By BOB WACHTER, MD
A couple of months ago, a Baltimore reporter called to get my take on a scandal at St. Joseph’s Hospital in Towson, an upscale suburb. A rainmaker cardiologist there, Dr. Mark Midei, had been accused of placing more than 500 stents in patients who didn’t need them, justifying the procedures by purposely misreading cath films. In several of the cases, Midei allegedly read a 90 percent coronary stenosis when the actual blockage was trivial – more like 10 percent.
Disgusting, I thought… if the reports are true, they should lock this guy in jail and throw away the key. After all, the victims now have permanent foreign bodies in their vascular beds, and both the stent and the accompanying blood thinners confer a substantial lifetime risk of morbidity and mortality. As I felt my own blood beginning to boil, the reporter asked a question that threw me back on my heels.
“Why didn’t peer review catch this?” he asked.
Hospital peer review is getting better, partly driven by more aggressive accreditation standards for medical staff privileging. In my role as chief of the medical service at UCSF Medical Center, I’m now expected to monitor a series of signals looking for problem doctors: low procedural volumes, unusual numbers of complications, and frequent patient complaints, unexpected deaths, and malpractice suits. When a flashing red light goes off, my next step is to commission a focused review of the physician’s practice. The process remains far from perfect, but it is an improvement over the traditional system, in which docs tapped a couple of their golfing buddies to vouch for their competence.
But cases like Dr. Midei’s don’t trip any alarms. Most of his patients were probably quite content – many had chest pain and a stent undoubtedly seemed like an appropriately aggressive, high-tech cure. “He put two stents in almost immediately,” said one grateful patient. “I felt relief.”
Although this patient, 66-year-old Peggy Lambdin, later received a letter indicating that her coronary artery was less than 50 percent blocked (clinically meaningless and not an indication for stenting), she was unfazed. “No one can ever tell me that I didn’t need that stent,” she told the Baltimore Sun. “I feel like [Dr. Midei] saved my life.”
Moreover, I’m guessing that Dr. Midei’s complication rate was quite low, as it usually is when one does procedures on healthy people. He probably followed all the protocols mandated by accreditors and the relevant specialty societies. (Oh yeah, except for the ones regarding professionalism.)
The problem is this: as long as the cardiologist reading the cath is the one who pulls the trigger on the intervention, we have a potential Fox/Henhouse problem. Every time a respected professional commits egregious fraud (think Jayson Blair or Bernie Madoff), the same question arises: is there any way to pick the few bad apples out of some very large barrels?
Obviously, the Mideis of the world could be caught by requiring that every cath undergo an independent second reading. Some insurers in New Jersey now require such readings before they authorize a stent, and at least one SoCal Kaiser hospital mandates that each cath be presented at a conference before a treatment decision is rendered, analogous to what many tumor boards do for cancers.
Such required peer review might have benefits beyond simply preventing the rare case of fraud. If done well, it might also ensure that other conflicts of interest and non-evidence-based decisions are avoided to the degree possible. For example, a meta-analysis in last month’s Annals of Internal Medicine illustrates the limited value of percutaneous coronary interventions – whereas older studies found that PCI was more effective than medical therapy in treating angina, more recent studies show that these differences have narrowed or even vanished. I’d guess that, when recommending a treatment for a patient with mild angina and a 60% LAD lesion, a peer review group is more likely to pay attention to this kind of evidence than the average cath jock – who may not only be staring at his kid’s private school tuition bill but also at a patient whose bias is to see a stent as a more intuitively satisfying solution than “just medications.”
Some will argue that mandating second opinions for every cath is the equivalent of hitting a nail with a sledgehammer, and they might well be right. However, I do favor at least random over-reads of a sample of catheterization studies. Something like this already happens in a few specialties. In many teaching hospitals, a random sample of pathology studies is reviewed by a second provider. In a few forward-thinking practices, radiologists re-read a sample of x-rays, looking for discrepancies. In response to this case, in fact, St. Joseph’s now requires that 5% of its cath cases undergo a random and blinded re-review. Random audits won’t catch every case of fraud, any more than IRS audits catch every tax scofflaw. But they do help keep people honest, particularly if the audits are coupled with a culture in which the docs welcome feedback and strive for continuous improvement.
