Is CDC “borrowing” pneumonia deaths from the long-term care population and adding them to the Covid-19 deaths tally?

Close analysis of CDC’s stated policies and their own data, as well as financial incentives for nursing homes to over-state Covid-19 deaths, strongly suggest that a large portion of the deaths attributed to Covid-19 should instead be attributed to normal pneumonia and flu, particularly in long-term care homes

About 1.3 million Americans live in nursing homes in recent years, according to the CDC, and another 1.7 million in other long-term care facilities (see slide 8 in the linked CDC presentation), for a total of about 3 million in long-term care facilities.

In normal times half of the nursing home residents die within five months from normal causes of death that afflict elderly populations. Five months is the median time before death; the average is longer because some patients last far longer before succumbing. 65% die within one year of admission.

That’s during normal times.

I’ll focus on nursing home populations in the rest of this piece, which ensures that my analysis is somewhat conservative because largely the same analysis would apply to the other 1.7 million people who live in other long-term care facilities.

Looking just at the approximately 1.3 million nursing home population means that about 0.65 million deaths will occur in that population in five months. And approximately 1.3 million will die, on average, within ten months, in times with normal turnover (2 x 0.65 million = 1.3 million).

This holds true only if the population is turning over in a normal manner and 2020 certainly was not a normal year for turnover due to the pandemic. We don’t have good data yet on the rate of turnover so the numbers I’m offering here are estimates only at this time.

Long-term care homes have significant new financial incentives to take on Covid-19 patients and to report Covid-19 as a cause of death

We may get an idea of the direction of turnover trends in 2020 by looking at the financial incentives provided for long-term care homes to increase turnover.

The Los Angeles Times reported in a May 2020 article about the new financial incentives for long-term care homes that (emphasis added):

Patients with COVID-19 could be worth more than four times what [long-[term care] homes are able to charge for long-term residents with relatively mild health issues. Some patient advocates and industry experts fear the premium pay available for coronavirus patients — and a simultaneous easing of regulations around transfers — could tempt some home operators to move out low-paying residents to bring in more lucrative COVID-19 patients, despite the obvious health risks to residents and staff.

“There are probably some unscrupulous operators who would jump at this,” said David Grabowski, a professor of healthcare policy at Harvard Medical School, though he thought most would not.

The article continues (emphasis added):

A new Medicare reimbursement system that went into effect last fall pays nursing homes substantially more for new patients — including those released from a hospital — particularly for the first few weeks. Under those guidelines, COVID-19 patients can bring in upward of $800 per day, according to nursing home administrators and medical directors interviewed by The Times.

By contrast, facilities collect as little as $200 per day for long-term patients with dementia, the industry experts said.

We don’t have comprehensive data at this point about the degree to which this incentive has in fact led to higher turnover at long-term care homes, but anecdotally it seems to have become a serious problem fairly rapidly in numerous states — as is quite easy to envision when we’re talking about up to four times higher payments for new patients.

The New York Times reported, in June (one month after the LA Times story, and a month or so after the new CARES Act incentives, but several months after the Medicare changes were enacted), in an article titled ‘They Just Dumped Him Like Trash’: Nursing Homes Evict Vulnerable Residents, about some care homes apparently turning out existing patients to make room for these more lucrative Covid-19 patients.

The story begins: “Nursing homes across the country are kicking out old and disabled residents and sending them to homeless shelters and rundown motels.”

The article continues (emphasis added):

On a chilly afternoon in April, Los Angeles police found an old, disoriented man crumpled on a Koreatown sidewalk.

Several days earlier, RC Kendrick, an 88-year-old with dementia, was living at Lakeview Terrace, a nursing home with a history of regulatory problems. His family had placed him there to make sure he got round-the-clock care after his condition deteriorated and he began disappearing for days at a time.

But on April 6, the nursing home deposited Mr. Kendrick at an unregulated boardinghouse — without bothering to inform his family. Less than 24 hours later, Mr. Kendrick was wandering the city alone.

According to three Lakeview employees, Mr. Kendrick’s ouster came as the nursing home was telling staff members to try to clear out less-profitable residents to make room for a new class of customers who would generate more revenue: patients with Covid-19.

… similar scenes are playing out at nursing homes nationwide. They are kicking out old and disabled residents — among the people most susceptible to the coronavirus — and shunting them into homeless shelters, rundown motels and other unsafe facilities, according to 22 watchdogs in 16 states, as well as dozens of elder-care lawyers, social workers and former nursing home executives.

