Legitimate or hysterical hit piece? “Doctors Ghost Patients, Charge for Surgeries Left to Residents”

[wamcp]

Surgeons Are Double and Triple Booking Procedures That Residents Must Perform

Doctors at some of the largest US teaching hospitals are blowing the whistle on a lucrative practice they say endangers patients: Surgeons scheduling two or even three operations at virtually the same time, leaving during critical portions, then billing Medicare for work they didn’t do.

www.bloomberg.com

Doctors at some of the largest US teaching hospitals are blowing the whistle on a lucrative practice they say endangers patients: Surgeons scheduling two or even three operations at virtually the same time, leaving during critical portions, then billing Medicare for work they didn’t do.
A review of more than a dozen federal and state lawsuits offers a rare glimpse into a tight-lipped profession. Many include separate allegations of bribery, kickbacks, and improper compensation. Some reveal closed-door debates by hospital administrators over the ethics, safety, and staggeringprofits brought by concurrent surgeries.
The University of Southern California’s hospital system is accused of billing for thousands of cases - costing taxpayers “hundreds of millions of dollars” - where the teaching physician left residents unattended to perform even spine and brain surgeries. When one doctor confronted a department head about an “embarrassingly high” rate of surgical injuries at one of its facilities, the administrator responded, according to the lawsuit:

“Well, that’s where the residents go to practice on the poor folks.”

---

Members don't see this ad.

 

[HighPriest]

Anecdotal and third person, but I do know someone fairly well who works at an institution where this type of thing 1-happens, 2-has lead to serious and easily preventable injuries to patients and 3-was covered up by the institution to the point of insinuating legal action against a whistleblower (who was the person that I know). As it isn’t my personal story I’d prefer not to give specifics, but I can say that this does happen and it is bull$#!t. And fraud. And in at least some cases, malpractice.

 

[anonperson]

Surgeons Are Double and Triple Booking Procedures That Residents Must Perform

Doctors at some of the largest US teaching hospitals are blowing the whistle on a lucrative practice they say endangers patients: Surgeons scheduling two or even three operations at virtually the same time, leaving during critical portions, then billing Medicare for work they didn’t do.

www.bloomberg.com

Doctors at some of the largest US teaching hospitals are blowing the whistle on a lucrative practice they say endangers patients: Surgeons scheduling two or even three operations at virtually the same time, leaving during critical portions, then billing Medicare for work they didn’t do.
A review of more than a dozen federal and state lawsuits offers a rare glimpse into a tight-lipped profession. Many include separate allegations of bribery, kickbacks, and improper compensation. Some reveal closed-door debates by hospital administrators over the ethics, safety, and staggeringprofits brought by concurrent surgeries.
The University of Southern California’s hospital system is accused of billing for thousands of cases - costing taxpayers “hundreds of millions of dollars” - where the teaching physician left residents unattended to perform even spine and brain surgeries. When one doctor confronted a department head about an “embarrassingly high” rate of surgical injuries at one of its facilities, the administrator responded, according to the lawsuit:

“Well, that’s where the residents go to practice on the poor folks.”

https://archive.ph/y1WaD

Non paywall link.

Interesting story. I have heard of these situations in the news but have never seen it in person. In residency on the east coast ( community programs), case would not go until attending was physically in the room.

In fellowship, I was at a major academic center where we operated at the university hospital and another county facility in Southern California (not USC) and no cases would start without the attending in the room.

The article seems to paint Ortho as a major player in all of this.

Seems like some greedy docs/administrators and a weak department chair.

It doesn't surprise me at the amount of leeway Ortho gets in a hospital system. They truly are the cash cow and admin doesn't hesitate to bend over backwards to accommodate them.

It does get frustrating that even if you are a busy non Orthopedic surgeon, due to arbitrary reimbursement etc, you don't get the red carpet treatment.

 

[StIGMA]

Saw this routinely in medical school, up to quadruple booked. Vascular surgery was the most notorious for it at my institution but many/most at least double booked.