Speaking of which, the Midei case made me wonder about the institutional culture at St. Joseph’s. Was Midei a rogue interventionalist working in isolation? Perhaps so – it’s common for no other doc to be looking over the shoulder of a cardiologist and his cath readings. But cardiologists don’t perform caths on desert islands – they are assisted by cath techs and nurses. In my experience, these folks become as adept at reading cath films as any physician. If the allegations against Midei are true, it strains credibility to think that no one in the lab knew that inconsequential lesions were being read as tight stenoses and treated with stents.
And what about the hospital administrators? Stents are big business. When Johnson & Johnson first launched their drug coated Cypher stent in 2003, Dr. Midei told the Baltimore Sun, “This is the hottest thing in cardiology in years.” And it was: Maryland hospitals chalked up nearly $250 million in stent business in 2009, and St. Joseph’s stent revenues were $38 million, up more than 50% in 5 years. Before the case broke, St. Joseph’s advertised itself as the busiest cath hospital in Maryland, averaging nearly 20 interventional cases daily. While it is possible that no St. Joe’s leader knew precisely what was happening, I’m guessing that some did but chose to look the other way: the pressure to steer clear of the golden-egg-laying goose must have been intense. Perhaps the fact that the hospital’s CEO and two other senior executives resigned after the case broke provides a clue as to who knew what when.
Cases like this one are terribly troubling, not just because they harm individual patients but because they do violence to the trust that is so fundamental to the physician-patient relationship. Part of the solution must be more robust oversight procedures, such as mandatory second readings of randomly selected cath films.
But these cases also force us to consider the kind of culture that could allow such a fraud to take root and go on for years – a culture that likely prized the hospitals’ and physicians’ financial health over the clinical health of their patients. If the allegations are true, the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or should have known – what was going on, yet remained silent.
Robert Wachter, MD, is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”
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This like the article in Vanity Fair on the sugeon out of Chicago performing hundreds of rhinoplasties and the Wall Street Journal article on the surgeons in Rapid City flying around in personal jet planes after opening a specialty hospital are all the reasons I advocate transparency. Publish on the internet the cost per patient per year for every physician in America! At least the public money spent ie Medicare and Medicaid, let the private insureres and millionaires sho pay out of pocket fend for themselves. Surely some enterprizing journalist will do a better job given the data than our conflicted peer review providers. Break this down by zip code and specialty or better yet by procedures ordered and see how long the scammers will continue to order hundreds of motorized wheelchairs order thousands of MRIs in their personal radiology centers and then inject the thousands of backs and joints with therapies that do not provide any benefit.
This is a great article. Our company provides external peer review services to leading hospital groups and ASCs across the country, to resolve exactly the types of issues that were raised above. The peer review process has been around for a long time, but most people know that it doesn’t work very well in many hospitals, due to one key issue: conflict of interest. Over-utilization and outright fraud are on the rise, and many hospitals are integrating external peer review into their performance improvement and quality management systems as a best practice. To lower the cost and improve the return on investment, we have developed a proactive and systematic review product called PeerScore OPPE which is perfect for summarizing physician performance and determining appropriateness of care on a random sampling of cases. We’re seeing lots more interest in monitoring interventional cardiology practices as a result of some of the issues raised above. External peer review offers a good solution in cases where there are political and social sensitivities, where there are conflicts of interest, where there is suspected over-utilization, or when a physician or group of physician’s core measures are beyond acceptable levels. More info at http://www.alllmedmd.com
Someone I know has said he knows of another hospital doing this. And when his friend, a cardiologist, reported this to be happening to administration, he was told that he was in breach of HIPAA for looking at the patient’s angiogram. He was threatened with dismissal.
Apparently the cowbow cardiologist is keeping the hospital afloat.
