Cardiologists accused of
implanting cardiac stents that weren’t needed
I now sport a shiny stainless steel stent implanted into
my left anterior descending coronary artery that was 99% blocked when I
survived a heart attack two years ago. Stents are like tiny chicken wire mesh
tubes inserted inside the obstructed coronary arteries of your beating heart
and then expanded using a small balloon to open blocked arteries that prevent
blood flow to heart muscle.
But it appears that some cardiologists like these
miraculous little devices so much that they are implanting stents into patients
who don’t need them. A current U.S. investigation in
Maryland involves Dr.
Mark Midei, who has
subsequently been relieved of his privileges* at
St. Joseph Medical Center in Towson, MD. According to Heartwire, the hospital, following up on a patient
complaint, discovered stenting rates high enough to bring them under scrutiny, and
determined that hundreds of Midei’s patients received stents they didn’t
need during his last two years at the hospital.
How could this happen?
One potential way to make
this kind of health care fraud easier to pull off is the way this doctor was
able to successfully sidestep his hospital’s peer review safety net. The
veteran cardiologist accused of performing hundreds of unnecessary and
potentially dangerous procedures was able to slip through this safety net
because, as a department chair, he could personally select
which of his cases would be evaluated, according
to Maryland’s Office of Health Care Quality.
A subsequent review by the Maryland Medical Board led to
administrative charges in June, accusing Midei of “gross
overutilization of health care services” and “willfully making a false
report or record in the practice of medicine,” according to a Board report.
In Midei’s defense, about 100 of his cases were reviewed
by another interventional cardiologist, Dr. William O’Neill,
of the University of Miami Miller School of Medicine, who told Heartwire:
“I concluded that (Dr. Midei)
really was a good operator and there was really no reason to have an emergency
suspension of his privileges.”
Quelle surprise. O’Neill
had been hired by the legal team of this “good operator” and was reimbursed by
these lawyers for his professional opinion of their client.
A U.S. Senate investigative report revealed
that Midei was a favourite of device-maker Abbott Laboratories, the company
that manufactured the stents. According to Maggie
Mahar, author of the book, Money-Driven
Medicine, Abbott even celebrated the
fact that the handy doctor had inserted 30 of the company’s cardiac stents into
trusting patients during a single day in August 2008:
“Two days later, an Abbott
sales representative spent $2,159 to buy a whole, slow-smoked pig, peach
cobbler and other fixings for a barbecue dinner at Dr. Midei’s home.”
Although St. Joseph’s Hospital has not
admitted to any wrongdoing, it did agree to pay a$22
million fine to
settle charges that it paid illegal kickbacks to Dr. Midei’s medical practice
in exchange for patient referrals. In other words, it seems that the
hospital encouraged the doctor to
implant stents into his patients’ arteries. Certainly, hospital executives knew
that they were making handsome profits on Midei’s stent procedures. As Maggie
Mahar explains: “Midei was a rainmaker.”
Clinical guidelines require that a coronary
artery must be at least 70% blocked before a stent is appropriate to open it
up, and St. Joseph’s own rules consider anything less than 50% blockage
to be “insignificant.”
But court documents allege that some of
Midei’s patients were told they had blockages in the 90% range, while a
subsequent review of their records shows blockages closer to 10% or less. Yet
even after being notified in writing by the authorities that their coronary
arteries had actually been less than 50% blocked (clinically meaningless
and not an indication for stenting), many of Midei’s stent patients appeared
unfazed. One woman even told the Baltimore Sun:
“No one can ever tell me that I
didn’t need that stent. I feel like [Dr. Midei] saved my life!”
Any patient who has undergone angioplasty
and stent implantation is duly impressed by the number of nurses and
technicians working alongside interventional cardiologists in the
catheterization lab, a reality that certainly implies collusion on the
part of Midei’s cath lab colleagues. As Dr.
Bob Wachter of
the University of California at San Francisco writes in his essay Badness In
Baltimore: Can Peer Review Catch Rogue Doctors?:
“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.”
A 2007 study in the New England Journal of
Medicine, while stopping short of concluding
that stents were not beneficial for some patients, rather reported that not
implanting a stent can
often be just as good, while avoiding the very real risks of complications or
even death from the procedure. But as the Baltimore
Sun pointed
out:
“Hospitals can’t bill $12,000
for deciding not to
implant a stent, even if that’s the best thing for the patient.”
The disturbing revelations about the
stent-happy Midei may be just the tip of the iceberg. The Sun also reported
that the State of Maryland has now expanded its investigation to include other
cardiologists and hospitals with stent-procedure rates significantly higher
than the state average.
