Family swamped by avalanche of bills after son’s death: 'It’s continuous'
After their seven-month-old son James died in hospice nearly three
years ago, the Cavatores face hundreds of thousands in medical bills –
despite having insurance
by Jessica Glenza - The Guardian - June 4, 2019
Twins Thomas and James Cavatore were only about a month old in winter 2016, still in the neonatal intensive care unit at a Houston, Texas, hospital, when the bills started rolling in. Just as steadily as Thomas improved, James deteriorated, undergoing nearly a dozen operations and as many emergency room visits during his short life.
James was just seven months old when he died in hospice. But the Cavatore family would be haunted by an avalanche of bills for years to come, despite having medical insurance.
“I got one bill, and it was $1.1m,” said Federico Cavatore, the boys’ father. “I joked to myself, I said, I’m going to frame this and put it in Thomas’ room and say, ‘This is why you’re getting a scholarship to college.’”
The Cavatore family’s situation is a graphic illustration of an American health system, where medical bills can feel like a second trauma, even for those who have health insurance. It can financially break those who don’t.
For the Cavatores the uncertainty and bills were part of how their health insurance was designed to function, and part of a larger trend of private health plans pushing costs on to patients.
The Cavatores were hit with “surprise bills”, expenses for medical supplies, co-payments and deductibles, and calls from bill collectors. James’ birth and treatment probably cost the family close to $38,000 out-of-pocket, though they were served with bills charging them many times that amount, forcing them to spend hours challenging the claims and bringing their financial costs down, even as their emotional costs spiraled upwards.
Even now, nearly three years after James’ death, it is unclear whether the family still owes money to doctors and the hospital where James was treated, Memorial Hermann. Their story is emblematic of America’s deeply flawed healthcare system, similar versions of which play out every day, in every corner of the country.
“Almost everything in health economics in the US is complex, difficult to explain and somewhat arbitrary and idiosyncratic,” said Dr John Lantos, a bioethicist and expert in neonatal intensive care units.
In the US health system, “everybody’s always getting ridiculous bills that they thought were covered by their insurance”, said Lantos. “I never pay attention to any medical bills I get for six months, because it seems like it takes that long for the hospital to deal with the doctor.”
But that hardly accounted for all bills. Physicians in Texas, even those whose specialized skills are only available in hospital settings, don’t work for hospitals. They charge separately, and are exempt from not-for-profit hospital “charity” policies. Feeding bags, night nurses and out-of-network providers were also their own category of bills.
Nearly three years after James’ death, the family has been unable to determine exactly how much they might owe, or have paid.
In one typical insurance document the Cavatores received, called an “explanation of benefits” by their insurance company, they were told that as of October 2016 they “may or may not have to pay” $387,270.69 to doctors and hospitals.
In March 2018, Federico was told the family’s balance was “zeroed out”. As recently as January 2019, Elle Cavatore said she received a phone call from Memorial Hermann asking for $11,000 for the twins’ care. The hospital offered a “payment plan”. Insurance documents described bills for hundreds of thousands of dollars the family “may or may not have to pay”.
“I need to close it in my own mind, and move on from this, but it’s continuous,” Federico said.
The Guardian could not determine an exact amount the Cavatores may owe because of restrictions on patient records and the large number of providers involved in their case. Although the Cavatores gave the Guardian access to hospital records to tell this story, Memorial Hermann declined to comment, citing patient privacy.
“While we are unable to comment specifically due to patient privacy, we express our deepest sympathies for the loss this family has suffered,” Memorial Hermann Health System said in a statement. “We recognize that healthcare billing can be complex and, like many health systems, we are committed to helping patients and their families better navigate the billing process and to making care more affordable for all.”
But she found out early in the pregnancy her twins were “mono-mono” or “momo” – short for monochorionic-monoamniotic twins who grow in the same amniotic sac. James and Thomas were so close in the womb her obstetrician initially thought they were conjoined, Elle said.
“They were nervous enough to have me go in for monitoring,” said Elle. During one of those visits, “one of the hearts stopped” momentarily, “a few seconds”. Elle was immediately sent to a hospital maternity ward, where she was on bed rest for nearly five weeks.
One day her husband came to visit, and in hopes of private time, she asked a nurse to check the twins’ vitals early.
“I’m so glad I did, because if I hadn’t said, ‘Do it right then’, they probably would have both died,” Elle said. “Right at the moment she put the monitor on my stomach, she noticed one of the heart rates was going up, and accelerating and then decelerating.”
The babies’ umbilical cords had twisted. With both babies in the same amniotic sack, doctors couldn’t figure out which child was under stress, so they rushed to deliver. Aides cut off Elle’s clothes and she was put under anesthesia for an emergency cesarean section.
“The next thing, when I woke up, the babies had been born,” said Elle. The babies were delivered at exactly 28 weeks and six days. Thomas was 2lb 9oz, and James was 2lb 12oz.
Both babies immediately went to the neonatal intensive care unit, a hospital ward with ultra-specialized equipment and staff designed to care for tiny babies. Both breathed through tubes and lay in incubators with round-the-clock nursing. The Cavatores could not hold their children.
It soon became apparent James was much sicker than Thomas. Within two weeks, James needed cardiac surgery to help a heart valve close, a chest tube to breathe, surgery for a tear in his intestines, and was later diagnosed with retinopathy, a condition which left him blind.
But by far the most serious complication James faced was severe bleeding in the brain. James had a grade IV intraventricular hemorrhage (IVH), a condition where tiny vessels around the brain’s spinal fluid-filled areas – called ventricles – rupture.
To relieve the condition, a shunt is placed. This is a tube which drains spinal fluid from the brain to the belly, regulating pressure. The risks accompanying these surgeries are profound.
Over the course of seven months, James underwent nearly a dozen surgeries, as his parents attempted to cope with the pressures of caring for a child with overwhelming needs and overwhelming costs.
“My pediatrician said: ‘You should be eligible for 24-hour nursing with the feeding tube and not being able to sleep, because you had to feed him every five hours,’” said Elle, “But they said we made too much money to be eligible for that. We were paying a night nurse just a couple nights a week so we could have two nights a week to sleep.”
Every feeding bag cost the family $5. They used about four a day. Then there was special formula. Once, James’ two-year-old older brother pulled out one of his brother’s tubes, called a Mic-Key button, and he had to be rushed to the emergency room. All of it costs money.
“They recommended we have [physical] therapy three times a week for both [twins],” said Elle. “But you only are allotted a certain number of visits [by insurance], and then you’re paying out of pocket, and it’s expensive, too. You want the best for your child.”
Night nurses rarely lasted two weeks. Elle suspected they were scared by the child’s fragile condition. Her stepsister helped pay for medical supplies and bills.
After three months of maternity leave – something just 15% of American workers receive – Cavatore left her job to care for the twins full-time. As a result, the family was forced to switch from employer-provided insurance to the individual marketplace commonly called Obamacare, a pejorative used by Republicans to describe the safety net which caught the Cavatore family.
“I was sitting outside the NICU trying to figure out what to do,” said Federico, about how to pick a health insurance policy. When they switched to Obamacare, the family was suddenly forced to pay $1,600 a month to maintain health insurance. “We paid that for a year.”
During this time, the Cavatores said they were able to ignore the letters demanding money. But the burden became greater with the phone calls.
“I [would] just get calls from random different collectors like: ‘You owe this from the gastroenterologist’ and ‘You owe this to the ophthalmologist’,” said Elle.
“It mean it was like survival mode for us,” said Federico. “I felt like it was all about the money. It was a horrible experience.”
