Tuesday, August 7, 2012

Oh Dear, Doctors Put Profit Ahead Of Patient Care?

  Well, as a New York Times investigation reveals, it is tragic doctors can provide unnecessary billable care. But where did they learn this practice? Titling their exposé, Hospital Chain Inquiry Cited Unnecessay Cardiac Work, reporters Reed Abelson and Julie Creswell describe the problem. 
  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 company’s hospitals in Florida. In a follow-up interview, the nurse said a doctor, at the small coastal city of Fort PierceLawnwood Regional Medical Center, performed heart procedures on patients who didn’t need them and put lives at risk.
  “It bothered me,” the nurse, C. T. Tomlinson, said in a telephone interview. “I’m a registered nurse. I care about my patients.” In less than two months, an internal investigation by HCA concluded the nurse was right. According to a confidential memo written by a company ethics officer, Stephen Johnson, and reviewed by The New York Times, “The allegations related to unnecessary procedures being performed in the cath lab are substantiated.”
  Punchline: The contract of the nurse, Mr. Tomlinson, was not renewed. A move Mr. Johnson said in the memo was in retaliation for his complaints. And no doubt The Times assessment of the ethics officer’s intent might be fairly accurate, but using the word retaliation in the memo is probably prosecutable and doubtful an ethics officer is that dumb.
  But the nurse’s 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.
  As noted by The Times, HCA is the largest for-profit hospital chain in the United States with 163 facilities. They uncovered evidence as far back as 2002, and as recently as late 2010, showing some cardiologists at several of its Florida hospitals were unable to justify many performed procedures. In some cases, doctors made misleading statements in medical records to make the procedures appear necessary, according to internal reports.
  Questions about medical procedures necessity, especially in cardiology, are not uncommon. None of the internal documents reviewed calculate just how many of such procedures there were or how many patients might have died or been injured as a result. But documents suggest HCA’s problems went beyond a rogue doctor or two.
  At Lawnwood, according to a confidential 2010 review, half the performed invasive diagnostic procedures known as cardiac catheterization, or 1,200, were determined to have been done on patients without significant heart disease. HCA countered recently with a different analysis, saying the percentage of patients without disease was much lower and within national averages. Seeming to contradict their uncovering improperly diagnosed shortcuts to revenue.
  Documents show 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 an outside expert later suggested might have been unnecessary. The man had to be revived and according to the testimony of Dr. Aaron Kugelmass in a medical hearing on the case, “They shocked him twice and got him back.”
  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. Not good, but has it served a real purpose showcasing doctors as the scapegoats in the astronomical rising of medical care cost?
  On Monday morning, in an investors conference call, company executives disclosed that in July the civil division of the United States attorney’s office in Miami requested information on reviews assessing the medical necessity of interventional cardiology services provided at 10 of its hospitals, in Florida, and two or three in other states. In the conference call and in a Web site statement, the company also referred to inquiries by The Times. HCA’s stock ended nearly 4 percent lower Monday, at $25.55. But of course doctors aren’t under enough pressure as it is, so all of them should suffer for there not being a coherent bottom line.
  In a recent HCA statement, the corporation declined to provide evidence it had alerted Medicare, state Medicaid or private insurers of its findings. Or that, as required by law, the socialized entities were reimbursed for any of the procedures the company later deemed unnecessary. Accountants can count, so what’s the problem?
  The statement said, “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.” So really the actual cost of medical care is obviously distant and removed from the actual doctor/patient relationship with both helplessly lost in the customer management quagmire that no one entity such as a private enterprise or government can solve. But make a real effort, at least, of more substance than just calculating profit while ignoring how that became the only real bottom line worth striving for.
  HCA also declined to show that it had ever notified patients who might have been entitled to compensation from the hospital for any harm. While some doctors accused in the reviews of performing unnecessary procedures are still practicing at HCA hospitals, while the real problem seems to be an obvious misdiagnosis of who the real victims are?
  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-mail company response. 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.” Get em. Sick em. How dare anyone want more compensation than our elected officials while under the Medical Industrial Complex watch?
  Details about procedures and company knowledge 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 reveal 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. Logical. Whatever else would the purpose of the financial management sector be?
  HCA denies its decisions were motivated by financial considerations, but rather to “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. More people, doctors or not, involved in patient care should be a good thing. No?
  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. HCA’s Florida hospitals provide about 20 percent of the company’s revenue, from which the doctors honestly receive ?.
  The need to root out Medicare fraud, billing for unnecessary procedures, for example, is high for all hospitals. In 2003, Tenet Healthcare agreed to pay $54 million to settle unnecessary cardiac procedure allegations that were 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 with the Justice Department involving a huge Medicare fraud case that eventually came 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 company’s chief executive. He was removed from the post by the board but was never personally accused of wrongdoing. How could anyone atop such large structures be personally accountable for anything? It’s not the military for gosh sakes.
  As part of the settlement with the federal regulators, HCA signed a 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. Right, the corporation won’t stand still preparing more doctors’ heads to roll.
  Michael Hirst, a former assistant United States attorney in California, who oversaw the case against Tenet, said 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.” Mr. Hirst now represents whistle-blowers. Get em. Sick em.
