Not Just a Bad Idea. It’s Against the Law!
Yesterday, the Office of the US Attorney, Eastern District of Kentucky, released a public notice that cardiologist Dr. Sandesh Rajaram Patil “pleaded guilty to charges that he falsely recorded the severity of patient’s illnesses in order to receive payment for numerous [medically unnecessary] heart procedures” while working at St. Joseph Hospital in London, then and now part of the CHI/KentuckyOne Health system. A prison term of some 3 years is anticipated. St. Joseph London has repaid the government $256,800 for an unstated number of cardiac stent angioplasties done in its hospital in 2009 and 2010 for which falsified bills were submitted. You can download a copy of the announcement at the FBI site, or here.
This means that we do not have to hedge anymore by referring to “alleged” angioplasty abuse. Frankly, I was not aware that criminal proceedings were underway but should not have been surprised. Neither do I know if there are ongoing criminal charges against other physicians at the hospital, or the hospital itself. Certainly there are a multitude of civil suits from patients pending against physicians and hospital alike. If I were a Blue Cross or a Humana, I would be getting in line for some refunds as well. The story is, unfortunately, far from over at this hospital and others in the state. The phrase “tip of the iceburg” comes to mind.
What was agreed to? Can we know?
As seems to be the case in such “settlements,” there appears to be a discrepancy between what the court assumes it has extracted in terms of admission, and what Dr. Patil is willing to concede. According to reporting by Andrew Wolfson, reprinted often in today’s papers, Patil’s attorney appears to claim (in contrast to the the use of the pleural in the announcement) that the degree of blockage in an artery was exaggerated for only a single patient, and that Dr. Patil “didn’t do anything that he didn’t think was medically necessary.” Its hard for me to get from one artery to three years in jail without access to the charges and the pleadings. What does the United States Attorney know that we do not? I am not completely surprised at the sentence, but how are we to judge its fairness without access to the facts. St. Joseph Hospital London had to give back a quarter of a million dollars. Was that too much… too little? The hospital submitted bad bills for payment. Does it have any culpability? If it does not, then it deserves to have its name fully cleared. As I have suggested for several months now, without full transparency and accountability, a cloud will hang over these and other hospitals and cardiologists for the foreseeable future. No one deserves that. Local physicians must be able to recommend their hospitals to their patients without reservation. Patients must feel comfortable going there.
[Addendum: I obtained additional insight into the matter of “how many” arteries were at issue, and what the magnitude of the hospital pay-back might tell us. See my comments below. Add your own]
Other unsettling aspects.
There are other aspects of this case that remain unresolved and troubling to me. I expressed my concern earlier and often that all of this set of accusations might dissipate in a parade of settlements and agreements. The public may never be able to penetrate the miasma of imputed malfeasance that inevitably hangs in the air. While this may have been a standard way of doing business in the past, and while I can understand why individuals and institutions may wish to sweep things under convenient rugs, such approaches violate overriding principles of transparency and accountability. What good are measures of quality and safety if bad results can be hidden from public view. Apologize, make recompense, move on, and do better– isn’t that supposed to be the new mantra?
What could the Medical Licensure Board have done?
It troubles me also that despite one of the worst outside professional reviews of a physician than I ever saw in my time sitting as a representative or consultant to Kentucky’s Medical Licensure Board, that Dr. Patil was permitted to retain his medical license without further review. It appears he was required to relinquish his medical staff privileges at St. Joseph London. However, Dr. Patil easily found a new professional home within the ARH hospital system where he became part of its Medical Staff Leadership Organization. If Dr. Patil enjoyed that kind of professional respect, he too deserved to have the air cleared quickly– one way of the other. Further audits of his practice were, in my opinion, clearly indicated and were not done.
Can the Licensure Board protect both doctors and the public?
If I can mount the courage, I will someday write about what I think is a structural inability of the Kentucky Licensure Board, and us physicians in general, to guarantee the professional competence and integrity of our guild to the public. In brief, the Licensure Board is in my opinion an extension of the Kentucky Medical Association which itself operates primarily to protect physicians, and then indirectly, the public. I do not personally believe it can do both well at the same time. This is a dilemma that bears on other issues, such as abuse of prescription drugs, or health professional manpower in underserved areas of the state. I believe there needs to be more separation of the KMA from the Licensure Board, and a more diverse representation on the Board by physicians who are not members of the KMA. This is not meant to be a personal criticism of individual Board members, who I count as my friends, nor of the KMA, of which I am a member. I perceive a built-in, structural conflict of interest. Indeed, I think the Commonwealth needs to rethink how it populates its various boards, committees, and work groups with health professionals. As it is now, by statute, most such appointments are made by means of nomination or recommendation from the respective professional guilds.
Can bad medicine really go unobserved by others?