They were ripe targets for fraud. With so many bills at once, it was impossible to sort which were legitimate, which they should pay right away and which might eventually be resolved by their insurance plan.
It was during this time some of her highest bills rolled in – including $387,270.69 from Memorial Hermann, from a time when Elle was listed as uninsured in their system.
After months of sleeping in the NICU, bringing James to the emergency room every week or so, of sleepless nights, midnight phone calls from nurses, heart-wrenching decisions for one brutal surgery after another, James developed bacterial meningitis, which caused swelling of the tissues surrounding his brain and spinal cord.
“By that time he was just in such bad shape. They were giving him anti-seizure medications,” said Elle. “He looked so beaten and bruised up … One neurologist had given me a pretty rosy outlook.”
Then, a new doctor came in the room.
“She just announced to us: ‘I don’t expect him to walk, talk, he is deaf, blind – I can’t see why they told you that,’” said Elle. “I just burst into tears.”
It was nearly the end of the road.
To put their son in hospice, the Cavatores had to argue their position before the hospital’s ethics board, before residents and physicians. Among the panel, just one physician wanted to operate again. Memorial Hermann would not confirm or deny this portion of the Cavatore’s case, citing patient privacy.
“The hardest thing I’ve ever had to do in my life is talk about wanting to put my son in hospice,” said Federico. “Knowing this was the best thing for him because he was suffering, and they wanted to keep it going.”
“If he did have any type of life, it wasn’t going to be any type of life that anybody was going to want to live, and it was going to be a year or two years,” he added.
While James was in hospice, the Cavatores received a statement from their insurance company, saying they “owe or already paid” $306,357.75. The company would not pay the claims because, the statement said, because “this dependent is not enrolled under this plan. If you can verify this dependent was effective at the time of service(s), we will reconsider this claim.”
James died two days later, on 25 July 2016.
The heroic task of caring for their son was finally over. But the bills resulting from that care were only beginning.
More than 150 million Americans get health insurance through an employer. Although Obamacare helped expand insurance coverage in 2014, it did little to reform employer-sponsored insurance.
Now, coverage among this group appears to be eroding. Nearly one-third of Americans who have employer-sponsored health insurance are underinsured, according to a report from the Commonwealth Fund. About half struggle to pay medical bills, and 41% delayed going to the doctor.
The Cavatores’ bills were a combination of deductibles, co-payments and “surprise bills”. Each year, the couple paid $10,000 in deductibles, a one-time payment required before insurance even kicks in.
Because they also switched insurance early in the year after Elle quit her job to care for her son, which sponsored the family’s insurance, they had to pay an additional $10,000 deductible for a new insurance plan the family purchased.
In addition, they had to pay “surprise bills”, or the cost of healthcare providers their insurance did not cover. Even though the family had insurance, hospitals and doctors negotiate separately with insurance, meaning families can often go to a hospital covered by their insurance, and see a doctor who is not.
The problem is so acute in Texas, a remarkable alliance of insurance companies and consumers groups came together to ask lawmakers to protect consumers. In some cases, people even hire professional medical billing negotiators to try to resolve these bills.
In addition to these expenses, the Cavatores’ insurance switch complicated matters. Some hospital charges appeared to be billed to an old insurance plan, rather than their new one, causing confusion and resulting in bills which it is still unclear whether they are paid today.
Those who buy insurance through Obamacare marketplaces, which the law set up for people who can’t get insurance through an employer, are even more likely to be underinsured.
There have been repeated warning calls about families facing mountainous bills after having a premature child.
As estimated 380,000 babies per year are born prematurely in the United States, about half of them to mothers on Medicaid, reserved for disabled and low-income Americans. Mothers on Medicaid are highly unlikely to receive any hospital bills.
For those with private insurance or uninsured patients, it is a different story.
“The question we face in America, like every other industrialized country and a lot of non-industrialized nations: do we collectively want to spend the money it takes to save these tiny babies? And if so, can we develop a system of financing that’s fair?” said Lantos.
“Most other countries in Europe have NICUs that are every bit as good as ours – nobody gets a bill,” said Lantos. “We in American take a different approach.”
https://www.theguardian.com/us-news/2019/jun/04/us-health-insurance-healthcare-child-death-charged-thousands
What's Doctor Burnout Costing America
by Pien Huang - NPR - May 31, 2019
Doctor burnout is costing the U.S. health care system a lot — roughly $4.6 billion a year, according to a study published this week in the Annals of Internal Medicine."Everybody who goes into medicine knows that it's a stressful career and that it's a lot of hard work," says Lotte Dyrbye, a physician and professor of medicine at the Mayo Clinic in Rochester, Minn., who co-authored the study.
She says the medical profession now carries an increasing load of paperwork and bureaucracy, adding stress to doctor's lives. "We want to be able to deliver good quality care to our patients, and our systems get in the way," Dyrbye says.
The study defines burnout as substantial symptoms of "emotional exhaustion, feelings of cynicism and detachment from work, and a low sense of personal accomplishment." This description tracks closely with the World Health Organization's newly updated definition for burnout.
To put a price on burnout, the study authors culled data from recent research findings and reports — including direct or inferred findings on doctors cutting back on hours or quitting as a result of burnout. They ran a mathematical model to estimate the costs associated with burnout, focusing on the costs of replacing physicians and lost income from unfilled positions.
A previous study, which shares some of the same authors, found that 54% of doctors reported experiencing at least one symptom of burnout, from the Maslach Burnout Inventory, a validated tool for measuring burnout.
Dyrbye says research shows that doctors find meaning in helping patients but are taxed by systemic burdens they consider tangential to patient care. "Cumbersome, inefficient" electronic health record systems; increased reporting requirements; and hectic, irregular schedules cause doctors to feel that they're socially isolated and lack autonomy.
"There is a general sense of loss of meaning [to the work]," she says.
The study authors calculate that for health care organizations, the cost of burnout comes out to $7,600 per physician per year. The study notes that their cost estimate is conservative, only taking into account lost work hours and physician turnover. But other research shows burned out doctors are also more likely to make medical mistakes, have less satisfied patients, and get sued for malpractice, all of which have indirect costs.
Constance Guille, a doctor and associate professor at the Medical University of South Carolina, who was not involved in the study, says that highlighting the economic costs associated with burnout is important work. However, she says, a weakness of the study is that it drew from inconsistent data, an issue baked into the literature: "We're not actually able to measure burnout well," she says.
Guille co-authored a paper, published last year in JAMA, that found at least 47 definitions of "burnout" across 182 studies. From Guille's perspective, mental health diagnoses offer clearer metrics.
"Burnout is highly, highly associated with major depression," she says. "It's measurable, and we have really good interventions for it." She adds that focusing on depression "could improve physician health, and reduce the financial impact of burnout."
The current study is accompanied by an editorial also published in the Annals of Internal Medicine by Edward Ellison, executive medical director of Southern California Permanente Medical Group, a health care provider in the Kaiser Permanente network that employs over 8,500 physicians.
He writes that burnout is associated with "anxiety, depression, insomnia, emotional and physical exhaustion, and loss of cognitive focus." But most concerning, Ellison notes, is that the physician suicide rate is much higher than the general public's and even exceeds that of combat veterans. "[W]e cannot underestimate the urgency, severity, and tragedy of the human cost," he writes.
Doctor burnout has been a known problem for years, the study authors note, and by putting a cost to the problem and using the language of policymakers and CEOs, they aim to compel organizations to act.
"We hope that people will think about these numbers and say: 'If I invested half that amount of money in systems that improve work efficiency, or ways to build better teams to offload some of the workload from the physician, not only is it the right thing to do, but it's also going to improve my quality and safety, and save me some dollars in the end,'" says Dyrbye.
