KFF Health News journalist Jordan Rau and New York Times data reporter Irena Hwang teamed up to uncover a disturbing trend among rehabilitation facilities owned by for-profit companies. Their story, “Even Grave Errors at Rehab Hospitals Go Unpenalized and Undisclosed,” looked at inspection reports, lawsuits, government data and corporate records, finding that Encompass Health, a key player in this arena, had major safety problems — including patient deaths — yet federal officials did little to penalize them.
In this How we did it, Rau and Hwang shed light on the specifics of their investigation and offer ideas for how other journalists can investigate for profit facilities in their community or state. Many of their suggestions can be used for reporting similar stories within other health care sectors as well.
What prompted you to look into rehab hospitals and Encompass Health specifically?
Rau: There’s been a wealth of great journalism and academic research on the increased for-profit presence in the health insurance, nursing home, hospice, psychiatric and home health industries. But there’s been no substantive reporting on medical rehabilitation hospitals for people needing intensive physical, occupational or speech therapy.
A well-regarded congressional agency called the Medicare Payment Advisory Commission, or MedPAC, has tracked the growth of for-profit medical rehab hospitals and noted their high operating margins and the fact that one chain owns an unusually large portion. MedPAC also highlighted differences in some key quality measures between for-profit and nonprofit. We thought this was worth looking into.
Did the results surprise you? Why/why not?
Hwang: Our analysis focused on three performance metrics defined by the Centers for Medicare & Medicaid Services, or CMS, as well as a tally of serious problems revealed through inspections. Two of the metrics, which were about readmission rates, showed that Encompass facilities accounted for a disproportionate share of performance classified as statistically significantly worse than the national rate. However, the third CMS metric, about patients returning to their homes, showed that Encompass facilities tended to perform better than the national rate.
At first glance, these results may seem to be contradictory. But there’s a subtlety, which is that readmission metrics say something different than a metric like return to community does. A facility can do well by sending a large proportion of patients home, but it’s also important to consider how a facility ranks in terms of its patients who are readmitted to a general hospital for potentially preventable reasons.
While these results were initially a bit surprising, the readmission trends we found between for-profit vs nonprofit facilities were similar to those found in peer-reviewed journal articles by academics who have spent years studying this stuff, like the researcher we quoted. We presented both types of metrics because they each tell you something about a rehab facility’s performance and are each important for readers to know about.
Rau: I was surprised [by] how rapidly the composition of the inpatient medical rehabilitation industry had changed. Our data analysis showed that in 2012, 41% of patients were admitted to for-profit rehabs. By 2023, 61% were. In our reporting, we were able to explain how Encompass Health has been expanding into new markets by striking deals with nonprofit hospitals, where the nonprofits got equity in the new hospital in return for closing their own rehab units.
How did you find patients/families willing to talk? Did you obtain actual copies of complaints or lawsuits? Did patients or lawyers reach out to you?
Rau: Locating people — especially ones willing to go on the record, and who have reliable documentation of their care — is often the hardest part of health care stories. I searched court records in counties where rehab hospitals were located and also scoured social media and consumer review sites.
I was able to identify some people by matching those findings with inspection reports we had obtained. We caught a lucky break when we noticed that one hospital had (presumably inadvertently) included the names of patients on its plan of correction, which is the formal response a health facility must make to a health inspection report that has identified deficiencies.
You lay out your methodology very clearly at the conclusion of the story. What else should local reporters know if they want to replicate this approach for facilities in their state?
Hwang: There’s quite solid public data available about rehab facilities and hospitals. But reporters interested in doing a similar analysis should keep in mind that each data source may span different timeframes or may even be missing a little information.
Make sure you supplement information about things like hospital name and profit status from one dataset to another, as appropriate. And note that these may also be out-of-sync with figures reported in a company’s SEC filings and other reports. So, as always, just make sure that the numerators and denominators you’re using pass basic sanity checks, and that you’re always comparing “apples” to other apples, so to speak.
What advice do you have about filing FOIAs or pursuing some of the settlement information, particularly if reporters work for smaller outlets without the resources of KFF Health News or The Times?
Rau: Since state health agencies perform complaint inspections on behalf of CMS, you should look to them first. Some states post the inspection reports on their websites (often in obscure places), but others make you file public records requests and may try to charge you. You can also ask CMS for the inspection reports, known as Form 2567 surveys. They are public documents and exempt from FOIA, and you won’t be charged for them.
We found the CMS press office was responsive when we asked for just a few, but the second time we requested a comprehensive database, they made us go through the FOIA office. We ultimately had to sue. After CMS settled the Freedom of Information lawsuit KFF Health News brought for the entire database of rehab hospital inspection reports, the agency added the reports to the hospital survey database it already posts on its website as a result of AHCJ’s efforts.
It’s still important to get PDF copies, because while the database version has a column indicating immediate jeopardies, the most serious type of violation, it lacks the introductory portion of the inspectors’ reports that would contain the text that explicitly explains what prompted the immediate jeopardy. And some of the state versions contain the hospital response — the aforementioned plan of correction — which can contain good details for your story.
If you do need legal support for a state or federal public records request, try contacting the Reporters Committee for Freedom of the Press, which can help line up pro bono attorneys and has a special program to help local reporters.
It took expertise to analyze all of this data. What tips do you have for local reporters looking to analyze data from CMS or other official sources? And in this era, can journalists trust the data being posted?
Rau: As far as we can tell, Medicare’s oversight of health care facilities has been largely spared the tumult going on in the federal government. As of six months into the new administration, we haven’t seen any changes in the way the federal government regulates health care facilities, or in the data it posts on data.cms.gov or Medicare’s Care Compare.
What other sources might be available to cross-check the information?
Hwang: Cross-checking and understanding potential limitations of data are so important! It’s so obvious I feel silly even saying it out loud, but don’t be afraid to seek an expert who can help you. Look for researchers who might have analyzed the same subject, or even the same database. Often, they’ve spent way longer on a topic than a journalist has, and they can provide a good gut-check about whether something has gone awry with the data. Or, lean on your reporting partner who has spent years immersed in CMS data — at least that’s what I did in this story!
I also found it helpful that two sets of information (PDFs of inspection reports and aggregate statistics on readmission rates reported by CMS) seemed to be telling the same story. While the inspections and metrics were both by CMS, they each examined slightly different facets about IRFs. The fact that the results aligned helped my confidence in our findings.
Any other advice for journalists interested in doing deep dives into local facilities, whether skilled rehab, nursing homes or hospitals?
Rau: These stories are easier to do on a local or state level than nationally. There are fewer facilities to look at, and you’re more likely to already be familiar with them. The first steps I recommend are checking county courts for lawsuits, getting the inspection reports and understanding what data exists on a federal or state level.
The federal data sets are easy to find at data.cms.gov/provider-data. Read the data dictionary first. Some states have their own data and do additional inspections. Be aware that if you’re looking into assisted living facilities, those are only regulated by states, not the federal government.
It’s also good to think about how you are going to assess performance. It may be how quality has changed over time. Or how one facility or subset of facilities compares to the group. Or how your area’s health providers compare to a state or national average. Or what new issues have developed that didn’t exist before?
Jordan Rau, a reporter for the nonprofit KFF Health News, has been writing about hospital safety since 2008. Irena Hwang specializes in data analysis for The New York Times.
