Nope, Healthcare doesn't need to be reformed. Not at all.

[CountDeMoney]

Patients learn they might have unneeded stents
Federal probe focusing on procedures; 369 St. Joseph heart patients affected

By Robert Little
Baltimore Sun reporter

January 15, 2010

St. Joseph Medical Center in Towson, whose cardiology business is a focus of a continuing federal health-care fraud investigation, has notified hundreds of its heart patients that they may have received expensive and potentially dangerous coronary implants they didn't need.

An internal review, begun last May at the behest of federal investigators and in response to a patient complaint, has turned up 369 patients with stents that appear to have been implanted in their arteries unnecessarily, CEO Jeffrey K. Norman said in an interview yesterday. Patients began receiving letters alerting them to the finding early last month, and more notifications are expected as the review continues.

"We take our interaction and the care of our patients with the utmost seriousness, and so we wanted to alert patients and their physicians to what we found," said Norman.

In several cases reviewed by The Baltimore Sun, patients who received coronary stents at St. Joseph - purportedly to open a clogged artery to correct a severe blockage - have since learned they had only minor blockage, if any. One 69-year-old man was told his artery had a 95 percent blockage, yet the new review suggests something closer to 10 percent, which is considered insignificant. A 55-year-old woman who agreed to receive a stent after being told she had a 90 percent blockage has since learned she had virtually no problem and that she never suffered from the heart diagnosis that has consumed her life for the past 18 months.

St. Joseph calls itself the busiest heart catheterization center in Maryland, and it is regarded as one of the primary cardiac care facilities in the region. The center typically performs about 6,500 cardiac procedures a year - an average of 18 a day. Last year St. Joseph highlighted the placement of its 100,000th coronary stent since 1980.

Hospital officials say the only doctor implicated in their review is one of the center's marquee physicians, Dr. Mark G. Midei, who abruptly stopped practicing and lost his privileges at the hospital last summer without notice to his patients or any comment from hospital officials.

Midei declined to discuss the matter in detail but released a statement Thursday saying he expects to be exonerated and to return to medical practice.

"I am confident that I have always acted in the best interest of my patients, and when all the facts are presented, I will continue providing quality medical care to my patients," he said.

Coronary stents are cylindrical devices that can open arteries clogged with plaque or create a bridge across areas of damage. They are typically inserted during a procedure called cardiac catheterization, in which a tool is inserted into the bloodstream at a small incision in the leg and threaded up to the arteries near the heart.

An alternative to open-chest surgery, cardiac catheterization with stent placement is a lucrative business for hospitals in the United States, which often charge $10,000 or more for the procedure. Most clinical guidelines, and reimbursement rules for Medicare and private insurance, set minimum thresholds for the procedure, often requiring at least 70 percent blockage of an artery before a stent should be placed. St. Joseph's guidelines regard blockage of 50 percent or less to be "insignificant."

Letters began arriving at patients' homes last month, alerting them to "differences" or "variances" uncovered in their medical files, and advising them to call their cardiologists. Packages sent to their cardiologists contained copies of the patients' X-ray images, along with the written laboratory report prepared when the stent was placed.

Jay D. Miller, a prominent medical malpractice attorney in Towson, said he has spoken with people who received letters and that many are contemplating legal action.

"A very substantial number of people received coronary artery stents they did not need," Miller said.

"And they not only had a procedure that wasn't needed, they have a stent in their artery for the rest of their life, they're on a serious blood-thinning drug, and there's the psychological effect of being led to believe that you have heart disease."

Vicki Marrs, a 55-year-old patient from Conowingo, is typical. She got a stent in July 2008 after arriving at St. Joseph's with chest discomfort and being told one of her arteries was 90 percent blocked. Now doctors and lawyers who have reviewed her files say Marrs had only a 10 percent blockage at most, and that she never suffered from the kind of heart disease described by Midei 18 months ago.