Bottom line, she says, addressing burnout is not just a moral responsibility: It could also be money-saving.
https://www.blogger.com/blogger.g?blogID=3936036848977011940#editor/target=post;postID=6474398631435236390
Editor's Note -
One of the most powerful memes influencing the development of the American healthcare system for the past 40 or so years is that healthcare is and should be a business, governed by the rules of business, including that it should be governed by the principle that increasing shareholder value of healthcare "businesses" is of prime importance, and that healthcare costs should be governed and quality assured by "competition" in the "marketplace".
Consequently, the managers of many hospitals view other hospitals as competitors, and that cooperation among them amounts to collaborating with the enemy. This anti-collaboration bias applies to the sharing of expensive high-tech services as well as the sharing of information, including outcomes data such as morbidity and mortality information.
After about 40 years of experimentation with the competitive model applied to hospitals in the US, the failure of this competitive model to control hospital prices is self-evident. America has the highest, most complex, irrational and secretive hospital prices in the world.
The following clipping is a chilling story about one of the effects of a culture of competition among hospitals on the quality of care - this time lethally afflicting pediatric cardiac surgical services. It's long, but worth reading.
-SPC
Doctors Were Alarmed: ‘Would I Have My Children Have Surgery Here?’
by Ellen Gabler - NYT - May 30, 2019
Tasha and Thomas Jones sat beside their 2-year-old daughter as she lay in intensive care at North Carolina Children’s Hospital. Skylar had just come out of heart surgery and should recover well, her parents were told. But that night, she flatlined. Doctors and nurses swarmed around her, performing chest compressions for nearly an hour before putting the little girl on life support.Five days later, in June 2016, the hospital’s pediatric cardiologists gathered one floor below for what became a wrenching discussion. Patients with complex conditions had been dying at higher-than-expected rates in past years, some of the doctors suspected. Now, even children like Skylar, undergoing less risky surgeries, seemed to fare poorly.
The cardiologists pressed their division chief about what was happening at the hospital, part of the respected University of North Carolina medical center in Chapel Hill, while struggling to decide if they should continue to send patients to UNC for heart surgery.
Dr. Blair Robinson Cardiologist
I ask myself, ‘Would I have my children have surgery here?’
In
the
past,
I’d
always
felt
like
the
answer
was
‘yes’
for
something
simple.
...
But
now
when
I
look
myself
in
the
mirror,
and
what’s
gone
on
the
past
month,
I
can’t
say
that.
And
if
I
can’t
say
it
for
my
kids
—
and
that
should
be
our
group
discussion
—
if
we
can’t
all
look
ourselves
in
the
mirror
and
think
we’re
doing
the
right
thing,
then
we
need
to
change
what
we’re
doing.
That March, a newborn had died after muscles supporting a valve in his heart appeared to have been damaged during surgery. At least two patients undergoing low-risk surgeries had recently experienced complications. In May, a baby girl with a complex heart condition died two weeks after her operation. Two days later, Skylar went in for surgery.
In the doctors’ meeting, the chief of pediatric cardiology, Dr. Timothy Hoffman, was blunt. “It’s a nightmare right now,” he said. “We are in crisis, and everyone is aware of that.”
That comment and others — captured in secret audio recordings provided to The New York Times — offer a rare, unfiltered look inside a medical institution as physicians weighed their ethical obligations to patients while their bosses also worried about harming the surgical program.
In meetings in 2016 and 2017, all nine cardiologists expressed concerns about the program’s performance. The head of the hospital and other leaders there were alarmed as well, according to the recordings. The cardiologists — who diagnose and treat heart conditions but don’t perform surgeries — could not pinpoint what might be going wrong in an intertwined system involving surgeons, anesthesiologists, intensive care doctors and support staff. But they discussed everything from inadequate resources to misgivings about the chief pediatric cardiac surgeon to whether the hospital was taking on patients it wasn’t equipped to handle. Several doctors began referring more children elsewhere for surgery.
[Listen to key moments from the recordings.]
The heart specialists had been asking to review the institution’s mortality statistics for cardiac surgery — information that most other hospitals make public — but said they had not been able to get it for several years. Last month, after repeated requests from The Times, UNC released limited data showing that for four years through June 2017, it had a higher death rate than nearly all of the 82 institutions nationwide that do publicly report.
UNC Health Care defends the surgery program, describing it as “very strong” today and citing its most recent data to support that. It denies any past problems affecting patient care. “We determined,” said Dr. Benny Joyner, chief of critical care at the children’s hospital, that “there is nothing here that is systematic, or systemic that would lead us to be concerned about the performance of operations on children that are high-risk, low-risk, no-risk.”
Other administrators, in a joint interview, said there was “a dysfunctional group” in 2016 that sowed mistrust, creating “team culture issues.” Lisa Schiller, a spokeswoman, said in a statement, “They were handled appropriately, and today we have new team members.” UNC cited leadership changes — most taking effect in 2017 or 2018, including the appointment of a new chief surgeon last year — to help improve the dynamics.
The turmoil at UNC underscores concerns about the quality and consistency of care provided by dozens of pediatric heart surgery programs across the country. Each year in the United States about 40,000 babies are born with heart defects; about 10,000 are likely to need surgery or other procedures before their first birthday.
The best outcomes for patients with complex heart problems correlate with hospitals that perform a high volume of surgeries — several hundred a year — studies show. But a proliferation of the surgery programs has made it difficult for many institutions, including UNC, to reach those numbers: The North Carolina hospital does about 100 to 150 a year. Lower numbers can leave surgeons and staff at some hospitals with insufficient experience and resources to achieve better results, researchers have found.
“We can do better. And it’s not that hard to do better,” said Dr. Carl Backer, former president of the Congenital Heart Surgeons’ Society, who practices at Lurie Children’s Hospital of Chicago. “We don’t have to build new hospitals. We don’t have to build new ICUs. We just need to move patients to more appropriate centers.”
At least five pediatric heart surgery programs across the country were suspended or shut down in the last decade after questions were raised about their performance; a Florida institution run by the prestigious Johns Hopkins medical system stopped operations after reporting by The Tampa Bay Times in 2018. At least a half-dozen hospitals have merged their programs with larger ones to achieve more consistent results. And more institutions are considering such partnerships.
There is no way to know if Skylar or other patients at the North Carolina hospital would have survived or done better had they been treated elsewhere. Surgeries to repair a child’s heart can be risky, and some deaths and complications are inevitable. But doctors and advocates have pushed to make pediatric heart surgery outcomes more transparent, so institutions would feel pressure to improve and parents could better assess the care their child might receive.
About 75 percent of the roughly 115 hospitals that perform pediatric heart surgery in the United States publicly share their mortality statistics on a website run by the Society of Thoracic Surgeons. UNC is not among them.
That information is risk-adjusted to help account for prematurity, some genetic abnormalities and other factors that could make a child less likely to survive, and to more fairly assess hospitals that take on the most compromised patients. The statistical method also helps evaluate if hospitals are losing patients who wouldn’t be expected to die. While there is some debate about whether the data fully captures the complexity of heart surgery, many experts say it is a strong indicator of a hospital’s performance.
“You should think twice about going to a center that doesn’t publicly report,” Dr. Backer said. “People don’t buy a car without knowing what the gas mileage is.”
UNC Health Care contends that using the mortality data isn’t an accurate way to assess its surgery program. The health system first told The Times it was “critically important” to use risk-adjusted data, but then released only raw, unadjusted numbers. The hospital later said no current risk adjustment adequately accounted for the breadth and severity of its patients’ medical issues. The Times is suing UNC for the risk-adjusted data.
