Dr. Weeks’ Comment: Once accountability disappears from the patient-doctor relationship on account of the satisfaction of 3rd party payers being far more important to doctors than is patient well-being and satisfaction, the door is open for abuse. When the doctor is paid by the patient (and not a for profit 3rd party), eternal laws of commerce and accountability remain intact and patient satisfaction soars. 3rd party payments require an inherent conflict of interest (see Who Pays My Doctor). Here is just a few examples for patients to consider: caveat emptor!
The Nazi Doctors Among Us
by David Edelberg, MD
For weeks, one of the most widely emailed articles on Medscape, the physician-only medical news source, concerned Dr. Farid Fata, the 50-year-old cancer specialist who received a sentence of 45 years for fraud after administering inappropriate chemotherapy to hundreds of patients. Some of these patients had been previously cured of their cancer and yet he continued to prescribe “lifetime maintenance chemotherapy.” Others, it turned out, never had cancer at all.
Fata had built, in his own words, a cancer “empire,” a “kingdom,” including a pharmacy, a diagnostic lab, and a radiation treatment center. He also received kickbacks from hospices and home health agencies, ultimately raking in millions. In the end, his own employees were the whistleblowers, contacting the Feds, who did such a thorough investigation that even Fata’s expensive legal team couldn’t keep him out of jail.
Reading the testimonies of Fata’s victims and their families is truly horrifying. They recount not only the grim physical symptoms of cancer chemotherapy, but the emotional burden of living with a diagnosis that they later learned had been an utter lie. The daughter of one victim said to Fata “I hate you. You are a monster. You are evil. You poisoned him. You tortured and murdered my dad.”
Almost as dramatic are the 247 physician comments that follow the Medscape article, with more being added daily. The general trend among the physician commenters is a hand-wringing “now patients won’t trust us” whimper. A second group graphically describes the punishment they would have administered had they been Fata’s judge (death sentence is popular, daily chemo another).
Just a few commenters remark on an uncomfortable yet germane issue: the likely financial collusion between Fata and anyone (physicians or hospitals) who benefitted from his brutal kingdom’s largesse. This includes deliberate or neglectful failures of a hospital’s review board, the checks-and-balances system designed to prevent such malfeasance. One interesting group of physician-commenters writes of their personal experience with specialists””including oncologists, but any procedure-driven specialty can be guilty-who they strongly suspect of utilizing services unnecessarily and yet they don’t have a strong case to make against them.
(When you’re a primary care physician hospitalizing two or three patients a month, the hospital administrator is not at all interested in your criticisms of, for example, a physician whose well-populated spine surgery hospital unit is keeping the hospital afloat.)
The euphemism is “overutilization,” which simply means doctors ordering tests, procedures, surgeries, or equipment that really are not needed except to circle back to some financial benefit for the ordering physician. In one recent case, an orthopedic surgeon had been encouraged to buy stock in a company that manufactured joint replacements. By performing a lot of procedures using the company’s equipment (some surgeries needed, most not), his stock appreciated wildly in value. The unnecessary surgical procedures are, of course, morally wrong. Billing an insurance company to pay for this surgery is called overutilization.
The Nazi Doctors
Both Fata’s crime and the way the survivors expressed their suffering reminded me of Robert Jay Lifton’s 1988 The Nazi Doctors, a meticulously researched and utterly horrifying book that tells how members of the medical profession during the Third Reich not only participated in bizarre experiments on concentration camp detainees (including children and the disabled), but also were instrumental in every step of the Holocaust extermination process, from transport to gas chamber and ultimately disposal of remains.
For his book, Lifton interviewed some of the participating physicians. Most believed their work was noble and had few regrets about being part of what they considered a cleansing and healing of their race. Testimonies from the handful of surviving victims, heard at the famous postwar Nuremberg Trials, sound frighteningly like what Detroit jurors heard last month during Fata’s trial.
Like the Nazi doctors interviewed by Lifton, I suspect Fata didn’t see himself as a monster. He may have had some misgivings, but I doubt he thought he was doing anything seriously wrong. He probably envisioned that final elusive cancer cell hidden somewhere inside every patient and, like the Nazi doctors scrubbing Germany to complete Judenfrei Aryanization, justified the chemotherapy with some cliché like “Let’s work together and mop up every last cancer cell.”
By the way, I didn’t pull that line out of the blue. Patients have told me stories of how, in the wake of their surgeon pronouncing their cancer surgery successful, in strolls the oncologist with that cancer “mop up, no-cell-left-behind” routine.
Over-utilization
The awful truth is that you have to wonder exactly how much overutilization (oh, that word again!) is actually going on in the $3.8 trillion being spent on US healthcare every year. Believe me, a lot more than you want to know. Creeping into the system is a shift from the Hippocratic “First, do no harm” to a pervasive and insidious “Where’s my share?”
- In June, a Nevada spine center and its surgeons were indicted for a complex scheme involving counterfeit joint replacements and unnecessary surgery.
- In May, a Michigan spine surgeon admitted to $11 million in fraud for unnecessary surgeries. I once remarked to a non-spine orthopedic physician about the increased number of spine procedures being performed and asked about the criteria for surgery. “These days?” he snorted. “Two criteria. Does the patient have insurance? Does the patient have a back?”
- Here in Chicago, executives at Sacred Heart Hospital are about to be sentenced for a complex kickback scheme that resulted in hundreds of unnecessary hospitalizations and surgical procedures.
In my own (many) years of primary care medicine, I’ve certainly heard about or seen myself countless instances of inappropriate treatments, both medical and surgical. Most of what you’re gut tells you is an unnecessary procedure is extremely difficult to actually prove. The best a doctor like me can do is simply avoid that particular specialist like the plague.
When a doctor becomes a veritable loose cannon of inappropriate care, various hospital committees, physician review boards, and even the federal government can step in, but the cost to investigate a case and finally prove damages or fraud must be enormous, what with chart review, interviewing victims and other physicians, and even taking steps like phone/internet tracking and wearing recording wires. The Illinois Department of Financial and Professional Regulation, which oversees anyone with a license (from acupuncturists to veterinarians), is, like everything in Illinois, understaffed and underfunded.
Over the years, I’ve followed investigations into cardiologists, ophthalmologists, dermatologists, urologists, and gastroenterologists-in fact, members of virtually every procedure-driven specialty-who had been accused of inappropriate overutilization. Procedures included unnecessary coronary angiograms, cataract extractions, colonoscopies, and removal of prostate cancers.
Generally speaking, some doctors involved in fraud are fined, some are required to return money to Medicare or to insurance companies, a handful are jailed. Some, if the pressure is too intense, will, like child-abusing priests transferred from parish to parish, simply set up shop elsewhere. And because every rogue physician is a cash cow for a lot of interested people, hospital executives can be extremely reluctant to initiate any investigation when issues of fraud or malfeasance are raised.
So we’ve got a health care system in which a physician can financially become as rich as Croesus if he follows the guidelines and moral code described in The Nazi Doctors. The questions become: How did we get here and what can we do about it?