patients are pawns with corruption in medicine

[member0007]

http://www.bloomberg.com/news/2014-...kes-nyc-heart-emergencies-by-appointment.html

http://www.wnyc.org/story/emergency-appointment/

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[colbgw02]

 

[member0007]

 

[sanityonleave]

I'm sure when Dr. Sharma gets to pay all of that money back for Stark violations (or outright fraud) he'll be singing a different tune.

Fun fact: hospitals / healthcare entities are not allowed to pay fees from Stark settlements against physicians -- the physician component must come out of their own pocket. You can defraud CMS for a period of time, but once they catch you, they get theirs. Don't **** with Uncle Sam.

Recent case in my hometown:
http://www.justice.gov/opa/pr/2013/July/13-civ-768.html
This is a great example of why you shouldn't assume that the hospital's lawyers have enough vested interest to protect you from an unwitting violation. If you have any questions about your compensation scheme, or if the compensation scheme seems too good to be true -- it probably is.

For those about to finish residency and sign contracts for actual jobs, make sure you a) have a lawyer familiar with physician healthcare contracts review your offer and b) read the AMA's nicely written "Stark Law Rules of the Road" here: http://www.ama-assn.org/resources/doc/psa/stark-law/stark-law.pdf .

EDIT: I realize that the article does not give enough detail to suggest that a Stark violation is occurring; however, with Sharma earning $4.8mm / yr, I'd be willing to bet that there's either outright fraud going on or something that falls in a Stark grey area at best.

 

[member0007]

The hospital was running the fraud because it's profitable, aka the hospital saw here how money can be made and then, they went ahead and set up the system to profit, apparently like $9k per case after expenses, even salaries! I doubt any individual practitioner can run this scheme without the approval of the micromanagers that run this organization and they were really greasing up these individual practitioners and incentivizing them monetarily and maybe even more sketchy stuff for their profit. I would bet that this is widespread practice within their ranks. That's usually the case with situations like these and in medicine, as the old saying goes about hoof beats... not a zebra.

 

[member0007]

Just as I thought - UPDATE:

"Cath labs thread wires and tubes into blood vessels to implant stents in a procedure that brings about $20,000 per patient to hospitals and is among the most lucrative in medicine."

http://www.bloomberg.com/news/2014-...ns-external-review-of-cath-lab-s-quality.html

 

[colbgw02]

They should totally shut down that cath lab. That'll show 'em.

 

[Arcan57]

They should totally shut down that cath lab. That'll show 'em.

If the cath lab was only used in appropriate patients, the vast majority of them would shut down due to unsustainable costs.

 

[colbgw02]

If the cath lab was only used in appropriate patients, the vast majority of them would shut down due to unsustainable costs.

I don't know. I'm not an epidemiologist, but I've heard that heart disease, more specifically coronary artery disease, is pretty common. Are you just opining or is there evidence of widespread unindicated cardiac catheterizations sustaining otherwise unnecessary cath labs?

 

[SouthernSurgeon]

I don't know. I'm not an epidemiologist, but I've heard that heart disease, more specifically coronary artery disease, is pretty common. Are you just opining or is there evidence of widespread unindicated cardiac catheterizations sustaining otherwise unnecessary cath labs?

Coronary disease is very common. But at the moment the pendulum has likely swung too far toward treating asymptomatic lesions just because we can.

 

[Arcan57]

I don't know. I'm not an epidemiologist, but I've heard that heart disease, more specifically coronary artery disease, is pretty common. Are you just opining or is there evidence of widespread unindicated cardiac catheterizations sustaining otherwise unnecessary cath labs?

That's funny you should mention that because I do have an MPH in epidemiology. CAD is ridiculously common, what has changed is our realization that much of what we used to believe stenting lesions did was wrong. In residency, we were taught that all chest pain had to be admitted for a functional study because if their atypical chest pain was actually from CAD then we'd save their lives because they'd have a positive stress test. That positive stress test would get them a cardiac cath which would lead to the culprit lesion being stented and you'd have saved the patient's life by preventing their MI.