This account is drawn from interviews with about two dozen current and former UNC physicians and nurses from multiple departments, as well as with patients’ families and doctors from other institutions. Some people spoke only on the condition of anonymity, for fear of retribution from UNC. The Times also reviewed emails, state death data, medical records and the audio recordings, obtained from someone who felt the institution had not been responsive to repeated concerns about the surgery program.
The recordings caught hours of cardiology department meetings and other discussions that were corroborated by multiple participants. The Times gave UNC transcripts of relevant portions of the conversations and some audio clips, but did not share the full recordings to protect the identity of the person who provided them.
UNC said it would not comment on some of The Times’s findings without an opportunity to listen to the recordings. Dr. Michael Mill, the chief surgeon at the time; Dr. Hoffman; and the four other cardiologists who remain at the hospital declined for the same reason. Dr. Kevin Kelly, who led the children’s hospital until retiring last year, did not respond to repeated requests for comment.
He met with the cardiologists in 2016, soon after they laid out their concerns to Dr. Hoffman. When discussing where to refer patients, Dr. Kelly advised: “Do what your conscience says.”
But, he warned, performing fewer surgeries at UNC could hurt revenues and cost the cardiologists their jobs. “If it reduces the volume of things,” he said, “I’ll just — we’ll just reduce the number of people that we have.”
Dr. Hoffman had been at the children’s hospital just over a year when he was confronted with the cardiologists’ mounting concerns. When he sent out an agenda for a routine department meeting in June 2016, one physician, Dr. Robinson, responded that the only topic should be the surgical results, and said an emergency faculty retreat might be in order. Two others quickly agreed.
The goal for that meeting, Dr. Hoffman said, was “to figure out where to go from here.” He said he and his counterparts from other specialties had had emergency conversations about options, including suspending surgeries and creating a task force to scrutinize the entire system — from critical care to surgery to anesthesia. “This is a program issue. It’s every aspect,” Dr. Hoffman said. “We need to do something.”
The physicians pointed to possible vulnerabilities. In 2015, UNC had lost two pediatric cardiac intensivists, who care for critically ill heart patients. The children’s hospital also had closed its CIC unit, a specialized area for cardiac patients coming out of intensive care; nurses experienced with those patients left. And unlike some larger hospitals, UNC didn’t have a dedicated cardiac intensive care unit, or CICU.
Dr. Timothy Hoffman Division Chief of Pediatric Cardiology
People are well aware. Nobody has their head in the sand like they’re not aware that the lack of cardiac intensivists, and the lack of nurses, and the lack of a carved-out CICU, and the lack of a CIC unit, and the lack of this and the lack of that is not piling up.
I
mean,
our
house
is
in
total
disarray.
This
is
crazy
what
we’re
doing.
I
should
be
as
pissed
as
anybody,
and
in
fact
maybe
more.
I’ve
never
seen
anything
like
it,
quite
frankly.
And
we’re
going
backwards,
not
forward.
Referring patients to other hospitals had been “discussed at a high level,” though nothing had been decided, Dr. Hoffman said. While noting that patient care was “paramount,” he cautioned that referring patients elsewhere could have long-term implications. Administrators might stop investing in the program, he said, as those at some other hospitals were considering.
In a recent statement, UNC said that sending patients to other medical centers had been discussed but was determined not to “be in the best interest of UNC or its most vulnerable patients.” Separately, the five remaining cardiologists, who include Dr. Hoffman, said in a statement that they had always “selectively referred particularly complex patients to outside institutions” but sent “the large majority of patients to our internal team at UNC, because we were confident that they would receive high-quality care.”
The cardiologists acknowledged in the meeting that multiple factors went into successfully managing cardiac patients, but expressed doubts about the chief heart surgeon at the time, Dr. Mill, who performed most of the operations. Just one other surgeon, who was more junior, was then on staff. They did not report directly to anyone inside the children’s hospital, but to the department of surgery within UNC’s broader medical system, which includes five hospitals in a Chapel Hill complex and about a dozen other facilities around the state.
A few weeks earlier, Dr. Mill had not come in on a weekend to perform a transplant on a baby when a donor heart became available, the doctors said. The surgeon’s reason wasn’t clear, but the incident could have led to a shutdown of UNC’s program if the United Network for Organ Sharing, which manages transplants throughout the country, had found out, Dr. Robinson said in the meeting.
The child’s parents, who weren’t aware of what happened, soon transferred her to nearby Duke Children’s Hospital, where she would eventually receive another heart a few months later. But the episode angered several UNC cardiologists.
Dr. Jennifer Whitham Cardiologist
As a mother of three children, oh my God. ... It’s inexcusable. As a physician, I mean, we all took the oath. We are supposed to do what’s right for our patients. ... This is what you signed up for. And who is he to play God with some kid’s life? I can’t get past this. This is beyond horrifying.Dr. Robinson, who has since left UNC, said in the meeting that he worried what it meant for other transplant patients if they couldn’t count on the surgeon to be available. Dr. Hoffman told the group he didn’t think the surgeon had offered an explanation for not doing the transplant. But no matter the reason, he said, the episode suggested that UNC lacked the infrastructure for that type of care.
In a statement, UNC said that under state law it could not discuss personnel information, but noted that no surgeon is on call 365 days a year.
Dr. Mill, now 65, has worked at the hospital for three decades. Parents of some patients described him as reassuring and skillful. Dr. Melina Kibbe, who leads UNC’s surgical department, called him an “outstanding surgeon.” He had never been subjected to disciplinary action by the North Carolina Medical Board, and was sued in the state once for malpractice, but the case was voluntarily dismissed by the patient who filed it.
Colleagues said he was often affable but could bristle when questioned about a case or appear aloof in group discussions. Several physicians said he had not been an effective mentor or leader, a role a chief surgeon is typically expected to play.
Dr. Hoffman told the group that he’d spoken to the surgeon, letting him know the cardiologists might discuss sending patients to other hospitals. “He’s frustrated with the results as well,” Dr. Hoffman said. “He’s wondering what’s going on, himself — with himself.” But, the chief went on, he believed that Dr. Mill was also looking at things that could be improved, like a more consistent operating room team.
Several cardiologists expressed a lack of confidence in the surgeon, without specifying why. Dr. Pamela Ro, who is Dr. Hoffman’s wife, and Dr. John Cotton said the hospital needed a new chief surgeon. Two others said they were not comfortable sending patients to Dr. Mill.
Some doctors also complained that Dr. Mill wasn’t providing mortality data intended to help hospitals assess their performance, improve results and identify trends beyond just one surgery or death. The Society of Thoracic Surgeons organizes and audits the data collection, and prepares extensive reports for each institution.
It also rates hospitals. UNC has one star, the lowest rating. The two other hospitals in the state with comprehensive pediatric heart programs are Levine Children’s Hospital, in Charlotte, with two stars, the middle rating; and Duke, in Durham, which will be upgraded to two stars this summer, according to a report provided by the institution. Each of those hospitals performs a larger proportion of high-risk surgeries than UNC, according to a data analysis, and two to three times as many heart surgeries over all.
UNC told The Times that during part of 2014 and 2015 it lacked a database coordinator — a position it said was difficult to fill — and didn’t submit its data for analysis then. The cardiologists acknowledged this during the meeting, but said Dr. Mill should nevertheless have shared basic statistics that might help them advise parents.
Administrators also told The Times that cardiologists could have tracked patient outcomes by attending morbidity and mortality conferences, where cases are discussed in detail. But the information the doctors sought — broader data to identify trends over time — was not available in those meetings, several doctors said.
