As reported in the Baltimore Sun last week, Catholic Health Initiatives (CHI) agreed to pay up to $37 million to settle civil claims of unnecessary coronary artery stenting at its St. Joseph Hospital in Towson, Maryland. The class action suit by some 273 patients was one of several federal and civil lawsuits against the hospital for the placement of, or billing for medically unnecessary invasive cardiac procedures beginning years before 2010. The settlement still needs the approval of court officials and an agreement of at least 60% of other plaintiffs to join the case. These and apparently other plaintiffs have the option not to join the settlement. The books are not obviously closed on the case. The Hospital’s principal invasive cardiologist, Mark G. Midei, is named in other open actions, but not this case.
Cost of doing business? Slap on the hand? Fair outcome?
Although this sounds like a lot of money, it amounts only up to $134,000 per patient before plaintiff’s attorneys take 40% and repayments are made to Medicare, Medicaid, and private insurance companies who paid for the “allegedly” unnecessary medical procedures. Frankly, I anticipated a higher penalty given my understanding of the severity of the “alleged” deeds. Naturally, as we have come to see in these cases, CHI admits no wrongdoing, presumably knuckling under to an alternative interpretation of heavy-handed litigation and to avoid further uncertainty and legal expense.
CHI settled earlier with the Federal Government for $22 million for illegal kickbacks. In May 2013, the Hospital settled confidentially with another 200 or so patients for unknown sums. CHI sold its unfortunately but inevitably-tainted hospital (but not its tort liabilities) to the University of Maryland in 2012. In my opinion, and based on what I have read from independent examination of the facts, including a US Senate investigation, I would not personally have visited the hospital for services. Regretfully, when all the facts in cases like this are kept from the public, confidence and trust can be lost for a long time. No one is served well, save perhaps attorneys for the plaintiffs. Continue reading
Both aggregate and detailed data for Kentucky and Louisville available for download below.
Its out there!
The release last week by the Centers for Medicare and Medicaid Services (CMS) of services by and payments to physicians and other non-hospital providers reverberated as expected throughout the nation. Analysis of the massive database is, and will continue to expose the complexity, quirks, inequities, fraud, and sometimes just plain bizarreness in our current health care system. Some large media outlets such as the New York Times, the Wall Street Journal, and the Washington Post were allowed to organize and work with the data before it was released to the general public. Both these sites and perhaps others allow the public to look up individual providers, but comparisons of individuals or groups is cumbersome to impossible. Furthermore, neither of these two portals to the data includes all non-physician providers. In any case, a host of individual providers or professional groups are now scrambling to try to explain why they stick out like sore thumbs in terms of frequency of services, charges, or payments from Medicare.
Eye doctors (and others) under the magnifying glass.
For example, ophthalmologists point out that the reason they receive among the highest payments is that they frequently inject an extremely expensive drug into the eyeball. While this may be rational and honest defense, it is not a reasonable one if, as is reported, it is true that a spectacularly cheap alternative generic drug works just as well. Thus, the issue of how much money a physician or other provider is entitled to make off a drug they chose to administer themselves is certain to enter public debate. Continue reading
Gov. Beshear used his line-item veto on the state budget passed by the General Assembly to alter two higher-education education items. They relate to the Kentucky Community and Technical College System, and to the University of Louisville.
With regard to the former, the Governor altered language with the intent of giving more leeway to the governance of KCTC to use agency bonds and fees to fund capital projects on their campuses. With regard to the latter, the Governor reduced the University’s role in evaluating its own need for QCCT funding for indigent care or the effect of the reduction in the amounts appropriated. Continue reading
Take a look at the results for Louisville and Kentucky.
Our colleague Terry Boyd at Insider Louisville was probably the first out of the block this morning to report on the local results of the much-debated, long-opposed, and likely system-changing publication by the Centers for Medicare and Medicaid Services of the amounts of money charged by and payed to individual physicians and other providers for some Medicare patients. This previously top-secret financial and utilization information had not even been available to other physicians let alone the public.
Long opposed by organized medicine as a violation of individual physician privacy, the public has gotten used to, indeed gained an appetite for such information about hospitals, nursing homes and the like. This is part of the movement to increase medical safety, quality, and efficiency. It also has been very helpful for identifying medical fraud and abuse. I predict that the release of physician payment data will have as much earth-shaking effect as last year’s release of hospital payment data illustrated by the now-famous article in Time Magazine, “Bitter Pill: Why Medical Bills Are Killing Us,” by Steven Brill.