"I'm angry and I'm upset," said Marrs, after telling of the changes in her emotions and lifestyle following that diagnosis. Patients who receive stents must take blood thinners, and she said she battles fatigue from her daily dose of the drug.

"You go to a doctor thinking he's going to take care of you and make you better, and now I have this thing that I don't need and that can't be removed," she said. "I trusted him."

Norman, while acknowledging the hospital has enountered patients "who've been upset and angry," said the hospital's investigation and patient notification process has been conducted in the interest of getting information to patients quickly so they can consult with their cardiologists. The investigation focused solely on Midei after a random sampling raised questions about him, Norman said, and it will include reviews of patient records over the past two years - the time during which potential complications from the procedure would be expected to surface.

While stent placement is a common and relatively safe procedure, it is not without complications and potential hazards. One study published four years ago in the Netherlands reported a 5.7 percent rate of "major" complications from stent placement, including a 2.3 percent death rate. Physicians with more experience at the procedure had fewer complications, it concluded.

Norman said that no other employees of the hospital have been implicated in the review.

"The physician is the captain," he said. "The physician is in charge."

Asked if the hospital bears any additional liability for the patients who received stents they didn't need, Norman said:

"I suppose we do. I think that we'll see what comes from these attorneys that are looking for cases, and we'll respond to that."

Doctors and hospitals in other parts of the country who placed stents when that blockage threshold wasn't met have faced lawsuits, fines and even prison time.

In 2007, a doctor at Peninsula Regional Medical Center in Salisbury was accused of performing unnecessary stent procedures and is being sued by 24 patients. The doctor, John R. McLean, resigned from practice, citing deteriorating eyesight.

Last year, a Louisiana doctor was sentenced to 10 years in federal prison on health-care fraud charges for placing unnecesary coronary stents and then billing Medicare and private insurance companies. Two hospitals where he worked paid a combined $5.7 million penalty to the federal government, and one paid an additional $7.4 million to settle a class action lawsuit brought by the doctor's patients.

St. Joseph announced in July that it had negotiated a settlement with federal health-care fraud investigators related to the hospital's relationship with MidAtlantic Cardiovascular Associates, the dominant cardiology practice in suburban Baltimore. Details of that settlement were not disclosed and are expected to be announced soon, but court records have speculated that the hospital will pay a fine that exceeds $5 million.

When federal subpoenas arrived at St. Joseph in June 2008 seeking records related to the cardiology business, the hospital's then-CEO, John Tolmie, was suspended along with two other top executives. All of them have since resigned.

Norman said the federal investigation is not directly related to the issues with stent placements. But Midei was a founding member of MidAtlantic, who left in January 2008 to become an employee of St. Joseph. In statements sent to The Baltimore Sun last year, St. Joseph's officials repeatedly said the federal investigation "has nothing to do with the quality of patient care." Yesterday, they noted that statements from the hospital ceased to include that claim around mid-2009.

When St. Joseph opened its new cardiac care center in early 2008, Midei was regarded as one of its big draws. His recruitment by the hospital, away from the MidAtlantic practice just as it was poised to enter a lucrative merger with Medstar Health, created tension among doctors and executives at the hospital that boiled over into the court system. In one court record, then-CEO of MidAtlantic, Hank Yurow, said he threatened in 2008 to "make it my mission to destroy him [Midei] personally and professionally."

In interviews with attorneys and other patients, it is clear that some of Midei's patients - even after getting letters from the hospital - reject the suggestion that he has done anything wrong.

Peggy Lambdin, 66, of Timonium describes waking up in July 2008 feeling as if she were drowning, and being diagnosed at St. Joseph a few days later with a 90 percent blockage. Midei placed a stent, and the symptoms cleared up almost immediately, she said.

She has since received a letter suggesting the blockage was less than 50 percent, but said she considers the details immaterial.

"No one can ever tell me that I didn't need that stent," Lambdin said. "I feel like he saved my life."

She also recounted another trip to the St. Joseph's lab during which Midei performed a heart catheterization but decided that no stent or other treatment was needed.

