Thursday, October 22, 2015

Conflicts of Interest Between Doctors, Hospitals, and Patients Result in Harmful Treatment

OK, I was going to write about the new social caste-system determining how you pay for your health care, but the New York Times article about the errant Dr. Ghandi from Indiana (I kid you not) and his over zealous love of invasive cardiac treatments is too good to pass up. First of all, the full color photo in the New York Times of this woman's scarred chest is a shock. The sleeveless pink floral top (not enough of it to merit calling it a blouse) is the standard rag you find so many many American woman wearing to places they should not. I mean really, this is what you wore for an interview with the New York Times? One could make a case that the cardiac chest-crack surgical scar is more aesthetic than that mom tattoo. I thought you were supposed to put your kids names on your body, not the word mom, isn't that reserved for sailors? Read on to find out how this all went wrong in the midwest.
 Malpractice and Medicare Rip-offs
The woman in the New York Times photo had been treated by Dr. Ghandi for thirty years, originating from the irregular heartbeat diagnosis and devolving into multiple surgeries involving stents,  and other invasive procedures. This plucky female did say no to Dr. Ghandi's insistence on getting a pacemaker (smart move sister) but she was pummeled into the insertion of a heart monitor. Unbeknownst to her, this monitor was linked directly to Dr. Ghandi's bank account. At last count, 293 patients have sued this doctor for installing unnecessary pacemakers, stents, and other cardiac devices. Thanks to Dr. Ghandi and his co-conspirators, little Munster (not to be confused with Muncie), Indiana placed within the top 10% for cardiac defibrillator implants (pacemakers) according to Medicare, which is also investigating. Munster is a town of 23,270 people, so it is pretty difficult to imagine they have that many defective tickers. But please remember, Indiana is pretty close to Wisconsin, where most of the world's cardiac devices are manufactured, so maybe they were being neighborly. However, here is where the story takes an even more twisted turn.
Hospital Administration Conflict of Interest
The hospital administrators knew that Dr. Ghandi and others in his cardiac practice were performing invasive medically unnecessary procedures and they did nothing to stop it. Lest you think this was a for-profit hospital, you'd be wrong. In fact, a nonprofit community hospital, much like any local hospital, such as  Harrison, in Kitsap County, made the decision to ignore the professional complaints brought by Dr. Mark Dixon, whom also practiced at the hospital. The hospital's chief benefactor it seems was a long time patient of  Dr. Ghandi's for his cardiac care, so no conflict there at all. Specifically, Dr. Dixon's complaint was unqualified people were installing some of these cardiac devices and Dr. Ghandi's patients did not meet the medical necessity requirements for some of the treatments.  So, why would the hospital ignore these concerns-because cardiac care is very lucrative and brings in lots of money for the facility. In fact, in hospital administration parlance, this is referred to as a service line, it isn't even called health care. And yes, in hospitals, the doctors who bring in the most money are treated with deference.
What You Can Do
Hold the phone-this is the lesson for all persons reading this article-(1.) ask questions about training and board certification before you consent to any surgery and (2.) get a second opinion. Sure Munster is a small town, but you do not have to have your treatment there, you can go to a bigger city, like Indianapolis or Chicago, or if you are really smart, the Mayo Clinic in Minnesota. Further, if you cannot commute to these locations, you can go to the following web sites to get information which is reliable on cardiac care:

Tip of the Iceberg
Lest you think this scenario of over diagnosis and money making through unnecessary medical procedures is an anomoly, it is one of the biggest problems in the U.S. healthcare system. Thankfully, in the last decade, better information has become available to consumers through websites and other resources, which make it easier for the average person to double-check the facts before submitting to a procedure.  The truth is you can't always trust what your community hospital is telling you, nor can the same be said for every doctor. The responsibility is on the patient and their advocate to ferret out all necessary information and make an informed decision. The Lown Care organization is in the midst of its' Right Care Campaign and that is one example of a collective effort of clinicians to curtail abusive practices in healthcare. I have written about health care scenarios and policies for the past eight years, and in 2013, I specifically targeted the layperson in my book, Unraveling U.S. Healthcare-A Personal Guide, of which five chapters were devoted to figuring out how to gauge health care quality.