It is both difficult and painful to contemplate how the abusive or poor quality medical care now under further scrutiny could have occurred within St. Joseph Hospital London in plain sight of its medical professionals and hospital executives. X-Rays and other medical studies are read by other doctors and technicians. Poor outcomes are reviewed by department chair-people. Other physicians consult on the same patients. Hospital administrators and workers sift through everything that goes on to prepare their bills for services. We of the public are best served by receiving necessary high quality medical services in the right amount, at the right time, and in the right place. That is not happening now as it must. The medical profession itself has not been able to manage the proper balance. Indeed, I fear that with the rise of hospital, health, and insurance systems; the employment of physicians by corporations; and the encroachment of commercial research and other interests on medical practice; that we physicians are losing or already have lost control of our ability to self-regulate. Instead, we have by default, allowed courts of law, legislative processes, and organizations of non-physicians to judge our professional competence and integrity. Can this be fixed as I earnestly wish it should? Not easily, and perhaps not within our present system. For the time being I predict more of the dysfunctional and adversarial same.
Enough of side issues for now. I am trying to access the relevant court records, but so far without success. I know how to access the scientific and policy literature, but not the court system. Any suggestions from out there? Help wanted!
Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
June 6, 2013
From a notice from the KMA to its physician members, July 16, 2013.
I rest my case!
“Notice of Application for Appointment to Kentucky Board of Medical Licensure
KMA members interested in being considered for a gubernatorial appointment to serve on the Kentucky Board of Medical Licensure (KBML) must submit an application and their curriculum vitae to the Kentucky Medical Association by July 30, 2013.”
For how many patients did St. Joseph London Hospital make a refund?
It is possible to estimate of the number of cardiovascular procedures on Medicare patients that were at issue in this criminal proceeding by extrapolating from the $256,800 refunded to the government by the hospital. I will assume that the majority of these were for Medicare patients, but there may be some Medicaid recipients in the mix. (Other insurance companies, payers, and individual patients will have to seek their own recovery.)
How many angioplasties will a quarter $million buy?
Medicare recently released the average amount charged by individual hospitals for the top 100 discharge diagnoses, and in a new twist, the amount they were actually paid. During fiscal year 2011, St. Joseph’s London billed Medicare $50,747 for each of 71 traditional Medicare patients discharged who underwent the most common cardiac angioplasty stenting procedure (MSDRG 247). However, the hospital received only an average of 27% of the billed amount– $13,779 per case. (I understand that not all in the payment figure came from Medicare, but included copays and supplemental insurance.) I assume that individual charges and payments have both gone up since 2009. Nonetheless, using this ballpark methodology and using this most recent payment figure, the total amount refunded to the government as a result of this criminal case against a single doctor would pay for more than 186 Medicare patients over the two year period.
Is this a lot of Medicare patients?
These are just back-of-the-envelope estimates. To put things in perspective, in fiscal year 2011, St. Joseph London did 92 of the two most commonly billed angioplasty-with-stenting procedures on traditional fee-for-service Medicare patients. This number represents 24% of the 388 done on all patients that year for the two procedures. This 388 is fewer than the 594 done during the 2009 peak angioplasty year before the abuse came to light, but nevertheless it seems to me that a substantial proportion, maybe even a majority of the hospital’s Medicare patients undergoing angioplasty in 2009 and 2010 were at issue in this first settlement. This is a big deal!
Anyone else want to look?
I have not been able to find any financials for St. Joseph London more recent than tax year 2007 when they were still the Catholic Health Initiatives hospital, Marymount Medical Center. Their total revenue was $118.9 million including investment income, with expenses of $108.4 million for an excess of $10.5 million or almost 9%. I don’t understand hospital financial statements well enough to know if this can be termed a profit, but a $250 thousand refund might be considered by some a cost of doing business. I don’t know how much this hurts the hospital or CHI. I rather expect that there will be more, and higher payments to come.
The Form 990 for 2007 that gives the figures above also tells us that St. Joseph London transferred $4.26 million to Catholic Health Initiatives. The hospital listed the compensation and benefits for its 5 highest paid employees other than officers and directors. Two cardiovascular surgeons were paid $867 thousand. I am unaware if any cardiologists were employees.
I believe the public has a right to review the full details and I hope they will be made available as this case comes to conclusion.
We may safely assume more than one case was involved.
I was able to get some clarification of the apparent discrepancies between the lengths of the proposed sentence, the large amount of money refunded by St. Joseph’s London, and the claim by Doctor Patel’s attorney that only a single record was falsified. Apparently this is standard operating procedure in the court system. Even when there are many individual counts in a given criminal complaint, for simplicity, only a single count may be on the table. However, in the mandatory federal sentencing guidelines used, other information is considered including “all other relevant conduct.” From the amount of money involved and the length of the sentence, we may reasonably assume that a broader pattern of falsification of records [and angioplasty abuse] was involved. Strictly speaking, Doctor Patel’s attorney may have been technically correct if he states that the doctor only pleaded guilty to a single instance of falsification, but I was misled.
I’ve also learned that it may be a while before records are available to the public. I will try to remember to look again at the time of sentencing. If anyone else can get there first, please share with the rest of us.