"I trusted him, and I still trust him," Lambdin said. "If I needed another stent, I would want Dr. Midei to do it."

Norman said he hopes the hospital's efforts to inform patients about the investigation demonstrate they can trust St. Joseph's.

"Like anything in healthcare, heart care is a team effort. And if there's any one individual on the team who isn't performing at the highest level, you take action, as we have in this case," Norman said. "We're confident that we still provide the highest quality care."

[CountDeMoney]

And when there's blood in the water, the sharks start circling.

Lawyers look for clients in cases of possibly unneeded stents
Angelos, Murphy team up to file class-action suit

Maryland attorneys are spending thousands of dollars to sign up clients who might have had heart stents needlessly implanted by a doctor at St. Joseph Medical Center - cases some say could be clear-cut victories for patients and a steady income stream for their lawyers.

The Towson hospital sent letters to hundreds of patients last month, telling them that the expensive stents in their arteries might have been placed there unnecessarily and under false pretenses. And almost immediately, attorneys began calling for clients online, on TV and in print.

One lawsuit was filed last week in Baltimore County Circuit Court, and the first suit to seek class action status was filed in the city Thursday.

"These patients were misled into having surgeries that they did not need," said attorney William H. "Billy" Murphy, who called a news conference Thursday to announce the class action lawsuit filed by his firm in conjunction with Peter Angelos' office. Among their demands are that the hospital cease its stent procedures unless certain requirements are met and that it pay for a review of patient records.

Hospital officials said they had not seen the court filings Thursday and so couldn't comment on the specifics, but issued a statementsayingthat they took "aggressive action to correct the problem" as soon as it was revealed and they don't believe affected patients are in any "immediate risk."

"St. Joseph was guided by the belief that it has a moral and ethical responsibility to inform these patients of what happened. This is consistent with our mission and core values. It was the right thing to do," the statement said.

The Baltimore County hospital has identified at least 369 people who might have had unwarranted operations - all tied to a single physician - and more could surface as the examination, prompted by a federal investigation, continues. Lawyers say it's a nightmare admission for the facility, which has a reputation for high-quality heart care. And it's extremely unsettling to the patients, who have to take a blood thinner for the rest of their lives and worry about what might one day go wrong.

For medical-malpractice and personal-injury attorneys, however, it's an opportunity, with the potential for consolidated cases and sizable settlements even though damages may be difficult to show.

We "are investigating potential lawsuits and legal claims," says Saiontz & Kirk. "You may have grounds for filing a Maryland medical malpractice lawsuit," advises Lebowitz & Mzhen. "Please give us a call as soon as possible concerning your legal rights," urges Azrael, Gann & Franz.

"This is a case of very clear liability. ... We'd be happy to take that on," said personal injury lawyer Vadim Mzhen. "What distinguishes this case from just about anything we or other attorneys see is the intent. ... Normally when there's medical malpractice, a doctor makes a mistake, it's not intentionally done. Here this was done intentionally. It's an incredibly distinguishing factor."

Stents, usually threaded into place through the body's bloodstream, act as artificial supports, opening clogged arteries or creating bridges around damaged areas. They're praised by patients as an alternative to open-chest surgery and valued by hospitals in part because they're lucrative, often costing $10,000 or more per procedure.

Clinical guidelines generally require that an artery be at least 70 percent blocked before a stent is placed, and St. Joseph's rules consider anything less than 50 percent blockage to be "insignificant." But Dr. Mark G. Midei, who abruptly lost his privileges at the hospital last summer, is accused of performing stent operations on some people with virtually no blockage, after telling them falsely that they were in danger.

"It's something like when you go to a car mechanic, and you trust them and they tell you you need a new transmission, when in fact, three-quarters of transmission problems don't require a new transmission, but you trust them and you have it done anyway," said Keith S. Franz. His law firm is looking into a handful of cases involving clients who received stents from Midei.

