There's nothing wrong in principle with a
for-profit medical system. What's wrong is that
the medical profession has been granted special
privileges by government enabling it to throw a
self-maintained protective barrier around itself
in order to artificially restrict its members'
numbers and maintain their incomes.
Keith
At 05:35 08/08/2012, REH wrote:
The for profit private sector is to the
economics of public health as leeches were to
healthcare 200 years ago. If anyone gets better it's a "fluke."
REH
August 6, 2012 NYTimes
Hospital Chain Inquiry Cited Unnecessary Cardiac Work
By
<http://topics.nytimes.com/top/reference/timestopics/people/a/reed_abelson/index.html>REED
ABELSON and
<http://topics.nytimes.com/top/reference/timestopics/people/c/julie_creswell/index.html>JULIE
CRESWELL
In the summer of 2010, a troubling letter
reached the chief ethics officer of the hospital
giant HCA, written by a former nurse at one of
the companys hospitals in Florida.
In a follow-up interview, the nurse said a
doctor at the Lawnwood Regional Medical Center,
in the small coastal city of Fort Pierce, had
been performing heart procedures on patients who
did not need them, putting their lives at risk.
It bothered me, the nurse, C. T. Tomlinson,
said in a telephone interview. Im a registered
nurse. I care about my patients.
In less than two months, an internal
investigation by HCA concluded the nurse was right.
The allegations related to unnecessary
procedures being performed in the cath lab are
substantiated, according to a confidential memo
written by a company ethics officer, Stephen
Johnson, and reviewed by The New York Times.
Mr. Tomlinsons contract was not renewed, a move
that Mr. Johnson said in the memo was in retaliation for his complaints.
But the nurses complaint was far from the only
evidence that unnecessary even dangerous
procedures were taking place at some HCA
hospitals, driving up costs and increasing profits.
HCA, the largest for-profit hospital chain in
the United States with 163 facilities, had
uncovered evidence as far back as 2002 and as
recently as late 2010 showing that some
cardiologists at several of its hospitals in
Florida were unable to justify many of the
procedures they were performing. Those hospitals
included the Cedars Medical Center in Miami,
which the company no longer owns, and the
Regional Medical Center Bayonet Point. In some
cases, the doctors made misleading statements in
medical records that made it appear the
procedures were necessary, according to internal reports.
Questions about the necessity of medical
procedures especially in the realm of
cardiology are not uncommon. None of the
internal documents reviewed calculate just how
many such procedures there were or how many
patients might have died or been injured as a
result. But the documents suggest that the
problems at HCA went beyond a rogue doctor or two.
At Lawnwood, where an invasive diagnostic test
known as a cardiac catheterization is performed,
about half the procedures, or 1,200, were
determined to have been done on patients without
significant heart disease, according to a
confidential 2010 review. HCA countered recently
with a different analysis, saying the percentage
of patients without disease was much lower and
in keeping with national averages.
At Bayonet Point, a 44-year-old man who arrived
at the emergency room complaining of chest pain
suffered a punctured blood vessel and a
near-fatal irregular heartbeat after a doctor
performed a procedure that an outside expert
later suggested might have been unnecessary,
documents show. The man had to be revived. They
shocked him twice and got him back, according
to the testimony of Dr. Aaron Kugelmass in a medical hearing on the case.
In another incident, an outside expert described
how a woman with no significant heart disease
went into cardiac arrest after a vessel was cut
when a Bayonet Point cardiologist inserted a
stent, a meshlike device that opens coronary
arteries. She remained hospitalized for several
days, according to a person who has reviewed internal reports.
On Monday morning, in a conference call with
investors, company executives disclosed that in
July the civil division of the United States
attorneys office in Miami requested information
on reviews assessing the medical necessity of
interventional cardiology services provided at
10 of its hospitals, located largely in Florida,
but also two or three hospitals in other states.
In the conference call and
<http://hcahealthcare.com/util/documents/Information_Regarding_NYT_Story_080612.pdf>in
a statement on its Web site, the company also
referred to inquiries by The Times. HCAs stock
ended nearly 4 percent lower Monday, at $25.55.
In a recent statement, HCA declined to provide
evidence that it had alerted
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicare/index.html?inline=nyt-classifier>Medicare,
state
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/medicaid/index.html?inline=nyt-classifier>Medicaid
or private insurers of its findings, or
reimbursed them for any of the procedures that
the company later deemed unnecessary, as required by law.