There will be much to learn from this extensive database. It is huge! My tricked-out Mac chokes on the size of it. You can look up individual physicians for a more detailed breakdown on the Washington Post Portal referred to by Terry Boyd, or the Wall Street Journal.. To give the community something to look at while I do the same, a more manageable aggregate list of all the physician and other non-hospital Medicare providers doing business in Louisville or the state of Kentucky is available below. I have ranked the lists by the amount of money actually paid to individual providers– highest paid providers are at the top. Definitions of the individual items and some other comments about the data are present in the designated tabs. Continue reading
Funding of Higher-Education in Kentucky– Death By a Thousand Cuts.
The 2014 Kentucky legislative session is not over yet, but some would say it never really got started. The Governor has time to veto bills that have already passed, including line-item vetoes in the Budget. The House and Senate still have a final day or two to try to pass additional legislation or override any vetoes. Unless there is a miracle on the Ides of April, the budgets of the state Universities are now graven in stone.
What Makes a Good Legislative Session?
Complaints have been voiced that this session was not a fruitful one because so few bills of any significance were passed. That would be a valid observation if the most important function of the General Assembly was to pass good laws. Another school of thought, to which I have some affinity, is that the highest function of legislative bodies is to prevent bad laws from being born– legislative contraception as it were. From that perspective, our Kentucky House and Senate committees with their competitively-adversarial political party structures serve to prevent attachment of many nascent bills to the walls of their respective full chambers. Many bills deserve to be thus aborted.
I spent a good bit of my free time these past few weeks trying to understand what was happening to funding for the Quality Community Care Trust fund (QCCT) that has for some 30 years provided supplemental funding to the University of Louisville Hospital to care for uninsured inpatients. The amounts of funding provided by the city of Louisville and the Commonwealth have been decreasing, the contractual parties have changed several times, and the permitted uses of the money had slowly changed over time in an evolving medical ecosystem. In my opinion, that program is nearing the end of its useful lifetime. I have written about these matters often over the past two years and will continue to do so as I go through the Louisville archive of contracts and correspondence now available to me.
Not a Great Legislative Session for the State Universities.
Our public institutions of higher education are probably more unhappy than most with the outcomes of the session. At a time when they are being urged to enroll and graduate more students, their budget allotments from the general fund continue to shrink. Just as our state retirement systems were systematically underfunded to the point of impending insolvency, so too has funding to renovate or replace our university inventories of aging or inadequate buildings been ignored. What might have been accomplished in small pieces has now become an unmanageable disaster. Money for new educational facilities is largely a gleam in the eyes of university Boards of Trustee members. As I combed through legislative documents this spring, I had occasion to examine the blunt-knife approach to carving up academic budgets, but also to gain insight into the priorities of these institutions and the hoops they must jump through to advance their interests. The initial budgets from the General Assembly called for an across the board cut to the university budgets of 2.5%, and according to some, the 14th year in a row of such cuts. Continue reading
Amounts in House budget reduced.
Meddling in Metro-Louisvile’s business.
The Kentucky House and Senate completed an increasingly contentious budget process last night after a weekend of behind-the-scenes horse trading. (The multitude of coal severance earmarks were also restored– a not-unrelated observation.) I suspect that few people actually believe the accompanying bilateral declarations of how well the two political parties worked so wonderfully together in the public interest. The lyrics of Kumbaya are known by heart in Frankfort: “Someone’s laughing, someone’s crying, someone’s singing, and lots of people are praying that things turn out all right!”
The 253 page document (House Bill 235) is only an outline of the various administrative units and projects receiving public funds, or of expenditures for which legislative approval is required. A summary of changes made in-conference is available here. No one can read it without recognizing the large number of earmarks that are the price for securing votes. The budget document also provides an indicator of the priorities of Kentucky’s State Universities and Community College system. Their itemized requests for public funds (or for permission to spend other money) make up 20% of the total budget document! I will write more about this latter use of the document later. In this article I summarize the partial restoration of funding by the legislature of the increasingly complicated and controversial QCCT indigent care program used to support inpatient services at University of Louisville Hospital. Continue reading
A $40.9 million settlement over issues of unnecessary cardiac catheterizations and coronary stents was apparently reached last February. Is it final yet?
Modern Healthcare reported yesterday on additional bad news for King’s Daughters Medical Center, including a $40.9 Million-plus settlement with the U.S. Department of Justice related to unnecessary cardiac procedures. The following language comes from the Medical Center’s annual independent audit for the fiscal year ending September 2013, as released this March 14.