All hearsay of course …
Someone I know has said he knows of another hospital doing this. And when his friend, a cardiologist, reported this to be happening to administration, he was told that he was in breach of HIPAA for looking at the patient’s angiogram. He was threatened with dismissal.
Apparently the cowbow cardiologist is keeping the hospital afloat.
All hearsay of course …
Someone I know has said he knows of another hospital doing this. And when his friend, a cardiologist, reported this to be happening to administration, he was told that he was in breach of HIPAA for looking at the patient’s angiogram. He was threatened with dismissal.
Apparently the cowbow cardiologist is keeping the hospital afloat.
All hearsay of course …
Someone I know has said he knows of another hospital doing this. And when his friend, a cardiologist, reported this to be happening to administration, he was told that he was in breach of HIPAA for looking at the patient’s angiogram. He was threatened with dismissal.
Apparently the cowbow cardiologist is keeping the hospital afloat.
All hearsay of course …
Someone I know has said he knows of another hospital doing this. And when his friend, a cardiologist, reported this to be happening to administration, he was told that he was in breach of HIPAA for looking at the patient’s angiogram. He was threatened with dismissal.
Apparently the cowbow cardiologist is keeping the hospital afloat.
All hearsay of course …
Someone I know has said he knows of another hospital doing this. And when his friend, a cardiologist, reported this to be happening to administration, he was told that he was in breach of HIPAA for looking at the patient’s angiogram. He was threatened with dismissal.
Apparently the cowbow cardiologist is keeping the hospital afloat.
All hearsay of course …
Someone I know has said he knows of another hospital doing this. And when his friend, a cardiologist, reported this to be happening to administration, he was told that he was in breach of HIPAA for looking at the patient’s angiogram. He was threatened with dismissal.
Apparently the cowbow cardiologist is keeping the hospital afloat.
All hearsay of course …
Someone I know has said he knows of another hospital doing this. And when his friend, a cardiologist, reported this to be happening to administration, he was told that he was in breach of HIPAA for looking at the patient’s angiogram. He was threatened with dismissal.
Apparently the cowbow cardiologist is keeping the hospital afloat.
All hearsay of course …
Yes. A problem. Over-testing and over-treating is rampant in our modern healthcare environment. This systemic problem exists primarily because the patients are insulated from the direct costs. The healthy market forces of pricing and payment for service by the individual are largely absent. If medicare-Peggy was told, “now ma’am, I want to perform this procedure and it is going to cost $40,000…” she might have said, “gee, doc, that’s a lot. What do you think. Is there anonther way? Can I wait? Do I really need this? Can I get a second opinion?” Over-reliance on the impersonal, bureaucratic, lumbering third-parties invites abuse and excesses.
That is just a wonderful attitude, Dr Bev MD. “We’ll just have to get there and find out.” Well, I hope your crystal balls are more accurate than the growing lies this legislation is showing itself to be. And, since you seem to be one who is rather ignorant of history, repeating mistakes is so educational! I am sorry I come across rude and insensitive, but, I see the writing on the wall, and it can’t be printed here!
Politicians cannot be trusted to guide health care initiatives. And if you have watched what has come out from political initiatives, that is the truth and facts.
You know, naivetee and wishful but clueless optimism does not serve our patients well. I once had these foolish traits, and then the process of living in reality basically pummelled me into accepting the truth. Healthful and appreciable patients often do not thank us at the beginning of treatment, but, if they realize our deeds match our words, and we perservere with them in the process of healing and caring, they often say, in so many words at times, “thank you for being the bastard I thought you were in the beginning”.
Unfortunately, the adage, “no pain, no gain”, has its applicability in the process. I know, I have lived it personally and with my patients, and I have to remind myself the ones I work the hardest for do appreciate my efforts in the end. Not the majority though, these days, is it?