When the company becomes aware of a situation
in which we might have a reimbursement
obligation, we assess, with outside resources,
what our reimbursement obligations might be, the statement said.
HCA also declined to show that it had ever
notified patients, who might have been entitled
to compensation from the hospital for any harm.
Some doctors accused in the reviews of
performing unnecessary procedures are still practicing at HCA hospitals.
The cardiologists say the reviews of their work
did not accurately reflect the care they
provided, and HCA says the reviews are not, by
any means, definitive, according to an e-mailed
response by the company. HCA says it took
whatever steps were necessary to improve patient
care. It also said significant actions were
taken to investigate areas of concern, to bring
in independent reviewers, and to take action where necessary.
Details about the procedures and the companys
knowledge of them are contained in thousands of
pages of confidential memos, e-mail
correspondence among executives, transcripts
from hearings and reports from outside
consultants examined by The Times, as well as
interviews with doctors and others. A review of
those communications reveals that rather than
asking whether patients had been harmed or
whether regulators needed to be contacted,
hospital officials asked for information on how
the physicians activities affected the hospitals bottom line.
HCA denies its decisions at these hospitals were
motivated by financial considerations, but
rather demonstrate the strong focus we have on
quality patient care. The company also says
that more than 80 percent of its hospitals are
in the top 10 percent of government rankings for quality.
Although HCA has hospitals in about 20 states
from California to Virginia and Alaska to Texas,
Florida, with its large older population, is a
critical and growing market for hospital chains
and especially for HCA. HCAs Florida hospitals
provide about 20 percent of the companys revenue.
The need to root out Medicare fraud billing
for unnecessary procedures, for example is
high for all hospitals. In 2003,
<http://www.nytimes.com/2003/08/07/business/tenet-healthcare-paying-54-million-in-fraud-settlement.html>Tenet
Healthcare agreed to pay $54 million to settle
allegations that unnecessary cardiac procedures
were being performed over six years and billed
to Medicare and Medicaid at one of its hospitals
in California, Redding Medical Center.
But the pressure is even greater for HCA. In
2000, the company reached one of a series of
settlements involving a huge Medicare fraud case
with the Justice Department that would
eventually come to $1.7 billion in fines and
repayments. The accusations, which primarily
involved overbilling, occurred when Rick Scott,
now the governor of Florida, was the companys
chief executive. He was removed from the post by
the board but was never personally accused of wrongdoing.
As part of the settlement with the federal
regulators, HCA signed a
<http://www.oig.hhs.gov/fraud/cia/agreements/the_hc_co_121400.pdf>97-page
Corporate Integrity Agreement that extended
through late 2008. It detailed what had to be
reported to authorities and provided for stiffer
penalties if HCA failed to do so.
If there were intentional violations of such an
agreement, it would mean that a defendant,
already caught once defrauding the government,
has apparently not changed its corporate
culture, said Michael Hirst, a former assistant
United States attorney in California who oversaw
the case against Tenet. Mr. Hirst now represents whistle-blowers.
In its statement, HCA said it fulfilled any
obligation it had under the agreement to report
substantial overpayment. The revelations in
the documents come at a significant time in the
evolution of medical treatment in the United
States from independently owned hospitals to large, corporate chains.
HCA exemplifies the trend. In 2006, HCA was
taken private by a group of
<http://topics.nytimes.com/top/reference/timestopics/subjects/p/private_equity/index.html?inline=nyt-classifier>private
equity firms, including Bain Capital, the firm
co-founded by Mitt Romney, the presumptive
Republican presidential nominee. (By that time,
Mr. Romney was no longer a partner in Bain.) By
mid-2010, the private equity owners were eager
to start cashing out of their investment. While
HCA prepared for an initial public offering of
its stock that took place in 2011, it borrowed
to pay the private equity firms $4.3 billion in dividends.
The ability to take these financial steps hinged
on HCA showing continued robust profit growth at its hospitals.
And for that the company turned, in part, to cardiac care.
An Early Sign of Trouble
Two years after the 2000 fraud settlement,
company executives uncovered problems in the
cardiac catheterization lab at Cedars Medical
Center, according to accounts that became public.
An outside consulting group hired by HCA
provided a report that raised questions
regarding the medical necessity of some of the
procedures, the company said in a news release
in early 2003. HCA said it was suspending eight
physicians from doing certain cardiac
procedures, was providing the report to a United
States attorney and would refund any inappropriately submitted hospital claims.
