The honor system is a fine thing when people are honorable. Not so much if they’re not. A medical example of the latter unfolded recently in Kentucky, where unnecessary heart procedures failed to help the patients, but certainly boosted the bank accounts of the hospital and the surgeons.
As reported last month by the Courier-Journal, a former meat cutter, Edward Marshall had undergone at least two-dozen heart procedures over two decades. They were disabling, and he finally decided in September 2010 to seek treatment by people other than the cardiologists at St. Joseph London hospital.
After consulting a specialist in Lexington, Ky., he was told that an artery in which Dr. Sandesh Patil at St. Joseph had implanted a stent was barely blocked. In other words, there had been no need for the balloon angioplasty procedure, which opens blocked arteries and keeps them that way with the use of a stent, a tiny tube that prevents surrounding tissue from collapsing.
“I would have not carried out this procedure,” the Lexington cardiologist told Marshall in a letter that is included in the court record. Marshall became the first of nearly 400 people to sue the London hospital and 11 cardiologists. The claim is conspiracy to perform unnecessary, risky and often painful heart procedures that served only the purpose of enriching the providers.
The problem in Kentucky is old, sad news. In “Hospital Profit Soars on Wings of Unnecessary Heart Procedures," we wrote about HCA, the largest for-profit hospital chain in the U.S. When the doctor there was performing heart procedures on patients who didn’t need them, the hospital slapped his wrist, fired the nurse who blew the whistle on him and pocketed enough money to run a small country.
Our blog a few years ago, “Baltimore Malpractice Cases Raise Broad Questions About Heart Stents,” concerned a case when a Maryland cardiologist performed more than 1,000 surgeries to implant heart stents. Except that the arteries weren’t blocked, and didn’t require the dangerous, expensive procedure.
The problem common to all of these unfortunate events is that the medical honor system monetarily rewards cardiologists for breaking the rules if they're willing to gamble on not getting caught. These surgeries happen only because one guy says they should. No peer or institutional review. It’s the honor system, and too often, it’s not working.
The Kentucky lawsuits also name the hospital’s parent company, Catholic Health Initiatives (CHI). Two patients died from the alleged unnecessary procedures, and the others must take blood-thinning medications for life. Not only do such drugs carry risks of dangerous side effects, the procedures leave these people at risk of potentially fatal complications.
The hospital’s defense? Exactly as you might imagine. “These were very sick people who needed the interventions, and got them,” its attorney told the Courier-Journal. He called the conspiracy allegations “Alice in Wonderland stuff.”
As the newspaper notes, however, it isn’t only the plaintiffs who are troubled by St. Joseph’s practices:
- The U.S. attorney’s office in Lexington is investigating the medical necessity of its cardiac procedures, and the financial relationship between the St. Joseph system and Patil’s cardiology group.
- A federal criminal health-care fraud investigation focusing on Patil has been launched. The doctor refused to answer 109 questions at a deposition in Marshall’s suit, declining even to confirm that he is a doctor.
- Earlier this year, the Kentucky Medical Licensure Board found that Patil provided substandard care to 4 of 5 patients whose records it examined. It said he used stents without justification in three of them.
- In 2011, the Centers for Medicare & Medicaid Services cited St. Joseph for failing to review the medical necessity of 3,367 cardiac catheterizations performed there in 2010. (That procedure, in which a wire is moved through an artery into the heart, was a problem as well in the HCA case.) This citation noted that one of the hospital’s patients had annual heart procedures (20 in all), never mind that he had no symptoms of heart disease.
Remarkably, however, the board allowed Patil to continue to practice, with monitoring and remedial education. (That’s not oversight, that’s sending someone to bed without dinner.)
The Courier-Journal quoted a researcher at the Kentucky Health Policy Institute who found that St. Joseph performed more angioplasties than either of the state’s major teaching hospitals. After the lawsuits were filed, those numbers declined by one-third.
Patil has not had privileges at St. Joseph London since December 2010, but he’s not the only problem at CHI—it paid $22 million in 2010 to settle allegations in a federal case that its hospital in Towson, Md., made improper payments to a cardiology group, and that doctors regularly performed unnecessary procedures.
Marshall’s case is moving slowly through the legal paces. Over the years he claims Patil and others unnecessarily implanted a pacemaker and stents and performed unneeded angioplasties and catheterizations. Unlike many such patients, Marshall said he did question Patil about the need for the procedures, but the doctor would change the subject.
Then, in August 2010, Patil was doing an angioplasty, said that he’d found no blockage in the artery but was going to insert a stent anyway. That’s when Marshall went to the Lexington cardiologist. His report, Marshall told the Courier-Journal, destroyed his faith in doctors.
“It is serious business when someone is fooling with your heart,” he said. “It is just not right what they put people through.”