Toby Edelman, an attorney with the Center for Medicare Advocacy, stated in a Dec. 4, 2020, article for the AARP online magazine:

“COVID-only facilities collect hundreds of dollars a day per resident, on top of other reimbursement. The financial incentives led to other residents being discharged inappropriately and sent to motels with nothing, or homeless shelters, or — worse — onto the streets. And the workers are still underpaid and risking their lives.”

I described in a previous essay how the U.S. is counting in its official statistics not only those people who die “from” Covid-19, but also those who die “with” Covid-19, based on new CDC guidelines, approved in April 2020 that strongly encourage Covid-19 being reported as a contributing or underlying cause of death, with or without any lab testing.

More than 40% of all Covid-19-related deaths in the US are in long-term care homes

According to the New York Times, more than 40% of Covid-19-related deaths so far are in long-term care homes, totaling over 106,000, as of December 4, 2020. The figure below is the first part of the New York Times table, showing the states with the highest Covid-19 death tallies from long-term care homes, with a dozen over 55%.

Figure 1. New York Times tally of states with highest Covid-19 deaths occurring in nursing homes.

When we compare the approximately 106,000 long-term care deaths attributed to Covid-19 (either “from” or “with” Covid-19, because the data available don’t make this distinction) we see that there would be about 12 times that many deaths (1.3 million divided by 106,000 = ~12) from all other causes in the long-term care population during normal times.

In other words, we have a normal death rate in this population that is 12 times the reported Covid-19-related deaths in this population (and up to 28 times higher if we include the full 3 million long-term care home population).

When we consider the heavy pressure from CDC, elected officials and other policymakers to report Covid-19 as the underlying cause of death (“the rules for coding and selection of the underlying cause of death are expected to result in COVID-19 being the underlying cause more often than not,” as the official CDC guidance states clearly), and the significant financial incentives for long-term care homes to do so, it is not difficult to see how the U.S. could be significantly over-counting Covid-19 deaths through re-classification of the cause of death in long-term care homes.

Indeed, leading policymakers have stated explicitly that this is happening. “If you died of a clear alternate cause, but you had Covid at the same time, it’s still listed as a Covid death,” Illinois’s director of public health, Dr. Ngozi Ezeke, explained to reporters in April, early in the pandemic.

This is in fact the approach used for tracking all U.S. Covid-19 deaths because each state tallies the death statistics in much the same manner, counting a Covid-19 death as any death associated with Covid-19 in any way, regardless of the actual cause of death.

This very loose approach to deaths tracking is summed up well by Dr. Deborah Birx, the White House Coronavirus Response Coordinator, in her statement that “if someone dies with COVID-19 we are counting that” as a Covid-19 death. I describe this generally very loose approach to counting “Covid-related deaths” in detail here and here.

We also have good supporting data for the possibility that much of this Covid-19 death rate is being “borrowed” from normal causes of death — but also that long-term care deaths may be significantly exacerbated by isolation and loneliness. I addressed this second possibility in an earlier essay. I’ll focus in the present essay on the possibility of significant “borrowing” of Covid-19 deaths numbers from normal deaths occurring in long-term care homes.

CDC’s National Center for Health Statistics announced in April that it will include pneumonia deaths in its Covid-19 deaths count

I’ll start by looking at pneumonia, which is the third or fourth highest cause of death in long-term care homes. CDC, through its National Center for Health Statistics (NCHS), has expressly stated its practice since April of including pneumonia deaths, but only those that don’t involve the flu virus, in the Covid-19 deaths category, because of concern that deaths coded as pneumonia may in fact be due to Covid-19 as the underlying cause.

The April 2020 NCHS guidance document states:

Pneumonia deaths are included in the provisional counts because deaths due to COVID-19 may be misclassified as pneumonia deaths in the absence of positive test results, and pneumonia may appear on death certificates as a comorbid condition. Thus, increases in pneumonia deaths may be an indicator of excess COVID-19-related mortality

In normal years, pulmonary diseases are the third largest cause of death for long-term care populations, at about 23% of the total, according to a small study of a single nursing home from 2008. Only Alzheimer’s/dementia and cardiac disease were larger, at 36% and 25%, respectively, according to Goldberg et al. 2008, “Causes of death in elderly nursing-home residents.”

Figure 2. Goldberg et al. 2008 looks at the most prevalent causes of death in nursing home populations.

