Monday, December 6, 2010

Just follow the Money for Cardiac Stents

History repeats itself again with the new expose' in the New York Times about the Baltimore Cardiologist who inserted (at the least) 585 stents in patients who did not need them.  On one single day he inserted 30 stents!  I didn't know there was that much time even available in the cardiac cath lab but with Medicare reporting payments of $3.8 million for a two year period to Dr. Mark Midei,  I guess it isn't a surprise that he might have worked "overtime".

The Times article is pretty scathing and implicates his hospital, St. Josephs,  who treated him like a king and gave him a $1.2 million dollar salary just to be on the medical staff and bring those $10,000 cases to their institution.  St. Josephs settled with the OIG by paying a $22 million dollar fine for charges that it paid a kickback to Dr. Midei.

Abbott labs, the maker of the expensive stent, was thrilled with his excessive surgeries and showered additional millions in consulting fees and perks for the good doctor since he was one of their best customers.  The fact that he inserted 1200 stents annually, a number that would raise professional eyebrows, didn't phase the stent maker.

I mention history repeating because there have been a number of similar high profile cases across the country over the past 5 years.  In 2005 a group of cardiac surgeons in Redding, California and the hospital owned by Tenet Healthcare paid nearly $1/2 billion to settle charges of unnecessary surgery.  The cardiologists did not lose their licenses.  Can you believe that?

Other cases include another Maryland cardiologist and a Louisiana cardiologist who did jail time for similar offenses.

About 1 million angioplasties are done in the United States each year and half are for non-emergencies. Studies reported in the New England Journal of Medicine in 2006 and 2007 showed that stents were unnecessary in many cases and that patients who received medication instead of stent had a slightly longer life expectancy.  NEJM also estimated that 100,000 heart attack patients in the U.S. do not need stents even though they are placed.   A 3rd article in NEJM in 2009 showed stents have been overused and cause potentially dangerous care.

So how do these cardiologists and hospitals continue to get away with it?  The decision to place a stent is often made "on the spot" during the angioplasty based on the doctors impression of how much blockage is seen.  The patient is told he had a 90% blockage and "isn't it lucky we found it in time and saved you from a heart attack?"  Patients see the cardiologist as a savior.   (I know Cardiologists who have received vacations, cruises, tickets to the Super Bowl from grateful patients)

Invasive Cardiologists who bring in the business are treated like kings at the hospital.   The "rainmaker" top physician is often the director of the cardiology catheterization lab.  Other specialist doctors are often part of the same group and the cardiology departments are small.  The hospital likes being the epicenter of cardiac referrals and has no incentive for enforcing peer review of the cases.  Dr. Midei ran the peer review at St. Josephs, guaranteeing no-one would be looking at his work.

Almost all of the surgery abuses at all of the hospitals over the past 5 years were discovered via a whistleblower.  I do not know of one that was discovered because of peer review.

St. Josephs Hospital was accredited by The Joint Commission last month and is in full compliance with all applicable standards.

Go figure!

20 comments:

Linda Leighton said...

WOW! That was a real eye opener. Thanks for making us aware of this, Dr. Brayer. Your blog is always so informative and interesting. It's a bright spot each morning.

DrPaula said...

This is a poor reflection of our peer review process. If we do not do a better job of policing ourselves someone else will.

BobbyG said...

585 unnecessary stent px's? In addition to perhaps criminal fraud sanctions, I'd say there are 585 civil lawsuits there.

Anonymous said...

I find your blog and posts like this incredibly valuable.

KM said...

Dr.Brayer, besides getting a 2ed opinion with a doctor at another hospital then the original doctor is affiliated with is there any other way to protect ourselves, relatives and friends from this kind of fraud,greedy and unethical physician/hospital behavior?

I know also sometimes it might be too urgent time wise for a 2ed opinion or an HMO might not authorize it so unless the patient is on a PPO they might not have the freedom.

Toni Brayer, MD said...

KM: Getting 2nd opinions is good if you have the luxury of time, but as you point out, that is not often how health care is delivered and in emergencies one just needs to trust the physician.

The good news is that most doctors are honest and have the patient's best interest in mind.

We doctors have to do a better job of examining ourselves and each other. We need a culture of peer review that calls out these outliers when we see them.

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