“In February 2014, the Medical Center and the United States of America, acting through the DOJ and on behalf of the Office of Inspector General (OIG-HHS) of the Department of Health and Human Services (HHS) (collectively the “United States”) and the Commonwealth of Kentucky, reached an agreement to settle the DOJ’s review related to unnecessary diagnostic cardiac catheterizations and coronary stents. Under the terms of the agreement, the Medical Center will pay $40.9 million (“Settlement Amount”) to the United States. Interest will accrue on the Settlement Amount at the simple rate of 2.5%. Accordingly, $40.9 million is included in the current accrued governmental settlement at September 30, 2013 for the Settlement Amount. An additional $8 million has been included in the current accrued government settlement at September 30, 2013 for legal fees associated with the investigation and settlement. In addition to the settlement, the Medical Center will enter into a Corporate Integrity Agreement with the OIGHHS.”
Little or no news about the settlement.
I find no announcement of any settlement as of this morning on the websites of the Eastern District US Attorney, King’s Daughters Medical Center, or Kentucky’s Inspector General. I will try to ask for such. Apparently there was an additional settlement in September, 2013 of which I have no other details. Can anyone help? Continue reading
As reported in these pages earlier, the Governor’s budget (and that of the House) decreased QCCT funding for indigent care at University Hospital by 70% percent over the next two years. The justification for this decrease was that the new healthcare reforms being put into place would result in fewer patients showing up for care at Louisville’s designated poor-people’s hospital. Perhaps there were other reasons too.
QCCT gets zeroed out.
The Senate’s Budget Committee upped the ante by immediately eliminating this subsidy altogether! Senate Republicans justify this further decrease with an amazingly cynical bit of political sophistry. Senate Republicans argue that because every person in Kentucky is now eligible for some form of health insurance, that no patient will be eligible for QCCT funding in any case. Some folks may actually believe this. Of course not even the most ardent defenders of the Accountable Care Act (ACA) claim that everyone will be covered by the complicated system of programs and options that could be cobbled together against intense partisan opposition. Among other reasons, out-of-pocket costs to patients will still present a prohibitive barrier for many. Failure to fund the full “traditional” $21 Million program releases University Hospital from its obligation to provide care to all comers. There will still be plenty of work to go around for all Jefferson County providers to take their share. Continue reading
St. Joseph’s London Hospital has notified the state that it will no longer perform coronary artery bypass graft surgery (CABG), the traditional open-chest cardio-thoracic surgical procedure used to restore blood flow to the heart of people with severe coronary artery atherosclerosis. Before the advent of the the less invasive angioplasty and stenting, CABG was the main surgical approach to re-vascularization of a diseased heart. For certain combinations of coronary artery disease, and in some clinical settings, CABG remains the preferred approach today.
Why fewer invasive procedures?
In Kentucky, the frequency of both angioplasty and CABG have been gradually decreasing, presumably because the effectiveness of aggressive medical therapy is better recognized, and because research showed that the invasive approaches were being used in circumstances where they offered no advantage over non-invasive treatment. Treatment of coronary artery disease is lucrative for hospitals and physicians alike which unfortunately caused some to stretch the envelope beyond what could be justified medically, even to the point of fraud. That bubble is bursting and accounts for a some if not much of the overall decrease in invasive procedures.
Where will patients go?
The new plan in London is to transfer those patients requiring emergency surgery to one of the nearer hospitals capable of treating such a patient, presumably Pikeville, Hazard, Corbin, Asheville, Summerset, or Lexington. (Some of these hospitals perform fewer CABGs than in London!) For non-emergency surgery, patients will be referred to another KentuckyOne hospital– St. Joseph’s Lexington. Angioplasty and stenting will continue to be performed at St. Joseph’s London presumably with safeguards in place to make sure that the most appropriate procedure will be offered for medical reasons and not for convenience. Continue reading
Legal same-sex marriages in Kentucky will not be recognized on March 21st after all.
Breaking News, March 19, 5:40 pm
Late today, Federal District Judge John G. Heyburn issued an Order further staying his Order of Feb. 27 which found that Kentucky’s statutes and constitution prohibiting recognition of legal same-sex marriages to be unconstitutional. To allow the Commonwealth to prepare for practical administrative changes, he had already extended his Order until March 20th.
Observing that Judge Heyburn’s opinion “got it right,” Kentucky Attorney General Jack Conway declined to appeal the Judge’s decision. Subsequently, Governor Steve Beshear retained outside council to make such an appeal, and it was that to which Judge Heyburn was responding today.
Judge Heyburn found merit on both sides of the argument. You can read the four-page argument here and decide yourself where the greater merit lies. Ultimately, and recognizing that the Sixth Circuit Court of Appeals may take years before the appeals process is completed, the Judge decided to further stay his opinion. The Judge recognized how his decision would affect the married-couple plaintiffs.