This issue at Cedars and the steps taken to
investigate and resolve it should be seen and
understood in the larger context of HCAs
commitment to quality care and patient safety,
Jack O. Bovender Jr., who was then the companys
chief executive, told investors in a conference call that February.
HCA will not say whether it had ever refunded
payments for the unnecessary procedures.
Medicare officials said they could not determine
whether the agency had received payments, and
the United States attorneys office in Miami
declined to comment. The hospital allowed four
of the physicians to return under monitoring,
according to HCA, and two did so. We believe
the hospital acted appropriately, the company
said in its recent statement. Still, the
negative publicity swirling around Cedars
worried HCA executives, according to internal
e-mails. They wanted to avoid a replay when
similar problems were discovered at another HCA hospital Bayonet Point.
An Outbreak of
<http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/stents/index.html?inline=nyt-classifier>Stents
Nestled along the west coast of Florida, about
45 miles northwest of Tampa, the town of Hudson,
with its winding canals, is largely a quiet fishing community.
Soon after the Cedars episode, HCA executives
noticed that the hospital in Hudson, the 290-bed
Regional Medical Center Bayonet Point, was
implanting an unusually high number of cardiac
stents, given the size of the population.
Late in 2003, executives from HCAs headquarters
in Nashville dispatched a group that oversees
its hospitals cardiac care to investigate. In a
confidential memo, the team cited incidents at
Bayonet Point where patients were treated for
multiple lesions, or blockages, even when the
second lesion (or third) did not appear to have
significant disease. The team went on to note
several cases in which patients were treated
even though their arteries did not have significant blockages.
In a transcript of confidential hearings held
later, the lawyers for HCA were blunt. In
looking at one physician, Dr. Sudhir Agarwal,
Dr. Martin I. Kalish, a physician who served as
an outside lawyer for HCA, said the style of
clinical practice leads to unnecessary
procedures and unnecessary complications.
On the teams recommendation, HCA brought in an
external company, CardioQual Associates of
Franklin, Mich., in 2004 to examine medical records from Bayonet Point.
In a confidential memo prepared in December 2004
and reviewed by The Times, CardioQual concluded
that as many as 43 percent of 355 angioplasty
cases, where doctors performed invasive
procedures to open up a patients arteries, were
outside reasonable and expected medical practice.
Worse, the investigation revealed that some
physicians had indicated in medical records that
the patients had blockages of 80 to 90 percent
when a later, more scientific analysis of a
sampling of cases revealed the blockages had ranged from 33 to 53 percent.
Cardiologists generally do not operate on any
blockage less than 70 percent, said Dr. Rita
Redberg, a prominent cardiologist at the
University of California, San Francisco. The
significant disparities between the magnitude of
blockage being cited by the doctors at Bayonet
Point and the CardioQual review raises real
concerns that this wasnt just error, but it was
intent by the doctors, she said.
After receiving the CardioQual report, Bayonet
Point suspended the privileges of nine
physicians in late 2004. But unlike the Cedars
episode, when HCA turned over its findings to
regulators and authorities, HCA took steps to
withhold details of its conclusions to the media
and others, according to internal
communications. In January 2005, David Williams,
who was then the chief executive of Bayonet
Point, wrote in an e-mail: Clearly, we have
protected ourselves under the peer review
umbrella and have released very little
information. The recipients of his message
included Dan Miller, who then oversaw HCAs
hospitals in western Florida, and Charles R.
Evans, a Nashville executive who was president
of all of HCAs hospitals on the eastern side of the country.
In his response, Mr. Evans thanked Mr. Williams
for the update and asked for a summary as to the business impact.
In a later internal communication, a
representative for HCA said the company had
successfully used confidentiality rules to
withhold the damaging CardioQual report from the
Florida attorney general, whose Medicaid Fraud
Control Unit had started an investigation of the
physicians. In response to questions from The
Times, however, HCA said it had provided
substantially all of the information in the
report to state regulators. The attorney
generals office did not return calls seeking comment.
One of the subjects of that investigation was
Dr. Agarwal. The CardioQual review of 20 of his
cases concluded that fewer than half were within
reasonable and expected practice. Dr. Agarwal
did not return a call to his office.
Anthony Leon, a lawyer for Dr. Agarwal and the
other eight Bayonet Point physicians, said in a
statement: There is absolutely no merit to any
allegation that any of these doctors were
performing unnecessary procedures or performing
procedures that led to unnecessary complications
as a style or pattern of practice. The
suspensions of Dr. Agarwal and another physician
were found to have been done in error by an
outside panel in hearings in 2005 and 2006, Mr.