This isnt new "news" or even hidden, see from 2019:

Association of Overlapping Surgery With Perioperative Outcomes

This cohort study assesses the association between overlapping surgery (in which the same primary surgeon is involved in ≥2 cases simultaneously) and in-hospital mortality, in-hospital complications, and length of surgery among adult patients.

jamanetwork.com

https://www.npr.org/sections/health-shots/2019/02/26/698080027/double-booked-surgeons-study-raises-safety-questions-for-high-risk-patients

 

[operaman]

Oh yeah definitely seen many varying degrees of this. There is definitely a right way to do it and I think overlapping surgeries can be done safely if you’re careful about the level of trainees left alone and so long as the boss is there for the important parts.

In my training we frequently had an attending who would leave the chief and fellow alone to start a case, go do something else with a more junior resident, then pop back in when we called him for the critical portion. In that case you have a chief plus a fellow who is also an attending, so I never saw anything bad happen as a result. We had another attending who tried to be like that but with lower level residents and very quickly lost posting privileges after residents spoke up about feeling unsafe. This is really something that should be policed at the dept/division level as it was in this case, but unfortunately that doesn’t always happen.

I remember being an intern in our plastics dept and they definitely did this and everyone looked away. But here again you’ve got trainees left alone who are pgy8-10 and board certified general surgeons. They definitely never left the terns alone to do anything! But they also weren’t really open about telling patients how things would be done and that the attending may not even come back after the first five minutes of the case. The dept came under fire for this and some other things, some faculty were strongly encouraged to retire and the institution put a stop to these practices.

While not mentioned in the article, there are also many private practice surgeons who run overlapping rooms and have either a midlevel or their first assist doing the non critical parts.

The Erlanger case is rather stunning. Pretty brazen for the hospital to recruit some big names only to fire them days after submitting safety reports on the overlapping cases. Obviously we have to take the plaintiff complain with a grain of salt and I’m sure there’s more to the story, but admin had to know retaliation would be very dangerous. It’s not like they canned a resident or junior attending here - these are mid/later career people with plenty of savings and clout who have much less to lose.

 

[dpmd]

Oh yeah definitely seen many varying degrees of this. There is definitely a right way to do it and I think overlapping surgeries can be done safely if you’re careful about the level of trainees left alone and so long as the boss is there for the important parts.

In my training we frequently had an attending who would leave the chief and fellow alone to start a case, go do something else with a more junior resident, then pop back in when we called him for the critical portion. In that case you have a chief plus a fellow who is also an attending, so I never saw anything bad happen as a result. We had another attending who tried to be like that but with lower level residents and very quickly lost posting privileges after residents spoke up about feeling unsafe. This is really something that should be policed at the dept/division level as it was in this case, but unfortunately that doesn’t always happen.

I remember being an intern in our plastics dept and they definitely did this and everyone looked away. But here again you’ve got trainees left alone who are pgy8-10 and board certified general surgeons. They definitely never left the terns alone to do anything! But they also weren’t really open about telling patients how things would be done and that the attending may not even come back after the first five minutes of the case. The dept came under fire for this and some other things, some faculty were strongly encouraged to retire and the institution put a stop to these practices.

While not mentioned in the article, there are also many private practice surgeons who run overlapping rooms and have either a midlevel or their first assist doing the non critical parts.

The Erlanger case is rather stunning. Pretty brazen for the hospital to recruit some big names only to fire them days after submitting safety reports on the overlapping cases. Obviously we have to take the plaintiff complain with a grain of salt and I’m sure there’s more to the story, but admin had to know retaliation would be very dangerous. It’s not like they canned a resident or junior attending here - these are mid/later career people with plenty of savings and clout who have much less to lose.