Dr. Hoffman told his team in the session that each department, including critical care, anesthesia, surgery and cardiology, would do a “deep dive” to look at its processes. He later added that things would be starkly different in two years, noting that UNC might not even have the surgical program anymore. “This is the fork in the road,” he concluded. But, he said about his patients, “I’m not sending them out of this hospital right now.”
Skylar Jones was a few months old when a cardiologist diagnosed a hole between the upper chambers of her heart, one of the most common and treatable heart defects. Surgery to correct it could wait until she was older, doctors said. She grew into a chatty toddler who bossed around her two older brothers.
By the spring of 2016, Skylar’s mother noticed the 2-year-old was sweating more than usual. Mrs. Jones could feel her daughter’s heart racing when she held her close. The right side of Skylar’s heart was enlarged, a UNC cardiologist said. She would need surgery soon, her parents were told, but her prospects were good.
The operation in June took about seven hours, twice as long as planned. Dr. Mill said the surgery had been more complicated than expected, Mrs. Jones recalled, but Skylar should do well.
In fact, her diagnosis before surgery had been inaccurate, according to her medical records. Instead of the more common condition, a vessel going into the right side of her heart wasn’t fully enclosed, allowing blood to leak into the wrong chamber. The condition, known as an unroofed coronary sinus, required a different repair by Dr. Mill, but one still considered relatively low-risk, with a mortality rate of about 2 percent.
But even given the procedure’s low risk, and that a child of Skylar’s age and overall health would typically be expected to fare well, there were complications. Records show that during surgery, Skylar’s heart stopped beating properly; Dr. Mill put in temporary wires to send electrical signals to the heart. That night in the intensive care unit, a critical care doctor was called to the toddler’s bedside: Her blood pressure was low. She struggled to breathe shortly before she went into cardiac arrest. She was put on life support, with a machine doing the work of her heart and lungs. That puts patients at risk for a cascade of other problems including bleeding, kidney damage and stroke.
After five days, Skylar improved enough to come off life support. But her condition fluctuated over the next seven weeks. According to the medical records, her vocal cords, or the nerve controlling them, had been damaged. That can happen during surgery or when a person is put on life support, making it possible for food or liquid to slip into the windpipe. Eventually, Skylar inhaled something into her lungs, and ended up back on life support. Several times, she had bleeding in her lungs.
By late July, Skylar seemed to have turned a corner. But one day, while watching “VeggieTales,” her favorite TV show, blood began dripping from her mouth, her mother recalled. Nurses said she was all right, but hours later it happened again. Her eyes rolled back in her head. Doctors rushed her into surgery to find the source of bleeding. After more than 30 minutes of CPR, she died.
Skylar’s autopsy noted multiple post-operative complications, and said she had been chronically treated with blood thinners that interfered with her body’s ability to properly clot. She died with severe bleeding in her digestive tract. The autopsy report also noted that her heart might have been damaged after being deprived of oxygen during rounds of CPR, including the nearly hourlong effort the night of her heart surgery.
At home in Holly Springs, N.C., Skylar’s bedroom door remains closed. Mrs. Jones has gone in only once in the nearly three years since her daughter died. One of Skylar’s brothers, Nathan, who is 11, taped a sign on the door to keep his friends out. The closet inside is still full of small pink clothes.
Skylar’s parents, of course, were not aware back then that doctors were concerned about the hospital’s cardiac surgery program. “We could have maybe went elsewhere,” Mr. Jones said in a recent interview. “But all that, I feel, was taken away.”
“I just wish somebody would have said something,” Mrs. Jones said.
Like other health institutions, UNC said, it is prohibited by federal law from discussing individual patients. The hospital said details about patients’ cases in this article were inaccurate or incomplete, but declined to discuss any specifics, even if the parents signed a waiver allowing it.
Another parent, a registered nurse named Ana Crow, remembers Dr. Mill telling her he had treated cases like her newborn’s before, typically with good results. Her five-pound baby, Adam, was rushed to UNC Children’s Hospital from a Raleigh hospital in March 2016, soon after his birth. He had transposition of the great arteries, a condition where the two main arteries carrying blood out of the heart are reversed.
In the operating room, it became clear that Adam’s condition was slightly more complicated. In addition to swapping the arteries, Dr. Mill needed to detach and reattach smaller blood vessels, which was more challenging given their unusual placement, according to his medical records. Still, the procedures are considered relatively low-risk, with a mortality rate of about 2 percent.
After the surgery, Dr. Mill sat on the edge of Ms. Crow’s bed, she recalled. “As soon as he said, ‘He’s not going to make it,’ I just tuned out,” Ms. Crow said. “You go through denial.”
Muscles supporting a valve in the baby’s heart were damaged, according to Adam’s medical records and autopsy report, apparently when Dr. Mill tried to remove a band of tissue in the heart. Without a functioning valve, the child couldn’t survive.
Adam was brought out of the operating room on life support. He was 1 week old when he was disconnected from the machine. As his mother held him for the first time, he took his last breath.
“They are not worried about you as cardiologists; they are worried about the surgical end of this and it’s a very broad worry right now,” he said. “You are the front-line filter.”
Dr. Kelly listened as one physician after another said that things seemed to be going badly for too many young patients. “The cardiologists that are talking to you in this room today are saying that we are not on track,” said Dr. James Loehr, who is no longer at UNC. “And I would argue that we have not been on track for some time.”
In discussing options, Dr. Kelly, an allergist and immunologist who had become interim head of the hospital just a few months earlier, acknowledged the moral dilemma for the doctors, whom he described as a “very, very upstanding group of cardiologists.” But in the two-hour session, he also clearly felt the weight of the situation and the possible consequences for his institution.
“I’ve been worried about this,” he said. “The implication of somebody like me declaring ‘pediatric cardiac surgery moratorium has occurred’ will spread like wildfire from North Carolina, and this will never be the same for five or 10 years.”
He mentioned he had seen the hospital’s data for several years through 2013, which showed a mortality rate of 6 percent. (The national average was 3.5 percent at the time.) The Times obtained UNC’s information from 2010 to 2013, showing 38 deaths out of 623 surgeries. The data is not risk-adjusted and has never been publicly disclosed by the hospital.
Dr. Kelly added that the hospital was working on more recent data, and said that while he believed the statistics “were O.K.” for a while, “we have just hit a really rocky piece of road,” according to a recording.
Dr. Kevin Kelly Head of Children's Hospital
And what you just described to me is surgery — cardiac surgery — here is not in a good situation, right? And you know it’s bad and I don’t have to give you the data.Dr. James Loehr Cardiologist
We don’t need the data. We know it.Dr. Kevin Kelly Head of Children's Hospital
And I’ve heard you loud and clear. I don’t know how long it’s going to take to do this. A lot of these things that get vetted with large groups of people, the final decisions of what we’re going to do happen behind closed doors in offices — you know, I think of scotch and cigar smoke and things like that. You know, some of these decisions about what we’re going to do: Is it a junior surgeon? Is it a senior surgeon? Is it a relationship with another local university? Is it a relationship with a further university? Is it close down the program?Several had come and gone over the years, working under Dr. Mill. “Each time, it has resulted in a negative outcome for the junior surgeon,” Dr. Kelly said. “We’ve killed four.” He and the cardiologists agreed that the junior surgeon at the time seemed likely to leave soon. In fact, she did leave later that summer, and for nearly two years afterward Dr. Mill was the hospital’s only cardiac surgeon.
