Inquiry into the spectacularly profitable HCA Hospital Chain cites unnecessary cardiac work

Hospital Chain Inquiry Cited Unnecessary Cardiac Work
By REED ABELSON and JULIE CRESWELL
New York Times
August 6, 2012

GRAPHIC: HCA’s Growing Profit

In the summer of 2010, a troubling letter reached the chief ethics officer of the hospital giant HCA, written by a former nurse at one of the company’s hospitals in Florida.

In a follow-up interview, the nurse said a doctor at the Lawnwood Regional Medical Center, in the small coastal city of Fort Pierce, had been performing heart procedures on patients who did not need them, putting their lives at risk.

“It bothered me,” the nurse, C. T. Tomlinson, said in a telephone interview. “I’m a registered nurse. I care about my patients.”

In less than two months, an internal investigation by HCA concluded the nurse was right.

“The allegations related to unnecessary procedures being performed in the cath lab are substantiated,” according to a confidential memo written by a company ethics officer, Stephen Johnson, and reviewed by The New York Times.

Mr. Tomlinson’s contract was not renewed, a move that Mr. Johnson said in the memo was in retaliation for his complaints.

But the nurse’s complaint was far from the only evidence that unnecessary — even dangerous — procedures were taking place at some HCA hospitals, driving up costs and increasing profits.

HCA, the largest for-profit hospital chain in the United States with 163 facilities, had uncovered evidence as far back as 2002 and as recently as late 2010 showing that some cardiologists at several of its hospitals in Florida were unable to justify many of the procedures they were performing. Those hospitals included the Cedars Medical Center in Miami, which the company no longer owns, and the Regional Medical Center Bayonet Point. In some cases, the doctors made misleading statements in medical records that made it appear the procedures were necessary, according to internal reports.

Questions about the necessity of medical procedures — especially in the realm of cardiology — are not uncommon. None of the internal documents reviewed calculate just how many such procedures there were or how many patients might have died or been injured as a result. But the documents suggest that the problems at HCA went beyond a rogue doctor or two.

At Lawnwood, where an invasive diagnostic test known as a cardiac catheterization is performed, about half the procedures, or 1,200, were determined to have been done on patients without significant heart disease, according to a confidential 2010 review. HCA countered recently with a different analysis, saying the percentage of patients without disease was much lower and in keeping with national averages.

At Bayonet Point, a 44-year-old man who arrived at the emergency room complaining of chest pain suffered a punctured blood vessel and a near-fatal irregular heartbeat after a doctor performed a procedure that an outside expert later suggested might have been unnecessary, documents show. The man had to be revived. “They shocked him twice and got him back,” according to the testimony of Dr. Aaron Kugelmass in a medical hearing on the case.

In another incident, an outside expert described how a woman with no significant heart disease went into cardiac arrest after a vessel was cut when a Bayonet Point cardiologist inserted a stent, a meshlike device that opens coronary arteries. She remained hospitalized for several days, according to a person who has reviewed internal reports...

In a recent statement, HCA declined to provide evidence that it had alerted Medicare, state Medicaid or private insurers of its findings, or reimbursed them for any of the procedures that the company later deemed unnecessary, as required by law...

Some doctors accused in the reviews of performing unnecessary procedures are still practicing at HCA hospitals...



A Giant Hospital Chain Is Blazing a Profit Trail
By JULIE CRESWELL and REED ABELSON
August 14, 2012

During the Great Recession, when many hospitals across the country were nearly brought to their knees by growing numbers of uninsured patients, one hospital system not only survived — it thrived.

In fact, profits at the health care industry giant HCA, which controls 163 hospitals from New Hampshire to California, have soared, far outpacing those of most of its competitors.

The big winners have been three private equity firms — including Bain Capital, co-founded by Mitt Romney, the Republican presidential candidate — that bought HCA in late 2006.

HCA’s robust profit growth has raised the value of the firms’ holdings to nearly three and a half times their initial investment in the $33 billion deal.

The financial performance has been so impressive that HCA has become a model for the industry. Its success inspired 35 buyouts of hospitals or chains of facilities in the last two and a half years by private equity firms eager to repeat that windfall.

HCA’s emergence as a powerful leader in the hospital industry is all the more remarkable because only a decade ago the company was badly shaken by a wide-ranging Medicare fraud investigation that it eventually settled for more than $1.7 billion.