I have on occasion gotten two rooms and would leave an assistant to close while moving to the next room to start the next case. Key part of that is it being the non critical part of the case (I am not plastics where the closure can definitely be considered the critical portion), but even then there is the potential for trouble. I never leave the fascia closure for the assistant but there is plenty of room for trouble in skin and subcutaneous tissue. Had an assistant break a needle while closing and I had to scrub back on to find it. It added half an hour to the case because the patient was obese and I had to get fluoro to find where the damn thing went. Had that been a two room day I would have had to make one of the patients wait with no progress because I don't let assistants open for me and I can't be two places at once. Some surgeons do let assistants open which is how it is possible for triple booked cases to happen, but that just leaves even more potential for trouble. In residency there were times when it was just a senior resident and a junior resident doing the case but not because the attending was scrubbed elsewhere, more that they were satisfied with how the case was being done and would leave the room while being immediately available for issues.

 

[Pir8DeacDoc]

Obviously we all have to learn. But it can be done safely and responsibly. Treating other people like Canon fodder or an ATM is shameful behavior.

 

[HighPriest]

There’s definitely a difference between having a mid level close a non-complex wound in a patient who isn’t overly concerned about scarring, and having a non-accredited fellow from a foreign medical institution do the whole case and then bill for it yourself.

As stated already: there’s a safe way to do things and there’s fraud. The problem is that this -will- eventually be a baby thrown out with the bath water. Just wait and see.

 

[DoctwoB]

Honestly I would avoid it if at all possible. Can your resident or midlevel safetly close? Of course. But anytime something bad happens (which it will whether you are there or not) you put a fat target on your back.

Wound infection? "Doctor were you present for this wound closure? No? Why not? You billed for the whole surgery. Why did you abandon your patient? Is this closure "not critical" to you?" And so on.

Jury of laypeople would open your checkbook. It's not worth it.

 

[PikminOC]

Honestly I would avoid it if at all possible. Can your resident or midlevel safetly close? Of course. But anytime something bad happens (which is will whether you are there or not) you put a fat target on your back.

Wound infection? "Doctor were you present for this wound closure? No? Why not? You billed for the whole surgery. Why did you abandon your patient? Is this closure "not critical" to you?" And so on.

Jury of laypeople would open your checkbook. It's not worth it.

Yes.

 

[PikminOC]

Surgeons Are Double and Triple Booking Procedures That Residents Must Perform

Doctors at some of the largest US teaching hospitals are blowing the whistle on a lucrative practice they say endangers patients: Surgeons scheduling two or even three operations at virtually the same time, leaving during critical portions, then billing Medicare for work they didn’t do.

www.bloomberg.com

Doctors at some of the largest US teaching hospitals are blowing the whistle on a lucrative practice they say endangers patients: Surgeons scheduling two or even three operations at virtually the same time, leaving during critical portions, then billing Medicare for work they didn’t do.
A review of more than a dozen federal and state lawsuits offers a rare glimpse into a tight-lipped profession. Many include separate allegations of bribery, kickbacks, and improper compensation. Some reveal closed-door debates by hospital administrators over the ethics, safety, and staggeringprofits brought by concurrent surgeries.
The University of Southern California’s hospital system is accused of billing for thousands of cases - costing taxpayers “hundreds of millions of dollars” - where the teaching physician left residents unattended to perform even spine and brain surgeries. When one doctor confronted a department head about an “embarrassingly high” rate of surgical injuries at one of its facilities, the administrator responded, according to the lawsuit:

“Well, that’s where the residents go to practice on the poor folks.”

What was the outcome? Did the hospital where the admin made that remark get sued?

And yes a local teaching hospital wanted to do a corpus colostomy on a child patient of mine and I wondered if part of the incentive was to hit the numbers the hospital needs for resident procedures. But I could be wrong

 

[TypeADissection]

This was common during my residency especially thoracic and vascular services. But to get more granular, it was actually just a 2-3 attendings that would run 2-3 rooms at a time. The argument was that there was a fellow or super-fellow in one of the rooms doing the initial exposure w/ the residents and that they'd be available for the "critical portions." In fellowship, I never saw this happen and even as I became an independent operator; my attendings would still be in the room either catching up on ultrasound reads or heckling me to suck less. In my practice now in a non-teaching hospital, it's just me so I've never been in this position to run more than one room nor would I. Although, if I'm on call and have another urgent case that needs to go and there's a room available; anesthesia has been super helpful to at least get the patient in and lined up while I'm finishing up and talking to family so that the next case can get started sooner rather than later.