But as the New York Times has
reported, stents are also big business, with powerful stent manufacturers like
Johnson & Johnson and Boston Scientific selling over $3 billion worth of
stents last year. They have invested heavily in expanding the use of these
stents; stent implants have become more popular as rates for the more invasive
open heart bypass surgery have dropped. According to the Times:
“The specialists who are most
likely to diagnose coronary artery disease are in many cases also the doctors
who implant stents. Cardiac surgeons have seen their annual incomes
dwindle to an average $425,000 down from $1.02 million in 1990, after adjusting
for inflation. Meanwhile,
the average income of an interventional cardiologist, as a stent specialist is
known, has risen to $550,000 from an inflation-adjusted $392,000 in 1990.”
Midei is not likely the only stent-happy
interventionalist out there. As cardiologist Dr.
Eric Topol reported
last fall:
“A case report* in
the Journal of the American College of Cardiology of a 56-year-old male patient
with 67
stents and
a history of 28
coronary angiograms is
symbolic of a health care system that is barreling out of control fueled by
outrageous costs and unbridled use of procedures. “
If I were Midei, I’d be very, very worried
right about now. Last year, another U.S. interventional cardiologist who
implanted stents in patients who didn’t need them was convicted on 51 counts of
health care fraud. Dr.
Mehmood Patel, a
64-year old Louisiana cardiologist, was sentenced to 10 years in federal
prison, the maximum legal punishment allowed.
Patel’s former employer, Our Lady of
Lourdes Hospital in Louisiana, also paid $7.4 million to settle a
class-action lawsuit brought by his former patients. His 11-week trial included
charges of fraud involving 75 patients. Medical experts testified that Patel
had:
§ performed
unnecessary tests and procedures in patients with little or no disease
§ falsified
medical test results
§ falsified
patient symptoms in medical records, including chest pain when patients had
never complained of such pain
§ billed
government health insurance and private insurance companies more $3 million,
during a time when he was the top cardiology biller in the state
§ personally
pocketed more than $500,000 in cash
And in perhaps the most celebrated
cardiology case in recent memory, Drs.
Chae Moonand Fidel
Realyvasquez of
Redding Medical Center in California remain the poster boys for dangerous
health care fraud after it was found that 50% of the procedures conducted
by the two physicians (diagnostic catheterization, angioplasty, and coronary
bypass surgery procedures) were medically unnecessary. Evidence from one
cardiologist who saw patients after they’d been to Moon claimed that in many
instances, Moon’s first interaction with the patients was to perform a heart
catheterization procedure. Two of Moon’s patients interviewed during FBI
investigations stated that Moon had conducted “urgent” angiography procedures
on them in the absence of any symptoms and a normal treadmill stress test.
Realyvasquez had billed Medicare over $3.5 million and Moon almost $4 million.
Redding Medical Center’s cardiac unit, home base to the two cardiologists, was
described as a “cash cow”, generating over $3,000 in revenue per patient per day,
or twice the hospital’s average. They and their hospital settled civil
cases for $450 million. Moon and Realyvasquez left medicine. Their hospital
also paid the U.S. government $900 million to settle claims regarding alleged
improper financial activities. Former New York Times and Washington Post
investigative reporter Stephen
Klaidman wrote
about this scandal in his book Coronary: A True Story of
Medicine Gone Awry.
Convictions like health care fraud may make
you wonder who is policing these guys – since their senior positions in
hospitals can mean that they, like Midei, hand-pick cases for peer review.
Not surprisingly, many docs don’t like the
idea of non-doctors looking over their shoulders.
Dr. Larry
Dean at
the University of Washington Regional Heart Center in Seattle, for example,
insists that neither governments nor lawyers are capable of doing this policing
job. He told Heartwire:
“This is our responsibility. If
it’s done properly, it will work. I’ll be honest with you. I don’t think that
the government or lawyers can do this. It comes down to the single individual
patient-level decision, and the only people who understand that are the ones
who are doing it every day.”
Earth to Dr. Dean: the
“ones who are doing it everyday” include the very cardiologists accused of
performing unnecessary and potentially dangerous procedures. Because such
cardiologists are like foxes guarding the henhouse, independent regulators are
the only secure protection that cardiac patients may have.
* NEWS UPDATE: July 14, 2011 – Baltimore,
MD – “Cardiologist’s
License Ordered Revoked In Stents Case” - A
state medical panel has declined to reverse a judge’s order to revoke a
cardiologist’s license on accusations he performed hundreds of medically
unnecessary coronary stent procedures. The Maryland Board of Physicians ruled
that Dr. Mark Midei violated five provisions of the Medical Practice Act,
including provisions that prohibit unprofessional conduct, making false
reports, keeping inadequate records and over-utilization of health care
services. The board declined to reverse the ruling, calling Midei’s violations “repeated
and serious”, and further writing that Midei “unnecessarily
exposed his patients to the risk of harm” and “increased
the costs of the patients’ medical care.”
