Medicine may finally be facing its own Enron moment

March 07, 2010|By Jay Hancock

As the century's sleazy first decade coasted to a finish, medicine was perhaps the only profession to emerge unslimed.

Wall Street and bond raters caused 10 percent unemployment. Businesses cooked books. Journalists fabricated. Priests abused. Intelligence analysts found fantasy nukes.

But doctors, again near the top of last year's Gallup "honesty and ethics" poll, may be prepping for their own Enron moment. Allegations that hundreds of patients at St. Joseph Medical Center received what might have been unneeded heart stents would, if true, combine Bernard Madoff-style fraud with Toyota-style injury.

And it might not be an isolated instance.

"There are probably a lot of cases like this" at hospitals across the country, says Dr. Christopher Mallavarapu, a cardiologist who implants stents at hospitals in southern Louisiana. "It's like incest. Nobody wants to talk about it."

He should know. Years ago, he noticed that his partner, Dr. Mehmood Patel, was installing many more stents for opening clogged coronary arteries than he was. And bringing in a lot more money.

When Mallavarapu pulled out the files, he was surprised to see that Patel was putting stents into unblocked vessels and billing Medicare and insurance companies for the work.

After years of litigation, Patel was sentenced in June to 10 years in prison for health care fraud. He's appealing, according to news accounts. Two hospitals in Lafayette, La., paid millions in federal settlements.

Mallavarapu and other doctors describe an environment in most hospitals where there are huge incentives to insert unneeded stents and shockingly few checks and balances to discourage them. However, only a few cases have come to light.

"You have a system without a lot of fail-safes, where a bad apple can do really bad things," says Dr. Robert Wachter, a medical professor at the University of California, San Francisco, who has written extensively about patient safety. "Even in a setting where the hospital administration was doing the right thing, where peer review was working as normal, that was accredited by the Joint Commission, you could see where this could continue for a long time."

Hardly anybody looks over stent doctors' shoulders. Stents are installed without a radiologist bringing a second set of eyes to diagnostic scans. The same doctor usually orders an artery study, reads the results, decides to operate and installs the little wire mesh that props open a vessel.

In a system designed to uncover botched surgeries and incompetent doctors, there are few measures to expose skillfully executed but unnecessary surgeries, doctors say. And even if nurses, technicians or hospital managers figure out what's going on, the negative consequences for speaking up are enormous.

"The hospital just got $10,000" for the stent implant, Mallavarapu said. "If I'm the nurse and I complain, I'm going to get fired. Anything you do to interfere with the medical-industrial complex is not a good idea."

In his case, Mallavarapu's lawyer urged him to contact a federal prosecutor. He eventually collected a "whistle-blower" award of a little more than $1 million, but much of that was spent on legal fees and taxes. He's still practicing in Lafayette, where he says he is "tolerated," but he cautions anybody reporting a rogue doctor to get ready for a long and stressful fight.

"If I did it for the money, it was definitely not worth it," he said.

He wants to sound the alarm about the huge dollars made on stents and the absence of safeguards against unneeded implants, which not only cost taxpayers and insurers millions but endanger patients and require blood-thinning drugs. He has approached people on Capitol Hill in Washington, he says, and gotten no response.

"I think he is absolutely right," says Dr. Jon Resar, director of the adult cardiac catheterization laboratory at Johns Hopkins Hospital. "There's really, in truth, not a lot of overview of the vast majority of cases that are done in catheterization laboratories," where stents and plaque-clearing balloons are inserted.

The lesson for patients is unambiguous, doctors say. Unless it's an emergency - you're having a heart attack - make clear to the cardiologist that you to want to see the angiography films before and after a stent implant or other procedure.

Consider insisting on a second opinion before a stent goes in - even though that involves two procedures instead of one. Insurers in New Jersey require a second opinion in nonemergency cases, says Resar. New York puts cardiac diagnoses and surgical results on the Web, not filed in some drawer.

"There have got to be independent people looking at this," says Resar. "It's a vicious circle because the hospitals have often just built new heart institutes, they want to pay the bills and so on," which increases pressure to perform surgeries.

Towson-based St. Joseph, which starting in December told 369 patients treated by Dr. Mark Midei that they might have received unnecessary stents, says it has hired a "corporate responsibility officer" and begun reviewing at least 10 heart catheterization procedures a month and 5 percent of the cases per year for the most active doctors. Midei has said he expects to be exonerated.

What a great idea - checking a small fraction of stent and other cath procedures to make sure they're needed. If St. Joseph wasn't doing that before, and if most hospitals aren't, either, who knows how many patients are walking around with unneeded scaffolding in their arteries?

What we do know, emerging from a decade of fraud and trouble, is this: When trusted figures are tempted to cheat by big dollars and lax supervision, many succumb.

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