 

[HighPriest]

Honestly I would avoid it if at all possible. Can your resident or midlevel safetly close? Of course. But anytime something bad happens (which is will whether you are there or not) you put a fat target on your back.

Wound infection? "Doctor were you present for this wound closure? No? Why not? You billed for the whole surgery. Why did you abandon your patient? Is this closure "not critical" to you?" And so on.

Jury of laypeople would open your checkbook. It's not worth it.

I agree with this and practice accordingly.

But the facetious part of my sense of humor would say that we should just get the nurses Union involved. After all, NPs are EQUIVALENT PROVIDERS!

 

[PikminOC]

I agree with this and practice accordingly.

But the facetious part of my sense of humor would say that we should just get the nurses Union involved. After all, NPs are EQUIVALENT PROVIDERS!

Nose in the camels tent

 

[sloh]

"Medicare billing is based on a system of hundreds of codes to define certain procedures, time and complexity of the surgery. Bills are submitted by hospitals, not the surgeons. Hospitals then pay millions of dollars annually to doctors.

The Justice Department settled with the University of Pittsburgh this year after alleging surgeon James Luketich routinely walked out in the middle of surgery, leaving “anesthetized patients for hours at a time while he attends to other matters.”

The hospital, which settled without acknowledging responsibility, allowed Luketich to double-book surgeries and place patients in danger because his star power brought in cash, the lawsuit said.

“(UPMC) regularly sacrificed patient health in order to increase surgical volume…. to ensure that Luketich—and only Luketich—performs certain portions of surgical procedures, and to maximize profit,” Justice Department lawyers wrote.

Lenox Hill hospital in New York agreed to pay the Justice Department $12.3 million in 2019 to settle charges that it billed for hundreds of surgeries that Dr. David Samadi never performed. Prosecutors said Lenox Hill paid Samadi as much as $5 million per year.

“Think of it like Las Vegas, where they pay to bring in big acts, then make money off the drinks and gambling,” said attorney Reuben Guttman of the Washington, D.C. firm of Guttman, Buschner and Brooks, who represents the Erlanger plaintiffs. “The star doctors bring in the patients, and hospitals make their money off the room and board and by keeping those doctors happy.”

 

[mmmcdowe]

To offer a slightly different opinion (as someone who does not run more than one room), you also have to understand that there are surgeons out there with a very particular set of skills that makes them, frankly, better at treating certain conditions than others. Star power isn't usually about charisma, it is about being able to achieve outcomes that are superior. That generates a lot of demand (and yes there is no doubt the potential for a profit motive, even if you are salaried) that you can't simply keep up with doing them skin to skin even if you do a single clinic day and have four operative days. I can't personally attest to what Dr. Luketich was doing, I don't think that I have ever met him even though I do work at UPMC, but if I had to guess he was probably doing other surgeries in other rooms most of the time. On some level you as a patient have to choose between having a trainee do some of your surgery or having some surgeon who does the case a couple times a year hack away at you and take twice as long as the rock star grinding out 300/year. You might get the same anesthesia time due to having to wait for the rock star, but at least you get the best possible surgical outcome. It isn't a perfect world. We can definitely do better but just realize this isn't always diabolical. Certainly there are cases where it is.

 

[Dr.LeoSpaceman]

I can't personally attest to what Dr. Luketich was doing, I don't think that I have ever met him even though I do work at UPMC, but if I had to guess he was probably doing other surgeries in other rooms most of the time. On some level you as a patient have to choose between having a trainee do some of your surgery or having some surgeon who does the case a couple times a year hack away at you and take twice as long as the rock star grinding out 300/year.