“Perhaps it is difficult for Plaintiffs to understand how rights won can be delayed. It is a truth that our judicial system can act with stunning quickness, as this Court has; and then with sometimes maddening slowness. One judge may decide a case, but ultimately others have a final say. It is the entire process, however, which gives our judicial system and our judges such high credibility and acceptance. This is the way of our Constitution. It is that belief which ultimately informs the Court’s decision to grant a stay. It is best that these momentous changes occur upon full review, rather than risk premature implementation or confusing changes. That does not serve anyone well.”
I have no doubt about the ultimate resolution of this issue. History will render its own judgements upon those who stand either in favor or in opposition to same-sex marriage. I already have.
March 19, 2014
[Addendum- March 19: The official proceedings of the telephone conference of March 17, 2014 have been published (Document 70) summarizing two principal orders of business. The deadline for filing an amicus brief on the intervening matter of whether prohibition of gay marriage in Kentucky itself is unconstitutional was extended until May 2, 2014. The Family Trust Foundation of Kentucky apparently plans to file such a brief. Additionally, the motion by the Commonwealth to further stay his opinion concerning recognition of legal (out of state) same-sex marriage was taken under advisement by Judge Heyburn who will issue a separate order.]
What Happened Today (March 17) in Judge John G. Heyburn’s Courtroom?
Gov. Beshear’s attorneys pledge an appeal to Sixth Circuit Appeals Court tomorrow, March 18, if Judge Heyburn does not further stay enforcement of his decision requiring Kentucky to recognize legal same-sex marriages on March 20.
Last Friday, March 14, attorneys for Kentucky Gov. Steve Beshear filed an appeal to Federal District Court Judge John G. Heyburn to stay enforcement of his decision that Kentucky’s statutes and Constitution forbidding the recognition of legal out-of-state same-sex marriages are unconstitutional. If Judge Heyburn does not grant their request, Governor Beshear’s attorneys declared their intention to appeal to the Federal Sixth Circuit Court of Appeals to overturn the Judges decision tomorrow, March 18. The existing temporary stay given to allow the Commonwealth to prepare its compliance expires on March 20. There is not much time left!
Today, attorneys for the married same-sex couples filed their response to the Governor’s request. A telephone hearing was held in Judge Heyburn’s chambers today, but I do not know what was discussed. The session may have been as limited as accepting the Governor’s consent allowing the withdrawal of Attorney General Jack Conway and other attorneys from his office to withdraw from the case. No further hearings are scheduled on the court’s docket as of this evening. Continue reading
Not All Details Made Public. School Minimizes Significance.
The headline above appeared in two local news outlets yesterday and is exactly the kind of publicity the University of Louisville does not need. The story was broken by David Mann of Business First reacting to a news release from the University. In a subsequent interview, Medical School Dean Toni Ganzel outlined some nine areas of concern to the Liaison Committee On Medical Education (LCME) that oversees the accreditation of American Medical Schools. It is by no means clear that all identified problems or their severity have been made public.
As it is, the deficiencies that were identified are fundamental to the basic mission of a medical school: teaching facilities were inadequate, the method of teaching was behind the times, the curriculum needed review, evaluation of students was uneven without appropriate feedback to the students, cooperation among different medical and scientific disciplines was not sufficient, faculty integration with off-campus teaching sites was sub-optimal, and academic affiliations with hospitals were not clear. What else is there to go wrong?
I have always admired Dean Ganzel. She did not create this embarrassing problem, but she was left holding the bag, probably without the authority or the resources to fix it. Control of the Medical Center, including its clinical activities, rests in the President’s office. She obviously needs to minimize the damage and present the matter honestly and in the best possible light. She was effective to the point that the Courier-Journal printed a sub-headline quote: “I don’t think this decision is based on the overall quality of the educational experience.” A medical student volunteered that “she had a good experience.” Would a student have dared say anything else?
Not a big deal?
The school’s understandable impulse is to make it sound like this is no big deal, and that most of the remedies have already been made or are on track. This self-portrait is belied by the language used by the LCME itself.
“Accreditation with probation is an action based on determination by the LCME, … that an accredited program is not in substantial compliance with accreditation standards. Such a determination may be based on the LCME’s judgment, … that the areas of noncompliance have seriously compromised the quality of the medical education program, or that the program has failed to make satisfactory progress in achieving compliance after having been granted ample opportunity to do so.”
We do not yet know whether or not the University of Louisville’s Medical School was placed on probation because of serious compromise of quality, or because it did not make satisfactory progress after having had a chance to do so. Which possibility is worse? Continue reading