Exhausted;
Actually the Reagan quote only applied to your second paragraph. You see, I live with someone of your political bent and he can’t keep politics out of a single conversation either, so my tolerance is low. (:
However, I do sympathize about your ostracism; I have seen that happen and it is shameful. I just don’t think ANYONE (least of all Maggie M), despite the confident predictions from all sides, really knows what will happen in 2014. We’ll just have to get there and find out.
That random chance moment has come and gone, eh, Bev MD?
One would think after reading that a person went to bat for the community and was treated as a leper by his alleged colleagues, that would get a pinch of some sympathy, but, you quote Reagan. There’s a person who really had the best interests of the community at heart, his own circle of community! I don’t quote Ronald Reagan as a source of inspiration and hope. Ask the Air Traffic Controllers how they feel after they named the airport outside DC after that person!
And it is not going back to making peanuts that is the answer, sarcasm or not by your comment. It is about making the fair and reasonable income anyone should be able to pursue, and all these commenters who continue to want to sell the public that we are “public enemy #1” in this debacle Washington is trying to pawn off, well, just keep laughin’ it off, bev MD.
We’ll see who is laughing last in 2014. Don’t think it will be many doctors. There is no humor in pain and suffering, and we are not interested in “told you so’s” when we will have to be sifting through the debris field this legislation will have created!!!
I’m not looking for accolades, but allies.
As Ronald Reagan said, “there you go again.” ((:
But I agree about the docs; only when they are all making peanuts will it go back to attracting people who want to help people – but who may be considerably dumber…..
Bev MD:
Thank you for the support. And, having once gone the full mile and filed complaints against a colleague and institution, and then been effectively ostracized by alleged colleagues who took the same oath I did, it is one reason why I have little faith these days with our peers. And readers need to consider this. As long as doctors act like they still practice in a fraternity, and not for a community, realistic respect will never be appreciably earned.
Frankly, I am not totally surprised that Obama is pulling off this farce of allegedly helping Americans. After all, who really with foresight and integrity has spoken out forcefully and earnestly against this and shown the public the true light? Cowards and whores. That is what doctors, in general, have become. Maybe not the majority, but tolerating even a sizeable minority taints us all!
Exhausted MD;
Although I often do not agree with your comments, you are dead on target on the “fraternity mindset”. Often this is driven, unfortunately, by the idea (fact?) that a physician will lose referrals/business if he/she speaks out about a misbehaving colleague. As you point out, this attitude has done our profession no good and has led to us being trusted only slightly more than lawyers nowadays. (Well, perhaps I exaggerate a bit.) The public, who really has no way of knowing anything, of course jumps on the bandwagon as they do with every public figure or profession who is vilified…..human nature, I guess.
Wow, I am amazed at the cynicism about peer review by propensity and Energetic MD, although the latter’s credibility is marred by the gratuitous swipe at Beth Israel. I don’t know where you guys work, but at my community hospital system peer review was alive and well, performed by each department’s unpaid chair, assisted by the Medical Staff Office staff; and reported to Med Exec each month.
Either you all work at academic centers, or the medical staff has allowed itself to be co-opted by administration, or both. None of these possibilities are good. Speak up!
Excellent post which really emphasizes the continued need for more aggressive peer oversight as we try to transition to a more value-based health care system.
The real problem however may preempt the actual cath (or in my case peripheral intervention), and relate to the initial indication rather than the degree of blockage. Ask your cath lab to publish their normal cath rate or justify extensive stenting a femoral artery for mild claudication, I suspect you’ll encounter some push back.
We are struggling with the oversight for indications which may be supported by best practices (ie Cochrane’s, etc) but are easily justified given the doc-patient interaction that relies on significant subjective criteria…ie “my chest pain (leg pain) is extremely crushing and really impacts my life”, or “I really want something done”. These are frequent ‘justifications’ we hear at our peer-review conferences, making altering behavior very difficult. It is much easier to show a film with a mild stenosis and then ask why did you do this?
I suspect that the pressure will eventually come from the institutions as they increasingly rely on outcomes and cost data to get paid. If we as practitioners don’t jump in, it will be another lost opportunity for maintaining control.