The best option, Dr. Kelly said, was to combine UNC’s surgery program with Duke’s. For years, physicians at both children’s hospitals talked informally about joining forces, but nothing came of it. They were “basically destroying each other’s capacity to be great,” Dr. Kelly said, by running competing programs less than 15 miles apart. But even combining the programs wasn’t an instant fix: It would take at least a year and a half, he said.
Dr. Kelly went around the room, asking if there were any patients the cardiologists would refer to Dr. Mill for surgery. One doctor said no. A second said she had a hard time recommending UNC even to parents of low-risk patients. Another, Dr. Cotton, suggested he might send some of the simplest cases, adding that he always encouraged parents to get a second opinion at top-ranked hospitals in Philadelphia, Boston or Michigan if the family could afford it.
Not everyone had a chance to answer Dr. Kelly, but five of the nine physicians expressed hesitation about sending certain types of cases to their own hospital. Dr. Scott Buck noted that there had been “some great recent outcomes.” But, he said of referring patients, “I do feel increasingly morally, ethically uneasy about this.”
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He told the cardiologists to let ethics guide their decisions about referring patients. But he also noted that a drop in internal referrals would hurt revenues and could lead to job cuts. “Because that’s all I can do,” Dr. Kelly said. “All I get to do is manage money.”
Soon after, an anonymous letter was sent to the UNC chancellor and hospital leaders. The letter, a copy of which was shown to The Times, complained about Dr. Kelly’s “threat” to eliminate doctors’ jobs if they stopped referring patients internally, and warned of “unsafe and unethical practices” in pediatric cardiology and cardiac surgery.
In a statement, UNC Health Care said the institution had conducted a “thorough internal investigation” of the concerns described in the letter, and “criticism of the program was found to be unsubstantiated.”
The inquiry involved looking at specific cases and interviewing “key informants,” said Dr. Thomas Ivester, UNC’s chief medical officer. Someone also sent a complaint with similar allegations to the state medical board, which found them baseless, he said. The board’s findings are confidential unless public action is taken.
UNC would not say whether a task force with outside experts, which was discussed in the 2016 meetings, was ever assembled, or what became of the “deep dives” by individual departments Dr. Hoffman had mentioned.
Several physicians said they had not been briefed on any findings from internal inquiries. UNC said in a statement that “not each and every physician would have been involved and aware of reviews” of other personnel.
At a conference last fall, Dr. Backer, the Chicago heart surgeon, urged fellow surgeons to consider “rational regionalization,” or joining forces in an effort to reduce mortalities nationwide for congenital heart defects, potentially saving hundreds of lives.
Reaching adequate case volumes to keep up skills is a challenge because so many hospitals are competing for patients — surgical programs are an important driver of revenue. The Orlando, Fla., and San Antonio metropolitan areas, for example, each have three hospitals doing pediatric heart surgeries. Cleveland has two about a mile apart. A study last year by Dr. Backer and other physicians found that 66 percent of hospitals doing the surgeries were within 25 miles of another one.
Several countries have consolidated programs to help ensure better, more consistent care. In Sweden, mortality rates dropped to 1.9 percent from 9.5 percent after surgeries in the early 1990s were consolidated to two hospitals from four. In the United Kingdom, the mortality rate fell from 4.3 percent to 1.9 percent — despite an increase in complex cases — after a series of babies’ deaths led to an overhaul in the late 1990s. Hospitals there must have multiple surgeons who each perform at least 125 operations annually.
There are no such requirements in the United States, although some hospitals have formed partnerships to better serve patients. Children’s Hospital of The King’s Daughter in Norfolk, Va., joined in 2017 with the University of Virginia Children’s Hospital, nearly three hours away in Charlottesville. Dr. James Gangemi, the chief of congenital heart surgery at UVA, collaborates with surgeons at both hospitals.
“When you get on an airplane, you want a pilot who does this every day,” Dr. Gangemi said. “By having a dedicated team, you reduce variability.”
In February 2017, for the first time in several years, the UNC cardiologists got a glimpse of their hospital’s heart surgery mortality data. They were ushered into a conference room, along with other staff and Dr. Mill, who presented some of the information, according to a recording.
Doctors were told that the rate had improved in recent years, but the program still had one star. The physicians were not given copies or summaries of the statistics, and were cautioned that the information was considered confidential by the Society of Thoracic Surgeons. In fact, surgeons at other hospitals often share such data with cardiologists from competing institutions.
While UNC said in a statement that it was “potentially reckless” to use the data to drive decision-making about where to refer patients, doctors across the country said it was simply one factor, among several, that should be considered.
In October 2017, three babies with complex conditions died after undergoing heart surgery at UNC. In a morbidity and mortality conference the next month, one cardiologist suggested that UNC temporarily stop handling some complex cases, according to a person who was in the room. Dr. Kibbe, the surgery department chairwoman, said in a recent interview that the hospital had never restricted surgeries.
In December, another child died after undergoing surgery a few months earlier for a complex condition.
The four deaths were confirmed by The Times, but are not among those disclosed by UNC. It has declined to publicly release mortality data from July 2017 through June 2018, saying that because the hospital had only one surgeon during most of that period, releasing the data would violate “peer review” protections.
Hospitals Not Publicly Reporting Mortality Data for Pediatric Heart Surgeries
| Reason: Low volumes, data deficiencies or other | ||
| Arizona | Tuscon | Banner University Medical Center Tucson |
| Mesa | Cardon Children’s Medical Center | |
| California | Long Beach | Miller Children’s and Women’s Hospital Long Beach |
| Los Angeles | Cedars-Sinai Medical Center | |
| Palo Alto | Lucile Packard Children’s Hospital Stanford* | |
| Colorado | Denver | Rocky Mountain Hospital for Children |
| Hawaii | Honolulu | Kapiolani Medical Center for Women and Children |
| Indiana | Indianapolis | St. Vincent Hospital |
| Iowa | Iowa City | University of Iowa Stead Family Children’s Hospital |
| Nevada | Las Vegas | Sunrise Hospital and Medical Center |
| North Carolina | Chapel Hill | North Carolina Children’s Hospital |
| Winston-Salem | Wake Forest Baptist Medical Center | |
| Texas | Dallas | Medical City Children’s Hospital |
| San Antonio | The Children’s Hospital of San Antonio | |
| San Antonio | Methodist Children’s Hospital | |
| Washington, D.C. | Children’s National Health System* | |
| Planning to publicly report in Summer 2019 | ||
| Florida | Jacksonville | Wolfson Children’s Hospital |
| Georgia | Augusta | Augusta University Health |
| Mississippi | Jackson | University of Mississippi Medical Center* |
| New Mexico | Albuquerque | Presbyterian Healthcare Services |
| New York | Bronx | Montefiore Medical Center |
| New York City | N.Y.U. Langone Medical Center | |
| Rochester | University of Rochester Medical Center* | |
| Tennessee | Nashville | Monroe Carell Jr. Children’s Hospital at Vanderbilt |
| Texas | Corpus Christi | Driscoll Children’s Hospital |
| West Virginia | Morgantown | West Virginia University Medicine Children’s Hospital |
| Internal reorganization or temporary stop to surgeries | ||
| Illinois | Chicago | Rush University Medical Center |
| Chicago | University of Chicago Medicine | |
| New Jersey | Newark | R.J.W. Barnabas Health |
| New Mexico | Albuquerque | University of New Mexico Hospital |
| Oklahoma | Oklahoma City | The Children’s Hospital at O.U. Medicine |
Source: New York Times reporting and 2018 data from The Society of Thoracic Surgeons
UNC also said it is the state’s “safety-net hospital,” serving “a high volume of Medicaid and uninsured patients with complex medical and socio-economic factors that complicate their conditions.” It contends that no risk adjustment can account for those factors. But other hospitals in North Carolina and across the country also treat a high percentage of Medicaid patients and publicly report their data.