The judge ordered Midei’s medical license
be revoked and not reinstated for at least two years, to which the board
agreed, adding that Midei had falsified the extent of blockages of patients’
coronary arteries by reporting them as being 80% blocked, when they were
actually lower – and in most cases, much lower. In some patients, he had also
falsely reported that they suffered from unstable angina when in fact they did
not.
MORE STENT INVESTIGATIONS:
§ March
3, 2011 –
Medical reviews at Pittsburgh’s Westmoreland Hospital have determined two
cardiologists there implanted coronary stents in at least 141 patients in 2010
who may not have had enough blockage in their arteries to need a stent.
Letters to these patients do not provide a reason why the patients received the
stents, but state their condition “may not have justified the
placement of a coronary stent.” Hospital
officials said the questionable stents were implanted by Drs.
Ehab Morcos and George
Bousamra, who voluntarily resigned their hospital
privileges at Westmoreland on January 12, 2011 after being investigated.
The two doctors performed more than 750 of the up to 2,000 stent procedures
done at Westmoreland Hospital that year.
§ July
26, 2011 –
A federal jury has convicted Maryland interventional cardiologist Dr.
John R. McLean, 59, on six charges of health
care fraud relating to insurance claims he’d filed for stents deemed to have
been placed unnecessarily, as well as for ordering unnecessary tests and making
false entries in patient medical records. A statement released by the Office of
the Inspector General said: “The
evidence shows that Dr. McLean egregiously violated the trust of his patients
and made false entries in their medical records to justify implanting unneeded
cardiac stents and billing for the surgery and follow-up care.” McLean
faces a maximum sentence of 10 years in prison for health care fraud and five
years in prison on each of five counts of making false statements. His
sentencing is scheduled for November 10, 2011.
See also:
§ Say What? Do
Patients Really Hear What Doctors Are Actually Telling Them?published
on my other site, Heart Sisters
* Khouzam RN, Dahiya R, and Schwartz R. A
heart with 67 stents. J Am Coll Cardiol.2010;56;1605.
This entry was posted in Marketing ethics and
tagged Abbott Laboratories, cardiac stents, Coronary: A True Story of Medicine Gone Awry, Dr. Chae Moon, Dr. Eric Topol, Dr. Fidel Realyvasquez, Dr. Mark Midei,Dr. Mehmood Patel, health, medicine, St. Joseph's hospital, Stephen Klaidman, unnecessary cardiac procedures by Carolyn Thomas. Bookmark the permalink.
“…some cardiologists like them
so much that they are implanting stents into patients who don’t need them…”
We now have research showing MOST people who undergo
angioplasty/stents may not actually need them, unless they suffer debilitating
cardiac symptoms or a heart attack is imminent. Five year outcomes for patients
treated medically (just medications) are actually better than for patients who
have had arteries opened with stents. So it might even be argued that most
cardiologists who implant stents – not just Dr. Midei – are doing so with
patients who don’t need them. But patients like the idea of a metal tube
keeping a formerly blocked artery open, so it’s an easy sell for cardiologists.
Here’s a link to a Harvard website with more information
suggesting medications alone work just as well for people with “Stable Angina”:http://www.health.harvard.edu/fhg/updates/medication-vs-stents-for-heart-disease-treatment.shtml
Thanks Carolyn – love your site.
Thanks for this Harvard link, Nurse Nancy.
This part leaped out at me:
“There are only two reasons for
undergoing any treatment: TO FEEL BETTER OR TO LIVE LONGER. If you aren’t
having chest pain or other symptoms, angioplasty to open a narrowed artery
can’t make you feel any better. And studies show it won’t help you live any
longer.”
ud Augeron June 30, 2011 at 10:58 am said:
Nurse Nancy – So true. Doesn’t this make
sense for all medical treatment decisions? If treatment is not proven to
prolong life or reduce symptoms, why on earth would doctors recommend any
invasive procedure like this? There seems to be only one reason: MONEY.
“…Cardiac surgeons have seen their annual
incomes dwindle to an average $425,000, down from $1.02 million in 1990, after
adjusting for inflation…”
If the New
York Times has this
right, I think we should feel sorry for these poor cardiac surgeons. Maybe
we’ll now see a big increase in bypass surgery to help bring their incomes back
up to normal?
Love your website, thanks for this.
Why isnt any of these people going to jail,
seems to me this is one of the most dastardly crimes anyone can commit
Dr Petrella is involved in a lawsuit
against Medicor Associates and Hamot Hospital, in Erie, PA :
http://www.goerie.com/article/20120122/NEWS02/301229939/Federal-suit-claims-Hamot-heart-doctors-defrauded-Medicare
http://www.goerie.com/article/20120122/NEWS02/301229939/Federal-suit-claims-Hamot-heart-doctors-defrauded-Medicare
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