Category: Health Care Reform

Alleged Angioplasty Abuse in Kentucky – Instant Replay.

paulus-heart-center Another shoe drops: New lawsuit in Ashland.

Just when I thought it was safe to write about something else, I learned about a new lawsuit against the King’s Daughters Medical Center, Comprehensive Heart & Vascular Associates, Inc., and Dr. Richard E. Paulus, M.D., all of Ashland KY. Of course, claims made in a legal action represent the views of only one party. Nonetheless, the complaint specifies issues essentially the same as those currently playing out at St. Joseph London in southeast Kentucky and are on their face inherently possible.

The case was filed in Boyd County Circuit Court on September 30, 2013 on behalf of a single plaintiff and his wife by the Poppe Law Firm of Louisville. This is the same firm handling numerous civil claims against St. Joseph London in Laurel County. The alleged circumstances and actual facts are disturbingly familiar. As stated in the complaint, the plaintiff is said to have undergone unnecessary angioplasty with the placement of a stent. The rate of angioplasty in the area surrounding King’s Daughters Medical Center is the highest in the state, and indeed one of the very highest in the nation. Following the purchase of the medical practices of two large cardiology groups, the number of angioplasties increased substantially. According to the complaint, following an investigation begun by the United States Department of Justice, the number of procedures dropped by 70%, remaining nonetheless the second highest for Kentucky hospitals. Continue reading “Alleged Angioplasty Abuse in Kentucky – Instant Replay.”

The Quest for Neonatal Intensive Care Beds. A Statewide Phenomena.

As the controversy between Norton Healthcare and the University of Louisville over control of Norton Kosair Children’s Hospital continues to unfold, our colleagues at Insider Louisville have emphasized a central role that control of neonatal intensive care unit (NICU) beds is playing. Every hospital that delivers babies will have a nursery, but not all are qualified to run the NICUs that take care of the very sickest and most vulnerable infants. Aside from providing necessary care, it is no state secret that NICUs are one of the very most profitable services in a children’s hospital.

The number of NICU beds in individual acute care hospitals is regulated by Kentucky’s certificate of need (CON) process. There are four possible levels of NICU beds ranging from Level I for routine infant care, to level IV for institutions capable of caring for virtually any sophisticated need, including surgery. Kentucky’s continuingly updated State Health Plan addresses the criteria and requirements for each level. On May 31, 2013, the Plan was revised to bring it more into line with the most recent “Guidelines for Perinatal Care” of the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. The Plan now includes specific requirements for a new state designation of Level IV. You can download the NICU-related pages of the 2013 State Health Plan here.

The new regulations make it possible for a level II facility to care for sicker babies if it has a written affiliation agreement with a Level IV facility. Similarly, a Level III facility must now also have a formal collaborative relationship with a Level IV facility for consultation and transfers. This puts hospitals with Level IV NICUs at the top of networks of care and referrals. In medical terms, this is also referred to as guaranteed income streams. You can see where this might be going. Continue reading “The Quest for Neonatal Intensive Care Beds. A Statewide Phenomena.”

Passport Takes Further Commanding Lead in Region 3 Medicaid Managed Care.

Who is getting paid for what? Why should we care?

Some months ago I reported on the shifting enrollments of Medicaid Managed Care beneficiaries among the four Managed Care Organizations (MCOs) in Region 3, which includes Louisville and a few surrounding counties. Although the initial assignments by the state gave roughly equal numbers of beneficiaries to each of the MCOs selected to do business in the Region, Passport was able to leverage its previous home-court, sole-source advantage; and cooperation from its existing participating providers to recapture the lion’s share of patients from its new competitors. In this installment, I show the final enrollment figures as of April 2013 when the relatively unfettered ability of a member to change from one plan to another expired. The big winner continues to be Passport which expanded its Region 3 market share to 75% compared to 64% early last February.

enrollment-april2013

Medicaid Managed Care was reintroduced elsewhere in the state in January 2012. In little more than a year, the distribution of enrollees outside Region 3 shifted to favor two of the three MCOs. (It didn’t help that one of the MCOs has already expressed interest in leaving the state.) Competition, as opposed to cooperation, produces winners and losers. The hope (and it remains a hope) is that patients will come out winners. I present some enrollment figures below as well as the rates paid by the state to the MCOs to cover the care of beneficiaries. A table of the data can be downloaded here.

Continue reading “Passport Takes Further Commanding Lead in Region 3 Medicaid Managed Care.”

Cardiologist Pleads Guilty to Doing Unnecessary Angioplasties at St. Joseph’s Hospital London.

Not Just a Bad Idea.  It’s Against the Law!

gavel-icon

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] Continue reading “Cardiologist Pleads Guilty to Doing Unnecessary Angioplasties at St. Joseph’s Hospital London.”