Of course we were completely mistaken. We know now that stress tests in low risk patients are essentially useless. We know that stenting people doesn't prevent heart attacks. An epidemic of unnecessary interventions doesn't require outright fraud. There just has to be financial and legal pressures combined with a doctor's desire to do something to help with a disease in whom it's proven to be so difficult to do effective risk factor modification. Although less prevalent, it could be argued that tPA (probably) or mechanical thrombolysis (pretty definitively for current devices) for acute CVA is being propelled not by science but by the same factors that have led to every hospital in America (only mildly hyperbolic) opening a cath lab.

 

[colbgw02]

Sounds like we should be doing more coronary CTAs out of the ER.

 

[Arcan57]

Sounds like we should be doing more coronary CTAs out of the ER.

At my previous job we were looking at doing more CTCA. We had the scanner, we had the techs, we had a radiologist eager to read them. The main sticking point then was that Medicare wouldn't pay for it out of the ED and if you did an observation stay (which pays by hour, not services provided) then the cost of the CTCA ate up all of the profit from the stay. I don't know if that's changed (my current job still has a 4-slice scanner in the ED), but it's probably better to accept a 1% miss rate and not incur all the expense, radiation, and procedural complications from trying to drop that down to a 0.5% miss rate.

 

[colbgw02]

At my previous job we were looking at doing more CTCA. We had the scanner, we had the techs, we had a radiologist eager to read them. The main sticking point then was that Medicare wouldn't pay for it out of the ED and if you did an observation stay (which pays by hour, not services provided) then the cost of the CTCA ate up all of the profit from the stay. I don't know if that's changed (my current job still has a 4-slice scanner in the ED), but it's probably better to accept a 1% miss rate and not incur all the expense, radiation, and procedural complications from trying to drop that down to a 0.5% miss rate.

Why would you do an observation stay after the coronary CTA? It has tremendous negative predictive value for low and intermediate risk patients, so they can be discharged safely from the ED. If the CTA is positive, then they're off to the cath lab.

 

[Arcan57]

Why would you do an observation stay after the coronary CTA? It has tremendous negative predictive value for low and intermediate risk patients, so they can be discharged safely from the ED. If the CTA is positive, then they're off to the cath lab.

Two reaons:

1) You don't have 24hr availability to do CTCAs

2) Insurance won't reimburse for CTCAs done during an ED stay

 

[colbgw02]

Okay, so you weren't observing patients following the CT, only in lieu of it. I was confused by your earlier post.

 

[Arcan57]

Okay, so you weren't observing patients following the CT, only in lieu of it. I was confused by your earlier post.

Actually the period of observation was supposed to take into account pts that came in during off-hours or when the scanner was already in use. And as mentioned previously, placing a patient into obs was because we couldn't get reimbursed for a CTCA on an ED patient. This was 3 years ago, so I don't know if that is still an impediment.

 

[member0007]

http://www.wnyc.org/story/emergency-appointment/
http://www.bloomberg.com/news/2014-...kes-nyc-heart-emergencies-by-appointment.html

The initial report of overuse and scheduled emergencies does not immediately jump into issues of quality. I think that there is a bigger story here if they are actually go into quality issues ( http://www.bloomberg.com/news/2014-...ns-external-review-of-cath-lab-s-quality.html) when it seemed as though the story was about corruption and fraud. My guess would be that Mt Sinai Medical Center's greedy practices put real people at risk and lead to serious harm, even mortality, a.k.a medical malpractice. An independent investigation at Mt Sinai Medical Center by themselves is meaningless. An outside investigation would depend on who is conducting it and what methods they are using, if they go by their in-house counsel, their write-ups are less useful than toilet paper. I have read the in-house and out-house counsels extensive garbage and lack of logic, combined with grade school writing skills, equates to worthless nonsensical drivel. Not to conflate the issues here, this organization is out to take advantage of vulnerable populations for profit because they are covered by public funds and they want to scam the easiest payer, which is medicare and medicaid, so they even went to the extend of enlisting community physicians into the scheme. It's some seriously devious conspiracy and that in of itself would be the crime here when the organization is ripping off CMS and the medicaid funds. However, to raise issues of quality could only mean that they probably caused serious harm to individual patients. As for the utility of interventional angioplasty, there have been multiple strong studies about when to perform them, these are not intended as routine for any abnormal blip on the stress electrocardiograph. Therefore, the discussion is not about the use of coronary angioplasty.

 

[member0007]

 

[Winged Scapula]

Moving to TIH