Leon added. A doctor on the panel said Dr.
Agarwals procedures were found to be within
established medical practice, and his full
privileges were reinstated in early 2006.
Dr. Agarwal and the other eight physicians have
filed defamation lawsuits in county court,
claiming the actions and statements of the
hospital and HCA ruined their practices. HCA has denied the claims.
HCA would soon discover its problems didnt end at Bayonet Point.
A Nurse Speaks Out
C. T. Tomlinson said he could not believe his
eyes as Dr. Abdul Shadani prepared to insert a
stent in a heart patient in the cardiac
catheterization lab of HCAs Lawnwood hospital in the late spring of 2008.
Mr. Tomlinson, a traveling nurse who had worked
at more than a dozen cath labs before arriving
at Lawnwood, said in a telephone interview that
he saw no blockages in the images of the patients artery.
Sir, what are we going to fix? Mr. Tomlinson
recalled asking Dr. Shadani. The doctor
responded by asking the nurse if he did not see
the 90 percent blockage in the artery. Mr.
Tomlinson did not, and looked at the others in
the room. They all shrugged, he said, and Dr. Shadani inserted the stent.
Mr. Tomlinson reported his concerns to hospital
officials. Shortly after, he was told his
contract would not be renewed. An internal memo,
however, concluded that Mr. Tomlinson had been
retaliated against. Even so, that summer the
hospital opened an investigation. Internal
communications show that HCA officials in charge
of quality were involved in the decision to
review a sample of cases from some cardiologists at the hospital.
The reviewer, an outside heart specialist,
concluded there were problems with 13 of the 17
cases performed by Dr. Shadani, including
unwarranted cardiac catheterizations and
patients who were needlessly subjected to multiple procedures.
While it is not clear whether HCA accepted the
reviewers findings, Dr. Shadani continues to
practice at Lawnwood, according to the Web site.
Dr. Shadani did not return several telephone calls seeking comment.
The outside reviewer found similar problems with
several other cardiologists at Lawnwood. The
company declined to say whether it alerted
regulators or patients of its findings but it
said it established stricter rules governing how
cardiologists should document their cases.
A Moneymaking Practice
Cardiology is a lucrative business for HCA, and
the profits from testing and performing heart
surgeries played a critical role in the companys bottom line in recent years.
Some of HCAs busiest Florida hospitals perform
thousands of stent procedures each year.
Medicare reimburses hospitals about $10,000 for
a cardiac stent and about $3,000 for a diagnostic catheterization.
But in recent years, doctors across the country
have been less quick to implant stents, instead
relying on drugs to treat blockages. Medicare
has also questioned the need for patients who
receive cardiac stents to stay overnight at the
hospital, cutting into the profitability of the procedures at many hospitals.
HCA has more than 100 catheterization labs
across the country and the one at Lawnwood was a
financial juggernaut. It accounted for 35
percent of the hospitals net profits, according to financial documents.
In fact, one of the physicians from Lawnwoods
cardiac cath lab, Dr. Prasad Chalasani, was
highlighted by the hospital in a 2009 business
plan as being the most profitable doctor at the
facility. Our leading EBDITA MD, the plan
described him. (Ebitda, or earnings before
interest, taxes, depreciation and amortization,
is a measure of corporate earnings.) Just a few
months earlier, hospital executives had received
an outside review that characterized Dr.
Chalasani as too quick to perform
catheterizations, often without first doing the
stress tests necessary to determine whether a
patient needed the invasive and costly test.
When reached by telephone, Dr. Chalasani
defended his work, saying the 2008 findings were
the result of poor documentation about what had
occurred before the patients received the
catheterizations. The tests were done, he said.
Dr. Chalasani emphasized that he was not paid by
the hospital, and had privileges at other
hospitals. Since 2008, he said, doctors have
improved their documentation. Among the changes,
he said, is the use of forms requiring the
doctors to indicate that they are following established guidelines.
To my knowledge, we have made tremendous progress, he said.
The questions raised by the 2008 incident might
have ended there if not for Mr. Tomlinsons 2010
letter to Alan R. Yuspeh, the head of HCAs
ethics and compliance. HCA undertook another
review of Lawnwood and some of its other
hospitals in Florida, including Kendall Regional
Medical Center, in Miami, and Palms West
Hospital, near West Palm Beach. The results
showed that some patients without heart disease
were receiving questionable treatment, and HCA
has responded by conducting still more reviews.
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Keith Hudson, Saltford, England http://allisstatus.wordpress.com
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