Maggy M,
This is one of the more logical statements you have made:
“As you suggest, we also need to take a close look at letting one doctor do the cath–and then decide on the need for intervention.”
For years, I performed diagnostic caths only, a filter for interventions, if you will. I did not perform angioplasties or implant stents because I would I would have had to “generate” volume to maintain credentials that were dictated by the stent prolific chief of cardiology. Neither the insurance carriers nor the hospital administration
were enamored with the idea of waiting a day to perform the intervention, if after careful thought, it was determined to be indicated. I persevered.
Since malpractice insurance carriers charge the same for physicians performing left heart caths only or left heart caths plus interventions, once the payment for a diagnostic cath was reduced to a pittance, I resigned left heart cath privileges.
My patients, despite best efforts, often got more than was indicated, or less when the easier, but wrong vessel, was stented. The stenters are uncontrollable.
Extras are always the case with cardiac surgeons, bypassing extra vessels (3 instead of 2) that do not need them, or chest tubes for small pleural effusions when draining a pericardial effusion.
ExhaustedMD – I agree that to paint all docs with the brush used to outline this particular fraudster is wrong. I do think, however, that NOT bringing it to light only makes the rest of us think there’s even more to hide. It’s because there is inadequate self-policing that everyone gets a bad name. And more importantly, to me at least – that any reporting is kept from the public. If more was known by the public – I would trust more. Transparency is trust.
If there’s a bad cop – the public has a right to know – if there’s a bad doc or hospital putting profits before people – the public has a right to know. The more we know the more we’re likely to trust our physicians and hospitals.
Related tangentially, how does having For Profit Hospitals effect the upcoding and unnecessary procedures?
Hospitals continue to use patients as grist for their cash registers. Not exclusively limited to churning in the cath lab or operating rooms,the EMR will facilitate fraud by printing out extensive progress notes to enable upcoding. The hospital administrators need to be subject to physician review. Hospital administrators are commonly in violation of Joint Commission Standards. The physicians do not have recourse. BODs are not accountable. The BODs are appointed by the CEOs. They are afraid to speak up. They enjoy having lunch downtown at the exclusive clubs. When it comes time to run a hospital, they vacate.
At BIDMC, one honorable BOD member resigned in response to the conduct of the rest of the BOD in its vacated accountability towards its unethical and irresponsible CEO.
One of the problems with this story, as was covered in The Sun, the local paper, is that it metastasizes into “all doctors are frauds or in collusion with the crooks”. Well, as I pointed out in a letter, if a cop is found to be committing crimes, is that an indictment of all police? No. Yet, as I have commented here in the past and now, we are in an environment that is quick to villify MDs now, so this story is only validation to the doctor bashers. Who I guess are hoping that Nurse Practitioners will replace us?
Yes, there are doctors who do irresponsible and terrible things. But, what is as bad is our peers do not make the effort to report those who are impaired or inappropriate. Well, one thing I have always resented in my training was this “fraternity” mindset that seems to validate the concerns of the public. Sorry, colleagues, but if I come across doctors who practice recklessly, irresponsibly, or frank criminally, I will speak up. It is sad that I am a lone voice, in my opinion.
How much do you want to bet this doctor gets a minimal consequence? We’ll see.
What are you smoking, Bev?
The peer reviewers are officers hand picked by the administration and serve in paid jobs, such as Med Staff President, Chief Medical Officer (“VP Medical Affairs”), etc. All are suck-ups and mouth pieces to and for the administration. That is how they got their jobs. All peer review is sham peer review, at the behest of the administration.
I think we are straying a bit from the point. Peer review is a medical staff function, not an administrative function. Properly constructed quality indicators should catch these things, by random over- reading of caths if necessary, as Dr. Wachter points out. This is meant to counteract the tempting dilemma presented to administrators regarding the $$ issues. I think the reporter’s question was a fair one and the public has a right to expect peer review to catch outright fraudulent doctors to the extent possible.