In a statement this month, Midei said he expects to be exonerated and to return to medical practice. "I am confident that I have always acted in the best interest of my patients, and when all the facts are presented, I will continue providing quality medical care to my patients," he said.

Malpractice attorneys acknowledge that the stents probably have helped some patients. But the hospital still recognized an obligation to notify people of the discrepancies it found in medical records and to encourage them to talk to their doctors.

"Questions about potential [legal] liability remain to be resolved," the hospital statement said. "St. Joseph Medical Center takes its responsibility to patients very seriously, which is why we conducted a review and notified patients and physicians."

Lawyers, too, vary on their predictions for legal action. Most see a filing stream of separate suits that are eventually consolidated or granted class status and settled for individual damages, each sum dependent upon the clinical circumstances of each patient.

No one contacted by The Baltimore Sun was willing to speculate on the amount of money at stake, beyond saying simply that a patient's connected death, should there be one, would likely bring in more than outcomes such as anxiety.

Still, the volume of potential plaintiffs alone is enough to attract the attention of at least a dozen plaintiffs' lawyers, including Orioles majority owner Angelos, and spur them to investigate. The Law Offices of Peter G. Angelos PC placed print ads in The Baltimore Sun recently saying that those who received a letter from St. Joseph "may wish to consult a lawyer" and it teamed up with Murphy's firm to file Thursday's lawsuit.

Angelos, who did not return an earlier call for comment, has made millions through civil suits against firms in the asbestos, tobacco and pharmaceutical industries.

Such plaintiffs' attorneys often earn revenue through contingency fees, which average around 30 percent of a court award. "The fact that a number of plaintiffs' lawyers are advertising for these kinds of cases suggests at the least, in their view, there's something here, that at the end of the day, they can make a profit," said Jack Schwartz, a health care law and policy professor at the University of Maryland School of Law.

"But that doesn't mean that it is so," he cautioned. "They just perceive it to be so."

Punitive damages would be hard to show, particularly in Maryland, which requires that there be actual malice to receive such awards. And you can't get damages for speculative "future events," said Maxwell Gregg Bloche, a law professor at Georgetown University.

Austin Kirk of Saiontz & Kirk said his firm, which is advertising for clients on television and has set up a toll-free number for qualifying stent patients, hasn't characterized the potential yet.

"At this point, we don't know how big of a deal it is," Kirk said. "We're investigating the case and looking into the matter. People have important rights that may go beyond apology letter."

On his Maryland Injury Lawyer blog, attorney Ronald V. Miller Jr. labeled the situation a "scandal" and said "the allegations are beyond stunning." But in an interview, he cautioned not to jump to conclusions.

"There's a temptation for many plaintiffs' lawyers to rush to judgment as to what the facts are," Miller said. He added that plaintiffs' lawyers are opportunistic; it's part of the business strategy.

"We've still got to uncover doctor liability and the hospital's liability and whether or not punitive damages would be appropriate, and whether, most importantly, whether the individual patient has suffered significant injury," he said. Still, he sees the possibility for settlements if for no other reason than to enable St. Joseph "to put the scandal behind them once and for all."

He added that his firm has had "several inquiries" from potential stent clients, whose cases he's happy to explore.

You can't share in potential profits, after all, if you're not among the players.

[Eddie Teach]

I'm not totally convinced health care is a service best provided by the free market. Convincing people to buy things they don't really need is good business.

[Caliga]

I agree, but I don't know for sure government can do it any better.  It seems like it can in some cases (I am under the impression alot of the board Euros like their national systems).  I am skeptical that our government is competent and efficient enough to actually pull it off, though.

[DisturbedPervert]

You go to a doctor thinking he's going to take care of you and make you better

[Iormlund]

I agree, but I don't know for sure government can do it any better.  It seems like it can in some cases (I am under the impression alot of the board Euros like their national systems).  I am skeptical that our government is competent and efficient enough to actually pull it off, though.

