs when trying to determine why a patient was hospitalized – the line between being hospitalized with Covid-19 or because of it is often too fine to separate out. Of course, sometimes it is obvious but many times it is not. We will not know, now, during the pandemic what the true death rate or hospitalization rate is. That can only be determined well after the fact with extensive case review and will be done by epidemiologists. For now – only a ballpark is possible. It’s admittedly frustrating because we have to make public health policy based on incomplete information. That is the nature of decision making during a crisis – we don’t know exactly what we are facing but we have to do the best we can with the information we can collect. And we are learning as we go.
Epidemiological studies are population based – and they are imperfect. There are always one off anecdotes that contradict the overall narrative. That doesn’t change what is happening in a population. There are several ways to count Covid-19 cases – we can count reported positives from clinical data, we can count actual positives from the laboratories themselves, we can count death certificates with Covid-19 somewhere on the certificate. State health departments can choose how they count with some guidance from the Federal government but they are not all the same, so the results are imperfect. It is impossible to know every false negative, every false positive, every recovery and every death – but we can get close. And this is the number we have to count on. Covid-19 cases are counted by people, fallible, imperfect people who are doing their best to give us good data. We will be able to dissect the data for years to come and will be able to identify mis-steps in hindsight. In the middle of the pandemic – all we can do is the best we can, follow established epidemiological principles and trust that those who are responsible for reporting the numbers are honest and are doing their best. And if they aren’t, there are mechanisms in place to hold them accountable.
Please don’t bog down in the data. The bottom line is, it’s a pandemic. People of every age and every health category have died. I do not accept the premise that our collective apathy about other illnesses like flu, cancer, heart disease or whatever other malady you can name warrants the same level of apathy and disrespect for an unfeeling, unwavering pathogen whose only motive is to replicate and spread, laying waste to its hosts in the process. If anything, it should help us recognize and overcome that pervasive apathy because every death whether it is due to Covid or cancer, influenza or injury, represents the loss of that most valuable commodity we are afforded. And please don’t misidentify the enemy. Your government, your local hospital, your public servants are not your enemy – the pathogen is. Please hold those of us who report the numbers accountable. We want to get it right and welcome your questions and suggestions – but we are here to help, not oppress or intentionally misinform.
Still in the trenches.
Benjamin A. Marcum, M.D.