The surgeons’ society frequently works to improve its statistical models. “It’s better than anything else that is out there, for sure, but it’s not perfect,” said Dr. John Mayer, a surgeon at Boston Children’s Hospital, who is leading an effort now.
UNC has said it will publicly release its mortality data through the Society of Thoracic Surgeons once it has had at least two pediatric surgeons for several years. Last June, Dr. Mahesh Sharma, previously of Children’s Hospital of Pittsburgh, replaced Dr. Mill as the chief surgeon. The hospital has said that was part of a succession plan as Dr. Mill nears retirement.
The hospital in April released raw data for the nine months Dr. Sharma had been at UNC, showing two deaths out of 82 surgeries — a mortality rate of 2.4 percent. That information does not meet the Society of Thoracic Surgeons’ standards for public reporting, which require, among other things, four consecutive years of data to more reliably assess how a program performs over time.
UNC says its recent results show that its surgical program is performing well, thanks in part to years of quality-improvement efforts including extensive reviews of each death; specialized training for nurses; and protocols to decrease infections, standardize preoperative care and manage post-surgical patients with irregular heart rhythms.
By 2018, four of the nine pediatric cardiologists had left the hospital. A new cardiologist was hired last year, and UNC says three more will start this summer. Although UNC maintains that its surgery program had adequate resources in 2016, it is now taking steps the cardiologists discussed back then, like hiring more cardiac intensive care doctors and opening a cardiac intensive care unit.
“The program today is not the program from 2016, and the program in 2016 was not the program from 2012,” said Dr. Ivester, the chief medical officer. “We are continually critically appraising and evaluating our performance and opportunities to improve.”
UNC has not joined forces with Duke. Last summer, Duke formed a partnership with East Carolina Heart Institute in Greenville, about 100 miles away, handling all pediatric heart surgeries for the hospital.
In recent weeks, as The Times story neared publication, medical personnel reached out to the families of some patients who had died or had complications, offering to discuss their cases. UNC began searching for a pediatric heart surgeon who could fill in at the hospital on a temporary basis, according to recruitment emails. Dr. Mill is taking a leave for family medical reasons, according to UNC.
In May 2018, Jeremiah Moore came to the North Carolina hospital for what was expected to be his final surgery. The child’s condition, hypoplastic left heart syndrome, requires a series of three surgeries to reconstruct the heart and blood vessels.
He had the first two operations at UNC — including the riskiest, which has a mortality rate of 15 percent — but given the complexity of his condition, his parents, Quanasia Dean and Sean Moore, said they considered taking him to a Philadelphia hospital that specializes in the third procedure.
By the beginning of 2018, Dr. Whitham had left UNC, so Jeremiah saw a different cardiologist there, Dr. Elman Frantz. After Dr. Frantz discussed Jeremiah’s case with other physicians at the hospital, a plan was made for the almost 2-year-old to have his third surgery there that spring, according to his medical records.
When the hospital called Jeremiah’s mother to schedule the operation, she was surprised, she said, because of the earlier recommendation about the Philadelphia hospital. It reports a mortality rate of less than 1 percent for the surgery, known as the Fontan procedure; the national rate is 1.1 percent.
When Ms. Dean called Dr. Frantz to ask about taking Jeremiah to Philadelphia, he assured her the surgery could be done at UNC, she said in an interview.
Jeremiah was on Medicaid, which can make it harder to go out of state, but his mother said Dr. Frantz never mentioned that as a reason to keep him at UNC.
It is unclear whether the cardiologist considered Jeremiah’s case to be complex, but Dr. Mill, the surgeon, noted that the little boy was a “high-risk candidate” last May, shortly before his operation, according to his medical records.
The surgery took twice as long as expected, his mother said, but after about 11 hours, he was wheeled into the pediatric intensive care unit.
Over the next two weeks, he struggled. He developed an irregular heart rhythm. A test showed his heart wasn’t functioning well. A cough doctors had noted before the operation progressed into a cold, a dangerous development for a child with Jeremiah’s condition. His organs began to shut down. Early one morning, his heart stopped and he died.
“They said Jeremiah was strong,” said Inez Holmes, the boy’s grandmother. “We trusted them.”
https://www.nytimes.com/interactive/2019/05/30/us/children-heart-surgery-cardiac.html
Hospitals Accused Of Paying Doctors Large Kickbacks In Quest For Patients
Hospitals are eager to get particular specialists on staff because they bring in business that can be highly profitable. But those efforts, if they involve unusually high salaries or other enticements, can violate federal anti-kickback laws.
by Jordan Rau - Kaiser Health News - May 31, 2019
For a hospital that had once labored to break even, Wheeling Hospital displayed abnormally deep pockets when recruiting doctors.
To lure Dr. Adam Tune, an anesthesiologist from nearby Pittsburgh who specialized in pain management, the Catholic hospital built a clinic for him to run on its campus in Wheeling, W.Va. It paid Tune as much as $1.2 million a year — well above the salaries of 90% of pain management physicians across the nation, the federal government charged in a lawsuit filed this spring.
In addition, Wheeling paid an obstetrician-gynecologist a salary as high as $1.3 million a year, so much that her department bled money, according to a related lawsuit by a whistleblowing executive. The hospital paid a cardiothoracic surgeon $770,000 and let him take 12 weeks off each year even though his cardiac team also routinely ran in the red, that lawsuit said.
Despite the losses from these stratospheric salaries and perks, the recruitment efforts had a golden lining for Wheeling, the government asserts. Specialists in fields like labor and delivery, pain management and cardiology reliably referred patients for tests, procedures and other services Wheeling offered, earning the hospital millions of dollars, the lawsuit said.
The problem, according to the government, is that the efforts run counter to federal self-referral bans and anti-kickback laws that are designed to prevent financial considerations from warping physicians’ clinical decisions. The Stark law prohibits a physician from referring patients for services in which the doctor has a financial interest. The federal anti-kickback statute bars hospitals from paying doctors for referrals. Together, these rules are intended to remove financial incentives that can lead doctors to order up extraneous tests and treatments that increase costs to Medicare and other insurers and expose patients to unnecessary risks.
Wheeling Hospital is contesting the lawsuits. It said in a countersuit against the whistleblower that its generous salaries were not kickbacks but the only way it could provide specialized care to local residents who otherwise would have to travel to other cities for services such as labor and delivery that are best provided near home.
The hospital and its specialists declined requests for interviews. In a statement, Gregg Warren, a hospital spokesman, wrote, “We are confident that, if this case goes to a trial, there will be no evidence of wrongdoing — only proof that Wheeling Hospital offers the Northern Panhandle Community access to superior care, world class physicians and services.”
Elsewhere, whistleblowers and investigators have alleged that other hospitals, in their quests to fill beds and expand, disguise these arrangements by overpaying doctors or offering other financial incentives such as free office space. More brazenly, others set doctor salaries based on the business they generate, federal lawsuits have asserted.
“If we’re going to solve the health care pricing problem, these kinds of practices are going to have to go away,” said Dr. Vikas Saini, president of the Lown Institute, a Massachusetts nonprofit that advocates for affordable care.
‘It’s Almost A Game’
Hospitals live and die by physician referrals. Doctors generate business each time they order a hospital procedure or test, decide that a patient needs to be admitted overnight or send patients to see a specialist at the hospital. An internal medicine doctor generates $2.7 million in average revenues — 10 times his salary — for the hospital with which he is affiliated, while an average cardiovascular surgeon generates $3.7 million in hospital revenues, nearly nine times her salary, according to a survey released this year by Merritt Hawkins, a physician recruiting firm.