At least in Spain most people will bitch a lot about health care ... until they have a serious problem. That is the trade off here. Elective or minor stuff takes ages. Which is why private insurers and clinics have filled that void. Any serious case they encounter though will be promptly forwarded to a "real" (public) hospital.

The biggest problem in state care over here is access to tests or a specialist in cases that will deteriorate relatively quickly without many signs (for example cancer).

It is also worth mentioning that there isn't a single European model. There's pretty much a different way to do stuff in every country.

[Tonitrus]

Sometimes I think the best way to go is just socialize the whole thing. 

Then I see how military health care is, and how other government ideas like the TSA are run, and think "fuck that". 

Things were a whole lot simpler when most people simply died by the age of 40.

[Grey Fox]

*hugs his HealthCare card*

[grumbler]

Then I see how military health care is, and how other government ideas like the TSA are run, and think "fuck that".   

Military health care was a hell of a lot better than any health care I have had since leaving the military.  Sure, it is bureaucratic, but not nearly as bureaucratic as non-military health care.

It is hard to argue that big business is more competent than government, given what we have just been through because of the massive incompetence of some big businesses.  I don't think any big organization can really be competent, though they can be incompetent in different ways.

[DGuller]

I'm not totally convinced health care is a service best provided by the free market. Convincing people to buy things they don't really need is good business.

Agreed.  The problelm is that free market requires perfect information, and perfect ability to interpret that information.  Obviously this ideal is never satisfied in practice, but in case of medicine the practice is much farther away from ideal than in most other fields.

[Malthus]

What the Spaniard said.  Socialized heathcare is great for major, non-elective procedures which would otherwise bankrupt any ordinary citizen, and possibly their whole family as well. I'm all for a "two tier" system on more elective matters. 

[Neil]

It is hard to argue that big business is more competent than government, given what we have just been through because of the massive incompetence of some big businesses.  I don't think any big organization can really be competent, though they can be incompetent in different ways.

Except big business survived and flourished.  It's not so much that they're incompetant, it's just they can afford to be completely reckless, as there is no risk for them.

[Martinus]

What the Spaniard said.  Socialized heathcare is great for major, non-elective procedures which would otherwise bankrupt any ordinary citizen, and possibly their whole family as well. I'm all for a "two tier" system on more elective matters.

But that's how the system works in countries with socialized healthcare (unless you are in a country like Cuba, I guess), so the alternative is really false. For example, I pretty much get all my medical care from private providers (e.g. when it comes to dentistry, minor illnesses etc.) but I'm safe knowing that even if I fall on harder times and get seriously ill there will be good specialists offering the service for free.

[Neil]

What the Spaniard said.  Socialized heathcare is great for major, non-elective procedures which would otherwise bankrupt any ordinary citizen, and possibly their whole family as well. I'm all for a "two tier" system on more elective matters.

Indeed.  We could use more of that here.

It boggles my mind how many rural types (my wife's extended family) keep telling me how they would come out ahead if they had lower taxes but were paying a thousand dollars a month for health insurance.  Some brands of conservative have trouble thinking things through.  I scrupulously avoid mentioning the gold standard around them, for fear that they'll get hooked.

[Malthus]

What the Spaniard said.  Socialized heathcare is great for major, non-elective procedures which would otherwise bankrupt any ordinary citizen, and possibly their whole family as well. I'm all for a "two tier" system on more elective matters.

But that's how the system works in countries with socialized healthcare (unless you are in a country like Cuba, I guess), so the alternative is really false. For example, I pretty much get all my medical care from private providers (e.g. when it comes to dentistry, minor illnesses etc.) but I'm safe knowing that even if I fall on harder times and get seriously ill there will be good specialists offering the service for free.

I'm talking about the Canadian system, where "two-tier" is a major political battle. It exists to an extent - dentistry for example - but extending it into other areas of healthcare is a big fight.

See for example:  http://ogov.newswire.ca/ontario/GPOE/2003/11/27/c7199.html?lmatch=&lang=_e.html