I consulted a geriatrician who is an acquaintance of mine and he estimates that about half of all pulmonary disease deaths are pneumonia deaths. If we assume half of the 23% of long-term care pulmonary deaths are pneumonia deaths, we get about 11.5% of all long-term care deaths from pneumonia, as a working estimate.

Many of these deaths are flu-related pneumonia (flu generally kills by causing pneumonia, which is a generic term for serious lung damage), but a large number are not from flu-related pneumonia, but, instead, bacterial pneumonia. Bacterial pneumonia is well-known to be the far more lethal form of pneumonia. In fact, CDC’s provisional deaths data for 2020 (see Figure 6 below) shows that about 140,000 deaths in 2020 are from pneumonia that is not related to flu or Covid-19.

If we multiply the 3 million long-term care homes deaths figure, from above, times 11.5% we get an expected figure of about 345,000 pneumonia deaths in long-term care homes in 2020 — a figure within the range of CDC’s calculated excess deaths on its excess deaths “dashboard.” The range in red at the top of the figure is 275,049–381,896.

Figure 3. CDC’s excess deaths “dashboard.” This option is displayed when you select the “number of excess deaths” option in the dashboard.

Accordingly, this single act of including pneumonia deaths from the 3 million-person long-term care population in 2020 could have resulted in the same range of deaths as CDC calculates for total excess deaths for 2020.

But is this what is actually happening? Is CDC, unwittingly, simply “borrowing” these deaths for its Covid-19 death count? I am not suggesting any kind of malfeasance. Rather, I’m suggesting that this borrowing may be happening due to the various policy choices and inadvertent financial pressure to overstate Covid-19 deaths in long-term care homes.

CDC is, in fact, explicitly borrowing from pneumonia and other causes of death by including a large number of these deaths in its Covid-19 death counts. CDC states in the technical notes to its excess deaths data for excess deaths that are not attributed to Covid-19: “These [non-Covid-19] counts excluded deaths with U07.1 as an underlying or multiple cause of death.”

In CDC’s “coding” (processing and re-categorizing of death certificate data from the states) process, a single underlying cause of death is chosen for each death and in the vast majority (92%, according to CDC) of Covid-19 deaths this will be the underlying cause of death. This practice is based on stated CDC and WHO death certification and coding guidelines to choose Covid-19 as the underlying cause of death as a policy choice (see my essay here on this issue)—and it seems to make some sense, at first blush, to include all of these deaths in the Covid-19 category and tally.

However, the quoted statement also includes “or multiple cause of death.” This refers to death certificates where Covid-19 is listed as a contributing cause of death but not the underlying cause of death (8% of all Covid-19 deaths). Forcing a Coding of Covid-19 death for both of these categories demonstrates that CDC is indeed borrowing from pneumonia deaths categories in a significant manner, and other respiratory and circulatory diseases in order to arrive at their overall Covid-19 deaths figures.

This is the case because if a large proportion of these deaths are normal mortality, as my numbers for normal rates of pneumonia death in long-term care populations shows, requiring as a matter of policy that these normal deaths be tallied as Covid-19 deaths because of some association with Covid-19, requires also that these deaths from normal causes be reduced exactly proportionately to the degree that Covid-19 deaths increase. This is what I mean by “borrowing.”

We can see visually that this is very likely the case, at least in part, by looking at the NCHS provisional mortality data for all causes (this spreadsheet is titled “Weekly counts of death by state and select causes”). The next figure shows this data and shows how the influenza and pneumonia category took a fairly sharp dip in the spring at the same time as CDC issued its guidance about including pneumonia deaths in its Covid-19 deaths tally. And then took an ever deeper dip in the winter of 2020.

Covid-19 deaths are in forest green. Alzheimer’s deaths are in yellow. Chronic respiratory disease is in light green. Heart disease deaths, by far the largest category, are in brown, and flu and pneumonia deaths are light blue. All of these five major causes of death show a very strange dip or leveling-off trend through the winter of 2020, which has not happened before in the last decade, at least.

Figure 4. US provisional all cause mortality data for 2020 through mid-December (chart compiled by Tam Hunt).

We can see clearly in looking at previous years’ mortality data that peaks in winter mortality always included many categories of deaths peaking along with seasonal flu and pneumonia. And yet in 2020 we’re seeing only slight increases early in 2020 in Alzheimer’s, flu/pneumonia, and diabetes, as well as an early peak in heart disease deaths followed by a relatively sharp decline or leveling trend in all of these categories. They should be peaking again with Covid-19 deaths during the winter, as has always happened in previous years, but they’re not.