Among the secrets to HCA’s success: It figured out how to get more revenue from private insurance companies, patients and Medicare by billing much more aggressively for its services than ever before; it found ways to reduce emergency room overcrowding and expenses; and it experimented with new ways to reduce the cost of its medical staff, a move that sometimes led to conflicts with doctors and nurses over concerns about patient care.

In late 2008, for instance, HCA changed the billing codes it assigned to sick and injured patients who came into the emergency rooms. Almost overnight, the numbers of patients who HCA said needed more care, which would be paid for at significantly higher levels by Medicare, surged.

HCA, which had lagged the industry for those high-paying categories, jumped ahead of its competitors and was reimbursed accordingly. The change, which HCA’s executives said better reflected the service being provided, increased operating earnings by nearly $100 million in the first quarter of 2009.

To some, HCA successfully pushed the envelope in its interpretation of existing Medicare rules. “If HCA can do it, why can’t we?” asked a hospital consulting firm, the Advisory Board Company, in a presentation to its clients.

In one instance, HCA executives said a private insurer, which it declined to name, questioned the new billing system, forcing it to return some of the money it had collected.

The hospital giant also adopted a policy meant to address an issue that bedevils hospitals nationwide — reducing costs and overcrowding in its emergency rooms. For years, the hospital emergency room has been used by the uninsured as a de facto doctor’s office — a place for even the most minor of ailments. But emergency care is expensive and has become increasingly burdensome to hospitals in the last decade because of the rising number of uninsured patients.

HCA decided not to treat patients who came in with nonurgent conditions, like a cold or the flu or even a sprained wrist, unless those patients paid in advance. In a recent statement, HCA said that of the six million patients treated in its emergency rooms last year, 80,000, or about 1.3 percent, “ chose to seek alternative care options.”

“Many E.R.’s in America, particularly in densely populated urban areas where most HCA-affiliated facilities are located, have adopted a variety of systems to determine whether a patient in fact needs emergency care,” the statement said. “About half our hospitals have done so. Typically, our affiliated hospitals have two caregivers — usually a triage nurse and a physician — make that determination. It should be noted that other non-HCA affiliated hospitals are using similar processes to address E.R. issues.”

As HCA’s profits and influence grew, strains arose with doctors and nurses over whether the chain’s pursuit of profit may have, at times, come at the expense of patient care.

HCA had put in place a flexible staffing system that allowed it to estimate the number of patients it would have each day in its hospitals and alter the number of nurses it needed accordingly.

Several nurses interviewed said they were concerned that the system sometimes had led to inadequate staffing in important areas like critical care. In one measure of adequate staffing — the prevalence of bedsores in patients bedridden for long periods of time — HCA clearly struggled. Some of its hospitals fended off lawsuits over the problem in recent years, and were admonished by regulators over staffing issues more than once.

‘Through the Roof’

Many doctors interviewed at various HCA facilities said they had felt increased pressure to focus on profits under the private equity ownership. “Their profits are going through the roof, but, unfortunately, it’s occurring at the expense of patients,” said Dr. Abraham Awwad, a kidney specialist in St. Petersburg, Fla., whose complaints over the safety of the dialysis programs at two HCA-owned hospitals prompted state investigations.

One facility was fined $8,000 in 2008 and $14,000 last year for delaying the start of dialysis in patients, not administering physician-prescribed drugs and not documenting whether ordered tests had been performed.

Claiming he provided poor care, the other hospital did not renew Dr. Awwad’s privileges. Dr. Awwad is suing to have them reinstated. HCA declined to comment. HCA says it stands by its procedures, billing practices and level of care...

Two black eyes? Kaiser and Komen Foundation

Kaiser and Komen

In a ghastly coincidence, the same day Komen pulled the money from Planned Parenthood because Stearns thought they were spending federal funds on abortions, the Journal of the America Medical Association published a damning study that almost half of women receiving second surgeries after lumpectomies didn't need the procedure. Painful, disfiguring, unnecessary surgery. At least three of the four sites studied in the JAMA report -- the University of Vermont, Kaiser Permanente Colorado, and the Marshfield Clinic -- has a relationship with the Komen Foundation. Kaiser Permanente is a "corporate campaign partner," the University of Vermont received a research grant, the Central Wisconsin Komen affiliate sponsors programs at the Marshfield Clinic. Maybe Komen should concentrate their granting criteria on whether the recipients are actually helping cancer patients.