  In its statement, HCA said it fulfilled any obligation it had under the agreement to report “substantial overpayment.” Certainly no confusion anything comes before that stack of money. However The Times states 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, and uh oh further muddling the issue, political controversy. In 2006, HCA was taken private by a group of private equity firms, including Bain Capital, co-founded by Republican presidential nominee Mitt Romney. Of course Mr. Romney by that time was no longer a Bain partner, just a dependent receiving free enterprise entitlements as everyone should know. But putting more carpenters to work, with medical coverage, should justify that. By mid-2010, the private equity owners were eager to start cashing out their investment. So HCA prepared for an initial public offering of its stock that took place in 2011, borrowing $4.3 billion to pay the private equity firms dividends. While 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. As The Times titles the next section of their article, An Early Sign of Trouble stating 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 HCA hired outside consulting group 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, and was providing the report to a United States attorney and would refund any inappropriately submitted hospital claims.
  Jack O. Bovender Jr., who was then the company’s chief executive, told investors in a conference call that February, “This issue at Cedars and the steps taken to investigate and resolve it should be seen and understood in the larger context of HCA’s commitment to quality care and patient safety.” However 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 attorney’s office in Miami declined to comment. God bless transparency.
  According to HCA the hospital allowed four of the physicians to return under monitoring, 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. 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. But 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.
  So late in 2003, executives from HCA’s 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. Hindsight I’m sure all of us wish we could afford to keep us in line at our own jobs. And who watches the watchers exactly?
  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.” Yet who is responsible this kind of practice became seen as a shortcut to prosperity in the medical field? Weren’t oaths taken to protect customer rights at all costs? Maybe once the number involved, who’d never taken the Hippocratic Oath, was so overwhelming corruption became the major game and player in all our communities across America?
  On the team’s recommendation, HCA brought in an external company, CardioQual Associates of Franklin, Mich., in 2004 to examine medical records from Bayonet Point. In a December 2004 confidential memo reviewed by The Times, CardioQual concluded as many as 43 percent of 355 angioplasty cases, where doctors performed invasive procedures to open up a patient’s arteries, were outside reasonable and expected medical practice. Worse, the investigation revealed 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 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 wasn’t 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 HCA’s hospitals in western Florida, and Charles R. Evans, a Nashville executive who was president of all of HCA’s 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.”
  But 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 general’s 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 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. Agarwal’s procedures were found to be within established medical practice, and his full privileges were reinstated in early 2006. Uh oh. Everyone has reports and findings they want to hear as business remains as per usual. As 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.
  In for the kill the last section is titled A Moneymaking Practice by The Times.
Cardiology is a lucrative business for HCA, and the profits from testing and performing heart surgeries played a critical role in the company’s bottom line in recent years. Some of HCA’s 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. You just have to lovingly hate the willingness to belittle the needs of the individual patient under the system’s care.
8/7/2012
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October 4 - ..., 2018
Oh Dear, Doctors Put Profit Ahead Of Patient Care?
8/7/21012 concluded: 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. You just have to lovingly hate the willingness to belittle the needs of the individual patient under the system’s care.
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Our Noblest, Best and Brightest Compromised
  Pursuit of truth's often muddled. The doctor patient relationship scattered to the winds of economic oblivion is what's not faced, taken in hand and solved. The price of everything is out of context to the consumers' actual ability to pay. Co-pay should be an out of pocket charge for an actual cost, and not a bill of dimensions so endlessly carved and picked apart that nothing's really to do with the health of health care. Where underutilized doctors and nurses aren't needed in this one huge pile of conglomeration. The relationships are with statistics and not patients with their doctors. The horror and shame of this nightmare on everyone's shoulders hinges on everyone's absolution from the blame. Just because all out exploitation was where things were going, doesn't mean change has to remain the same inconclusivity.
  Files aren't patient-doctor relationships. 
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Climate Change
  Too serious. Not serious enough. The denial's been back-brakingly regressive in the ongoing experienced future. Tree lover or tree shrugger? Cutthroat philosophy. We're tied to economic levers rather than moving them. Heartlessly contrarian? Yeah, that'll maintain things. Wrapped however you please.
  That look at what I can do attitude's quite similar to what's gotten away with, when toxicity lasting past our lifetimes is evidence of time marching on despite, and not because of, us. Be realistic? Selfish. Bah. Humbug. Smarter than this? Why when we don't have to be's proven therapeutic? 
  "We're the hottest country in the world." So, then there's no reason to not face whatever's misplaced in understanding our world. Perhaps the notions of entitlement that've so twisted our universe, the word's meaning and usage so repetitious - that's all - repetition. Out of sorts such that nothing's faced when confronting anything at all. Starting for instance with the situation in the city where the above quote's deliverer's from. Where adequately supervised and financed housing supported a very lucrative career. However the balance sheet's tallied. So then to justify some things at least on a culture-wide understood level we're told to see public housing as an under-appreciated failure. The marketing of less expensive housing hardly describes what we built for ourselves. Going on the prejudices of his time, and his own, Robert Moses designed New York City Public Housing barracks style, such that when you walk the narrow halls the only thing that separates you from the feeling this is exactly like a prison is the absence of cell bars. And even prisons are better supervised than the systematically shortsighted management of public housing. Saving money not having doormen as thoroughly run buildings have and maintenance crews assigned to individual buildings they're responsible for. As is, maintenance can seem to roam looking for the next apartment scheduled for maintenance when no one's home. One thing the working poor do is work. 
The Soapbox View pursues the ornery Legacies of Murphy BrownAndy Rooney 
and I.F. Stone.

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