The anomalous nature of these small peaks, or lack of peaks entirely, for each mortality category is made clear in the following chart. Note how previous winter peaks in mortality are always the result of peaks in almost all of the deaths categories, led by heart disease and flu/pneumonia.

Figure 5. US CDC all cause mortality data 2014-Nov. 2020 (chart compiled by Tam Hunt).

On a related note, Canada appears to be doing similar “borrowing”, according to a recent analysis of Canada’s Covid-19 deaths: “As 8,795 deaths with COVID-19 were recorded, there were 10,295 fewer deaths ascribed to cancer, heart diseases, lung diseases, stroke, pneumonia and influenza. ‘Government records indicate that deaths from cancer, heart diseases, lung diseases, stroke, pneumonia and influenza have dropped by more than 10,000 during the first eight months of 2020, and are at their lowest point in years,” states Justice Centre President John Carpay.’”

The similarities across countries in these trends is readily explained when we realize that they almost all follow the WHO death certification and coding guidelines as described at CDC’s website: “Causes of death are coded according to the International Classification of Diseases, 10th Revision (ICD–10). On January 31, 2020, the World Health Organization (WHO) established a new emergency code for COVID-19: U07.1.”

In sum, it seems clear that CDC is “borrowing” significant numbers of deaths in many major categories and counting them as Covid-19 deaths, reducing those other causes of death commensurately. This is particularly the case in nursing home and long-term care home populations because these populations have such a high mortality rate even in normal times.

But aren’t some deaths still being caused by Covid-19?

Considering the totality of the data, including the large spike in deaths in the spring of 2020, it is still likely that a significant number of the nursing home Covid-19 deaths did in fact result “from” the virus, rather than from other causes, including overly aggressive use of ventilators (one peer-reviewed study found that 97% of NY and NJ Covid-19 patients placed on mechanical ventilators from March to May of 2020 died), particularly in the spring. But it seems that many of the deaths, perhaps a large portion, associated with Covid-19 in 2020, including in the spring, actually died from other, normal, causes that commonly afflict the elderly. We are forced to this conclusion when we consider the five-month normal median survival time for long-term care patients, and approximately 1.3 million nursing home deaths that result from the basic fact that nursing home residents don’t survive long even in normal times.

The spring peak in deaths outweighs significantly the 2019 and previous years’ mortality numbers, so even when we account for “borrowing” we still see a significant upward trend in deaths, particularly in the elderly, as Figure 6 shows. We cannot explain all of these deaths through borrowing because the overall numbers of deaths have risen too. There are, however, a number of discrepancies in the data behind Figure 6 that a later essay will address in detail.

Figure 6. Weekly death counts by age group (source: CDC).

Additionally, Covid-19 victims have averaged 2.9 comorbidities (other serious medical conditions that may have led to death), according to the CDC, up from 2.6 in the first version of this data that was released over the summer. CDC states (see the notes for Table 3): “For deaths with conditions or causes in addition to COVID-19, on average, there were 2.9 additional conditions or causes per death.”

Another consideration must be mentioned, but I won’t dwell on it in this essay. It is also likely that a significant number of the increased Alzheimer’s/dementia deaths we have seen in long-term care homes are due as much or more to increased isolation and loneliness (in many cases, extreme isolation such as being locked in one’s bedroom for months on end with no visitors allowed) in long-term care homes and elder populations more generally, than from the virus itself. As mentioned above, an earlier essay focused on long-term care patients and Covid-19 reviewed the data regarding isolation and loneliness being major causes of death in these populations. Figure 7 shows the ~125,000 excess deaths tracked by CDC in 2020 that are not attributed to Covid-19, including as a very large category a significant excess of Alzheimer’s deaths (40,000).

Figure 7. CDC excess deaths not attributed to Covid-19 (source).

In conclusion…

In sum, we may explain a substantial portion of CDC’s Covid-19 death count through this examination of the CDC’s stated practice of “borrowing” from pneumonia deaths by including non-flu-related pneumonia deaths as Covid-19 deaths, and by a similar but unstated practice of “borrowing” other categories of deaths, such as heart disease, cancer, and respiratory disease, in the Covid-19 deaths count.

As more data comes in, I’ll update my analysis.

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