When the Foundations Are Wobbling, Part II

May 22, 2020 • Posted in Blog

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Death Certificates and COVID-19

D. Joy Riley, M.D., M.A.
Executive Director

One of the tasks assigned to physicians is the completion of death certificates—at least, the portion of death certificates that list cause of death (COD). I learned the importance of accuracy of death certificate completion as a pathology student fellow, an extra year of pathology training in the middle of my medical school career. We were instructed never to use the mechanism of death, such as cardiac or respiratory arrest, as a cause of death. Additionally, the use of terms like “probable” or “suspected” were not allowed. After all, the goal of a pathologist was to determine the cause of death.

In cases where there is no autopsy involved, if the death is a “natural” death (resulting from disease or age), and the sequence of events is not clear, then qualifiers such as “presumed” or “probable” may be permissible. But the physician still is obligated to use his/her best medical opinion. (Learn more.) It is incumbent upon the physician to remember that when he/she signs the document, “he or she has legally certified that, to the best of his or her knowledge, the individual died for the reasons listed under the cause of death,” according to the CDC online course, “Improving Cause of Death Reporting” (accessed 2 May 2020).

Further, death certificates are legal documents, and accuracy is very important, as explained by Brooks and Reed in “Principles and Pitfalls: a Guide to Death Certification”:

  The death certificate is an important legal document. In addition to providing the decedent’s family with a cause of death, it has critical administrative and epidemiologic applications. Death certificates may be required to settle decedents’ estates and obtain insurance or other pensions/benefits. In many states, death certification is required prior to cremation or burial services. At both the state and national level, mortality data compiled from death certificates is used to track disease trends, set public health policies, and allocate health and research funding. For these reasons, it is important that death certificates be filled out completely, accurately, and promptly.

The Office of Vital Statistics uses death certificates to collect and report data on disease and mortality in the U.S. This data is combined with other mortality data worldwide, and published by the World Health Organization, using an alphanumeric code, the International Statistical Classification of Disease and Related Health Problems (currently ICD-10).

The COVID-19 pandemic has produced some changes in the completion of death certificates, and the uses of such data. In April 2020, the Centers for Disease Control and Prevention (CDC) “updated its guidance for counting COVID-19 cases and deaths. It now includes both confirmed cases and probable ones, but each state still determines what to report.” This happened through “the urging of a group of epidemiologists.” (See here also.)

Dennis Nash, (Ph.D.), who is the executive director of the City University of New York Institute for Implementation Science in Population Health, explained to WebMD why this happened:

  If probable cases aren’t included in the death toll, it can compromise efforts to flatten the curve. Most deaths reflect infections that took place 10-12 days earlier, Nash says, so public health experts can use the number to track how well restrictions that were in place then were working.

As a result of the change, New York added 3,700 to its death toll from COVID-19. Of the three desired qualifiers of reporting—completely, accurately, and promptly—that was certainly promptly accomplished.

The change in the guidance from the National Vital Statistics System (NVSS) regarding death certification was confirmed by the Tennessee Department of Health (TDH) in their weekly Friday noon webinar call on 10 April. Even if coronavirus testing has not been performed, as long as there is “compelling clinical suspicion of COVID-19,” one can certify death accordingly:

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This sudden departure from calls for accuracy in reporting on the death certificate has consequences, some of which are financial. Consider the benefit to families, as shown in this screen shot from the 10 April webinar of the TDH:

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A COVID-19 diagnosis, as dire as that can be, can also benefit hospitals through the CARES Act: “During the emergency period, the legislation provides a 20% add-on to the DRG rate for patients with COVID-19. This add-on will apply to patients treated at rural and urban inpatient prospective payment system (IPPS) hospitals.”

Further, the CARES Act provides “in addition to IPPS hospitals, the bill expands the program to children’s hospitals, cancer hospitals and critical access hospitals (CAHs). All eligible providers are able to request accelerated payments for inpatient services that cover a time period of up to six months. The amount of payment is up to 100% (or up to 125% for CAHs) of what the hospital would have otherwise received, up from 70% in the current program, and payment could be made
periodically or as a lump sum.”

Senator Scott Jensen, M.D., (R-Minn) stirred controversy when he said, “Hospital administrators might well want to see COVID-19 attached to a discharge summary or a death certificate. Why? Because if it’s a straightforward, garden-variety pneumonia that a person is admitted to the hospital for – if they’re Medicare – typically, the diagnosis-related group lump sum payment would be $5,000. But if it’s COVID-19 pneumonia, then it’s $13,000, and if that COVID-19 pneumonia patient ends up on a ventilator, it goes up to $39,000.”

USA Today verified Jensen’s financial understanding of the situation. It will be instructive to ascertain the various states’ claims with respect to COVID-19 caseloads and deaths. While our sympathies are rightly disposed toward victims of this pandemic and their loved ones, a healthy skepticism toward financial accounting of cases and deaths is warranted.