Part of the issue here is disclosure. I won't say I disagree that this can be a way to do things, and some patients may be ok with it, but you have to tell patients that this is how things operate. You can't just assume they'll understand. I bet if you asked patients, the vast majority would assume the surgeon they saw in clinic is the one who is in the OR the entire time. As for this specific situation, the "trainee" was generally a "super fellow". So you at least had another board-eligible/certified surgeon conducting the rest of the case. But you still have to make sure the patient knows what's going on.

The second piece is the billing angle, and what's "critical" to the operation. Running multiple rooms so that patients can have access to your expertise may make sense. However if that's the case, and the patients are aware of it, then you probably should not be billing as the primary surgeon in all four rooms.

Also, there is some inflection point between the potential benefit gained by having a "rockstar surgeon" and the downsides of extended anesthesia.

And finally, knowing UPMC, there was almost undoubtedly a money angle (even if everyone was careful not to explicitly say as much). If you read through the stuff published on the case, the admin thought it was an issue but no one ever did anything about it (because it was driving referrals).

 

[dpmd]

To offer a slightly different opinion (as someone who does not run more than one room), you also have to understand that there are surgeons out there with a very particular set of skills that makes them, frankly, better at treating certain conditions than others. Star power isn't usually about charisma, it is about being able to achieve outcomes that are superior. That generates a lot of demand (and yes there is no doubt the potential for a profit motive, even if you are salaried) that you can't simply keep up with doing them skin to skin even if you do a single clinic day and have four operative days. I can't personally attest to what Dr. Luketich was doing, I don't think that I have ever met him even though I do work at UPMC, but if I had to guess he was probably doing other surgeries in other rooms most of the time. On some level you as a patient have to choose between having a trainee do some of your surgery or having some surgeon who does the case a couple times a year hack away at you and take twice as long as the rock star grinding out 300/year. You might get the same anesthesia time due to having to wait for the rock star, but at least you get the best possible surgical outcome. It isn't a perfect world. We can definitely do better but just realize this isn't always diabolical. Certainly there are cases where it is.

I don't think it is actually the case that star power comes from having better outcomes for a particular type of procedure. In fact some of these stars will have worse outcomes because they take the sicker and more complicated patients (and maybe there is an argument to be made that they should have less hubris and be more selective but people like to gamble so they will often accept the risk of worsening if there is a chance of improving a lot. There are also options in between having the rock star do your case and having someone who has done it only a few times and it isn't unreasonable to place limits on the rock star to avoid them being needed in three different places at once. In fact, if the rock star isn't allowed to double and triple book all the time then there would be more surgeons out there who do the procedure more than just a couple of times a year meaning more patients getting good surgial outcomes.

 

[DoctwoB]

Part of the issue here is disclosure. I won't say I disagree that this can be a way to do things, and some patients may be ok with it, but you have to tell patients that this is how things operate. You can't just assume they'll understand. I bet if you asked patients, the vast majority would assume the surgeon they saw in clinic is the one who is in the OR the entire time. As for this specific situation, the "trainee" was generally a "super fellow". So you at least had another board-eligible/certified surgeon conducting the rest of the case. But you still have to make sure the patient knows what's going on.

The second piece is the billing angle, and what's "critical" to the operation. Running multiple rooms so that patients can have access to your expertise may make sense. However if that's the case, and the patients are aware of it, then you probably should not be billing as the primary surgeon in all four rooms.

Also, there is some inflection point between the potential benefit gained by having a "rockstar surgeon" and the downsides of extended anesthesia.

And finally, knowing UPMC, there was almost undoubtedly a money angle (even if everyone was careful not to explicitly say as much). If you read through the stuff published on the case, the admin thought it was an issue but no one ever did anything about it (because it was driving referrals).

This. It is all about informed consent and billing compliance.

I agree that most patients (and probable members of a jury) would reasonably expect that the surgeon they meet is performing their whole surgery unless disclosed otherwise. If a patient understands that by signing up for surgery with you, that means the fellow will perform the case under your intermittent supervision, then that's fine by me. In practice this rarely happens and is morally wrong in my view.