Stay healthy by choosing wisely and this is the healthpolicymaven signing off, encouraging you to share this article widely. Roberta E. Winter is a graduate of the University of Washington School of Public Health and the University of Washington Evans School of Public Affairs and publishes under the trademark healthpolicymaven.

Friday, October 2, 2015

Affordable Care Act Program Shows Reduced Medical Costs Through House Calls

The Affordable Care Act funded the Shared Savings Program which financially rewards health care organizations for reaching targets for patient care, such as reductions in hospital re-admissions, and thereby reduces plan costs. One of the most compelling projects from this pay-for-performance program has been a resurgence in house calls by doctors to vulnerable Medicare patients. The Wall Street Journal recently featured an article on this phenomena and found the "Independence at Home" Medicare demonstration project has shown a 25 million dollar savings for Medicare in the first year of the program. (1) This article reveals more about how this program works, who participates, and what it might mean for health care plans. Here are the creative health care organizations which elected to participate in this three year initiative (sans the LLC, Inc, or other corporate modifiers): Boston Medical Center, Christiana Health Care Services, Cleveland Clinic Home Care Services, Comprehensive Geriatric Medicine, Doctors Making Housecalls, Housecall Providers, MD2U, Medical House Call Program at Medstar Washington, National House Call Practitioner Group, North Shore Long Island Jewish Health Care, RMED, Schnabel In-Home Care,Virginia Commonwealth University, and Visiting Physicians Association (locations in 4 states). (2)
Awarding Value-Based Payments
As a part of the value-base care initiative, participating practices were able to reduce emergency room re-admission costs by 16.4%. In order to receive a shared savings reward, the organization had to meet the following clinical targets for qualified Medicare patients:
  • Have fewer hospital re-admissions within 30 days of discharge
  • Have follow-up contact from their provider within 48 hours of a hospital admission, hospital discharge, or emergency department visit
  • Have their medications identified by their provider within 48 hours of discharge from the hospital
  • Have their preferences documented by their provider
  • Use inpatient hospital and emergency department services less for conditions such as diabetes, high blood pressure, asthma, pneumonia, or urinary tract infection.
This pay for performance effort resulted in incentive payments for four group practices and one consortium of health care practices. The top three shared savings recipients for this program were; Visiting Physicians Association capturing the lions share of the compensation, totaling 7.8 million, followed by the Mid-Atlantic Consortium, which includes Medical House Call Program at Medstar, Schnabel In-Home Care, and Virginia Commonwealth,  receiving 1.8 million, and  Portland, Oregon, Home Care Services, getting 1.2 million dollars in incentive pay.(2) It is pretty obvious that the health practices which were exclusively organized to provide home health care had an advantage for the first year of this program, based on the results achieved. However, the other groups may catch up in the three year period, as Medicare has stated it wants to tie 30% of all CMS reimbursements for patient care to incentive plans by 2016 and increase that to 50% by 2018. (3)  I am skeptical these results are possible, nor are all health care organizations going to be able to achieve this outcome, especially smaller practices, so there will be some fall-out on these bold goals. Finally, there is some concern that the focus on health metrics has gotten in the way of patient care, as so much of the clinical day is now devoted to completing forms and reports.

Today's house calls can include portable MRI machines for imaging as well as on-the-spot blood draws and testing, which enable clinicians to gauge the health of especially frail patients more closely. For a vulnerable Medicaid patient who is just out of the hospital, being able to remain at home, and not risk travel or hospital acquired infections could be a plus. However, all you have to do is walk your rounds in today's hospitals to see who the patients are, frail elderly people, who are often without family to look after them, so the house call bonanza won't apply to the entire population.

This article was written by Roberta Winter, a healthcare advocate who has published under the trademark, healthpolicymaven since 2007, and may be shared virally. For more straight talk on health care programs and policy you can follow me on twitter at:.
Roberta Winter is the author of: Unraveling U.S. Healthcare-A Personal Guide, which may be found at

(1) Laura Landro, "How House Calls Cut Medical Costs", Wall Street Journal, September 27, 2015
(2) Innovation Projects, Centers for Medicare and Medicaid, Independence at Home, Year One Results
(3) Centers for Medicare and Medicaid, Media Release, June 18, 2015