Last August, William Beaumont Hospital, part of Michigan’s largest health system and located outside Detroit, paid $85 million to settle government allegations that it gave physicians free or discounted offices and subsidized the cost of assistants in exchange for patient referrals.
A month later in Montana, Kalispell Regional Healthcare System paid $24 million to resolve a lawsuit alleging that it overcompensated 63 specialists in exchange for referrals, paying some as full-time employees when they worked far less. Both nonprofit hospital systems did not admit wrongdoing in their settlements but signed corporate integrity agreements with the federal government requiring strict oversight.
“It’s almost a game of ‘We’re going to stretch the limits and see if we get caught, and if we get caught we won’t be prosecuted and we’ll pay a settlement,’” said Tom Ealey, a professor of business administration at Alma College in Michigan who studies health care fraud.
Dubious payment arrangements are a byproduct of a major shift in the hospital industry. Hospitals have gone on buying sprees of physician practices and added doctors directly to their payrolls. As of January 2018, hospitals employed 44% of physicians and owned 31% of practices, according to a report the consulting group Avalere prepared for the Physician Advocacy Institute, a group led by state medical association executives. Many of those acquisitions occurred this decade: In July 2012, hospitals employed 26% of doctors and owned 14% of physician practices.
“If you acquire some key physician practices, it really shifts their referrals to the mother ship,” said Martin Gaynor, a health policy professor at Carnegie Mellon University in Pittsburgh. Nonprofit hospitals are just as assertive as profit-oriented companies in seeking to expand their reach. “Any firm — it doesn’t matter what the firm is — once they get dominant market power, they don’t want to give it up,” he said.
But these hires and acquisitions have increased opportunities for hospitals to collide with federal laws mandating that hospitals pay doctors fair market value for their services without regard to how much additional business they bring through referrals.
“The law is very broad, and the exceptions are very narrow,” said Kate Stern, an Atlanta lawyer who represents hospitals.
‘A Man We Need to Keep Happy’
Lavish salaries for physicians with high potentials for referrals was the key to the business plan to turn Wheeling Hospital, a 247-bed facility near the Ohio River, into a profit machine, according to a lawsuit brought by Louis Longo, a former executive vice president at the hospital, and a companion suit from the U.S. Department of Justice.
Between 1998 and 2005, Wheeling Hospital lost $55 million, prompting the local Catholic diocese to hire a private management company from Pittsburgh, according to the suits. In 2007, the company’s managing director, Ronald Violi, a former children’s hospital executive, took over as Wheeling’s chief executive officer.
The hospital remained church-owned, but Violi adopted an aggressively market-oriented approach. He began hiring physicians — both as employees and independent contractors — “to capture for the hospital those physicians’ referrals and the resulting revenues, thereby increasing Wheeling Hospital’s market share,” the government alleged. Along with greater market share came the ability to bargain for higher payments from insurers, according to Longo’s suit.
The government complaint said at least 36 physicians had employment contracts tied to the business they brought to the hospital. Hospital executives closely tracked how much each doctor earned for the hospital, and executives catered to those whose referrals were most lucrative.
In 2008, the hospital’s chief financial officer wrote in an internal memorandum that cardiovascular surgeon Dr. Ahmad Rahbar “is a man we need to keep happy” because the previous year “he generated over $11 million in revenues for us,” according to the government’s lawsuit.
Dr. Chandra Swamy, an obstetrician-gynecologist the hospital hired in 2009, was another physician whose referrals Wheeling coveted. By 2012, Wheeling was paying her $1.2 million, four times the national median for her peers, according to Longo’s suit.
An internal memorandum by the hospitals’ chief operating officer quoted in Longo’s lawsuit said that the labor and delivery practice where Swamy worked was the biggest money loser among the specialty divisions and that her salary made it “almost impossible for this practice to show a bottom line profit.” But the memo went on to conclude that Wheeling should “continue to absorb the practice loss” because it “would not want to endanger the significant downstream revenue that she produces” for the hospital: nearly $4.6 million a year, according to the lawsuit.
In some cases it was the specialists who demanded lopsided pay packages. When Wheeling, eager to get a piece of the booming field of pain management, decided to recruit Tune, the anesthesiologist responded that he wanted an “alternative/undefined model” of compensation that could earn him $1 million a year, according to Longo’s lawsuit.
Instead of making Tune an employee, Longo alleges, Wheeling leased clinic space to a company created by Tune and paid him $3,000 a day — more than $700,000 a year. In its initial contract, Wheeling also let Tune keep 70% of his practice’s net income, according to the government’s complaint.
Two years later, when the hospital’s chief lawyer raised legal concerns, Wheeling revised the contract, dropping the profit-sharing provision but boosting Tune’s daily stipend to $6,100. The government complaint said this was designed to make up for the lost incentives and thus remained illegally based on how much business Tune generated for Wheeling. Indeed, Tune and his clinic earned roughly the same amount of money as they had received before the new compensation package, the complaint indicated.
Longo said his resistance to such deals rankled both Violi and physicians. He was fired in 2015 because, he alleged, of his objections to various contracts the hospital struck with physicians. The hospital countersued in March, saying Longo had breached his fiduciary duties because he never reported any financial irregularities when he worked there. Wheeling said that after Longo was fired, he threatened to file his lawsuit unless he received a settlement. Longo has asked that the case be dismissed and said in court papers he told Violi about his concerns on “multiple occasions.”
As a whistleblower, Longo is entitled to receive a portion of any money the government collects in its complaint. Longo’s lawyer said he would not comment for this story.
In financial terms, Wheeling’s tactics succeeded. According to the government’s suit, over the first five years under Violi, Wheeling earned profits of nearly $90 million. Violi’s management firm, R&V Associates, also prospered: Wheeling more than doubled the firm’s annual compensation from $1.5 million in 2007 to $3.5 million in 2018. Violi and his lawyer did not respond to requests for comment.
“The hospital has benefited tremendously from Ron’s keen business acumen,” Monsignor Kevin Quirk, the hospital board chairman, said last week in announcing Violi’s retirement.
Wheeling’s quality of care has not excelled commensurately, however, according to Hospital Compare, Medicare’s consumer website. Patients with heart failure or pneumonia are more likely to die than at most hospitals. In April, Medicare awarded Wheeling Hospital its lowest rating, one star, for overall quality.
https://khn.org/news/hospitals-accused-of-paying-doctors-large-kickbacks-in-quest-for-patients/
California health care company embarks on hiring spree in Lewiston
by Lori Valigra - Bangor Daily News - June 4, 2019
A California health care company plans to hire more than 200 employees in Lewiston by the end of 2019.
Grand Rounds, which is based in San Francisco, originally
planned to hire 150 people in Lewiston by 2022, but is hiring so quickly
that it revised plans to add more staff before the end of the year.
The company partners with other companies to help their employees find doctors and medical services.
“By combining data, technology and clinical expertise, Grand
Rounds is helping our employees to efficiently navigate the health care
system,” said Guy Langevin, vice president and chief administrative
officer at Dead River Co., in a statement.
Grand Rounds, founded in 2011, started East Coast operations
in Lewiston in April 2017. It is located in the historic Bates Mill
Complex.
Danielle Snow, senior vice president of patient care in
Lewiston, said Grand Rounds is looking for detail-oriented customer
service and clinical care professionals for positions as care
coordinators, records specialists and managers. More information is on
its website.https://bangordailynews.com/2019/06/04/business/california-health-care-company-embarks-on-hiring-spree-in-lewiston/
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