Opponents of peer review have raised the specter of competitors’ bias – e.g. having the doctor’s competitors over-reading the caths with perhaps a conflict of interest to either collude with him or kill his business. Some hospitals, as suggested by rbar in another post (see “Glass half empty, half full”) use blinded, off site peer review to compensate for this.
Yes, Bob, administration had to have known: with digital labs, the techs record and measure the stenosis. Any single case of a 10% lesion getting a stent would have been reported to the cath lab supervisor, then the cath dept director, then the Heart Center Executive Director, then the COO, then the CEO.
Over 300 unnecessary stents means that after just 2-4 unnecessary stents, the CEO had to have told everyone back down the chain to “shut up and just do it…it’s research”.
In fact, this CEO and two other administrators at Towson have resigned.
This CEO came from St Joes in Lancaster that was driven under financially and had to be sold because he constructed a “Heart Hospital” scheme to pay docs for referrals – a scheme that after costing patients $2M in consulting fees, the OIG ruled was fraud but did not prosecute because no money had changed hands to the docs yet.
So, the CEO then got this huge promotion from the health system, Catholic Health Initiatives, to Towson CHI’s “flagship heart hospital”. Hopefully, the feds will look into the hiring practices and total lack of Board fiduciary and compliance oversight by CHI as well …
The stent implant work at academic medical centers pays for the salaries of nearly all internal medicine faculty. The hyped benefits of stents were published by academic medical centers and any reports that had a chance of strangling the goose laying the golden eggs were denigrated by the same centers. The news media hyped the advances even though 80 mg per day of lipitor was proven equivalent if not better than stent implantation for patients with stable coronary disease.
You forgot to mention that as medicare and other payors pay less per diagnostic coronary angio (about $250 nowadays, down from $625 a few years ago), the stent implant rate went up (eyes see, hands work). For a few more minutes of work, why not implant a stent for a 50% lesion and take home another $500?
Bob,
Where have you been? The less they are paid, the more are done. You hit upon the inflationary force which has perverted hospital administrators, stentomaniacs,peer reviewers (selected by admin), stent makers, general surgeons, employed hospital physicians, radiologists, pcps, and the team.
Should any one disrupt the food chain going to the pockets of the admin, the tongue is removed.
There are reports out of a $ 8 billion non profit in Pittsburgh that at least 15 “leaders” take home more than $ 1 million. To do that, docotros complain that they manipulate its ranch of doctors to keep the operating rooms full, to see more patients per hour, to keep the scanners running 24/7, to self refer for hang nails, and to churn patients from hospital to its lab and lab affiliates, senior living, rehabs, snfs, transitional cares, while allowing a patient to die on its roof.
I dare you to complain.
“And what about the hospital administrators? Stents are big business.”
So, are peer reviews counter to hospital income goals?
Expensive procedures without any solid justification for health care spending is would really create a sense of a fraud system and abusive health cause. However, if this expensive procedures will have an equal treatment among patient’s health care, then its worth it spending such amount.
Bob–
Thanks very much for a post that highlights what so many patients don’t want to believe–but do need to know.
When medical professionals write about these abuses, patients pay attention. At the same time, you’re helping to heal that crucial trust between doctor and patient that rogue docs like Midel are undermining.
As you suggest, we also need to take a close look at letting one doctor do the cath–and then decide on the need for intervention.
Moreover, as you point out, this doctor wasn’t doing caths “on a desert island.” Others must have noticed the high volume. . .
But hospital administrators don’t like to challenge the rain-makers. Meanwhile, nurses and even doctors know that they put their careers in jeopardy if they try to report them… (I wrote about what happened to one whistle-blowing anethesiologist in Money-Driven Medicine.)
What you are doing at UCSF to try to pick up on warning signs sounds good. Unfortunately, too many hospital administrators think that their job is simply to grow revenues, and so they will look the other way when a
rainmaker overtreats.
This is the real health system fraud and abuse. Expensive procedures performed without solid justification amount to a high percentage of our health care spending. If we can get this under control, we can truly pay for “health care for all”.