The Komen Foundation's Black Eye
Linda Hirshman
The Atlantic
FEB 1 2012

By no longer donating to organizations "under investigation" by any federal, state, or local government, the Susan G. Komen Foundation is replacing its pink ribbons with a black list.

Recently, the Susan G. Komen Foundation, whose ubiquitous pink ribbon symbolizes its mission of curing breast cancer, adopted a mysterious rule. They would no longer make bequests for any services to any organization that was "under investigation" by any branch of any federal, state, or local government. Of course Komen is completely free to do whatever it likes. But recent American history contains a powerful warning against letting random legislators determine who gets cut off by their funders. Years ago, when Hollywood screenwriters invoked their constitutional right not to incriminate themselves in front of the red-hunting House Un-American Activities Committee, the private members of the Motion Picture Association put them on a blacklist, never to be employed again. In the years since the McCarthy fever abated, the blacklisting episode has come to be a symbol of political cowardice and wrongdoing. Komen does itself a disservice by replacing the pink ribbon with a black list.

Had anyone been looking, they might have asked why the cancer foundation needed such a rule. After all, how likely is it that a research university or cancer screening provider would attract the attention of the protectors of the public weal? Just before Komen passed its new rule, a passionately anti-abortion Republican congressman, Cliff Stearns, had announced he would be investigating the nationwide cancer-screening service provider Planned Parenthood. Not anything to do with cancer screening of course, but because Americans United for Life had told Rep. Stearns that they suspected the longtime contraceptive pioneer of using some of its federal funding for abortions. And yesterday, Komen pulled the million dollars it gives Planned Parenthood annually for cancer screening. After all, rules are rules.
What if the IRS was looking into a hospital's tax status? Would Komen have to pull their funding too?

Skeptical commentators are speculating that Komen bowed to political pressure. As conservatives increasingly targeted Planned Parenthood in recent months, various organizations explicitly upped the ante with Komen over their support of the non-profit. The Southern Baptists pulled their Pink Bible program, which produced a dollar for Komen with every Bible sold. Last April, Komen hired as vice president for public policy Karen Handel, a failed Republican candidate with a long online history of hostility to Planned Parenthood and contraception in general. And then it enacted its new rule.

The skepticism is further fueled by the weirdness of a rule letting any city council member or random state legislator decide to defund a Komen grantee just by starting an "investigation."...

Many U.S. surgeries on elderly may be unwanted: study

Many U.S. surgeries on elderly may be unwanted: study
Oct 6, 2011

(Reuters) - One out of three elderly Americans covered under Medicare plans undergo surgery in the last year of their life, a new study shows.

Medicare reimbursement and the availability of hospital beds are more likely to influence a doctor's decision to operate than a patient's need or desire, according to the study published in the latest issue of Britain's Lancet medical journal.

"While some of these surgeries are clearly needed and helpful to patients, probably a substantial portion are not," lead researcher Ashish Jha of the Harvard School of Public Health told Reuters.

"We (physicians) don't really ask patients what they want and we end up doing a lot of procedures," he said.

The number of patients receiving surgery toward the end of their lives is higher in regions with high total Medicare spending, the study found.

For example, the rate of end of life surgeries was three times greater in the Munster, Indiana region than in Honolulu.

The study, which looked at data from more than 1.8 million beneficiaries of the government's Medicare health plan who were aged 65 years or older and died in 2008, also found that about one in five elderly patients underwent a surgical procedure in the last month of life.

Doctors should consider the benefits of surgery on elderly patients more carefully before performing procedures that may not improve their quality of life, Jha concluded.

In addition to regional differences, the study found decisions to perform surgery on elderly Americans during the last year of their lives are more likely to be influenced by the patient's age than a patient's need or desire for such procedures.

The likelihood of undergoing a surgical procedure declined significantly as patients get older, Jha's team found.

About 38 percent of patients underwent surgery at age 65, 35 percent by age 80, while only 24 percent had surgery when they lived to between the ages of 80 and 90.

Jha said physicians need to talk to patients who are about to die and inform them that a procedure may not necessarily improve their quality of life.