By Tricia Bishop, The Baltimore Sun
9:50 AM PST, December 10, 2011
It took 25 years for Dr. Mark Midei to build his reputation and less than two for it to come crashing down.
In the spring of 2009, he was a superstar cardiologist with a seven-figure salary and a staff that adored him. By late April 2011, he was disgraced, depressed, in a rehab facility, and so financially strapped he would soon have to put his sprawling home up for sale.
"I've been near suicidal at times, my whole identity was stripped from me," Midei said last week in an exclusive meeting with The Baltimore Sun. It was his first extended interview since inquiries into whether he performed unnecessary medical procedures — the placement of coronary stents — were initiated by federal investigators and his employer in May 2009.
Since then, the heart doctor has been sued by more than 200 former patients, including his secretary; investigated by a U.S. Senate committee; forced to resign from St. Joseph Medical Center in Towson; and ordered to relinquish his medical license — a decision he is fighting to overturn on appeal.
His critics say he subjected patients to risky procedures they didn't need.
He says he did nothing wrong.
Over three hours in his attorney's office last week, Midei gave his side of the story, which stretches back a decade and features a cast portrayed as vengeful competitors, biased investigators and back-stabbing friends, who would rather see Midei pay for something he didn't do than take responsibility for their own wrongdoing.
The account is supported by his admirers, who note his technical gifts and generous nature, and countered by his antagonists, who characterize him as a public menace in nearly 3,000 pages of recently released court and hospital records reviewed by The Sun. The papers reveal extensive details about the months of secret proceedings and accusations that led to Midei's downfall.
Midei has filed a petition asking a Circuit Court judge to review that lengthy legal record, in the hopes that it will lead to a different conclusion about his work and rights to practice medicine.
"We'll continue until all of our avenues are exhausted," said Midei, 54, sounding tired, but firm.
"I've never treated a single patient that didn't need to be treated," he said. "Every one of them needed the treatment, and they received high quality care."
"One of the best"
Mark Midei is an unlikely villain.
His fans describe him as a "superb" physician, who's selfless, patient and a fine maker of peach ice cream. He has saved dozens of lives, climbed mountains for charity and missed his own family's milestones so he could care for others.
"It is a running joke amongst my friends that if you ever have chest pain that you should Sharpie 'only Mark Midei please' on your chest before they take you to the hospital," one woman wrote on a website devoted to Midei's good works.
He has always been at the top of his endeavors. He graduated from Colerain High School in Cincinnati as the 1975 class valedictorian and earned an expedited medical degree through a program that combined it with a bachelor of science degree.
He completed his training in the 1980s at Johns Hopkins Hospital, where a mentor, Dr. Jeffrey A. Brinker, steered him into cardiology.
"He was energetic, very bright, very hard-working," said Brinker, a professor of medicine and radiology at Hopkins' medical school. "He was one of the best — if not the best — technically expert persons I've ever trained."
Brinker wanted Midei to join the faculty full-time, but the young doctor and his wife, Denise, had a family of three small children by 1991 (with a fourth to follow two years later) and wanted more financial security than academia could offer. Midei formed a private cardiology consulting group with several members of Hopkins faculty that year.
The group later merged with a handful of competing entities to become MidAtlantic Cardiovascular Associates, known as MACVA. It would grow to become the largest cardiology practice in the state, wielding tremendous power through patient referrals and supplying hospitals with some of the best practitioners available on a contract basis.
"I had worked at almost every hospital in town at one time or another," Midei said in the interview, his tone defensive. "And nobody ever questioned me once."
St. Joseph's catheterization lab, which he directed, became Midei's home base with a loyal team. One cardiac specialist would later tell a St. Joseph investigative committee that he commuted from York, Pa., just to work with Midei.
'The cure for disease'
Years passed without incident. But then MACVA got into some trouble.
In a 2001 lawsuit filed by a group of cardiac surgeons known as CSA, MAVCA was accused of using its referral power to commit extortion from other health care organizations.
MACVA was also accused in a separate 2004 court filing of stealing patients from the CSA surgeons under false pretenses. The filing claimed that Midei personally misled a heart patient at St. Joseph, claiming the man's CSA surgeon wasn't available and steering him toward a MACVA member.
Midei said in a statement to The Sun at the time that he was "happy to have my friends and colleagues who know the truth stand by me." He would express a similar sentiment years later in a different situation.
Meanwhile, stents were soaring in popularity as a relatively risk-free alternative to bypass surgery, particularly after a drug-coated version of the tiny mesh tubes was approved for use in 2003. It prevented scar tissue from forming around the stents, sharply reducing the need for follow-up procedures.
"We really thought we had the cure for disease, and we were using these things aggressively," Midei said last week.
The devices are similar in shape to the spring inside a ballpoint pen but slimmer. They're threaded into place through an artery by interventional cardiologists, like Midei, then expanded to open up blockages and improve blood flow, relieving symptoms such as chest pain.
Stent use in Maryland peaked in 2006, at about 14,255 procedures, according to data from the Health Services Cost Review Commission. Midei alone averaged about a thousand stent procedures per year.
The practice guidelines in use at that time, crafted in 2005, recommended that an artery be at least half blocked before using the devices, and that other, less invasive, medical therapies be tried first. The minimum blockage was increased to 70 percent in 2009.
Stents slightly increase a person's risk for blood clots, which could be deadly, and require that patients take blood thinners for various lengths of time.
Most interventional cardiologists determine an artery's blockage by talking with patients about their symptoms and eyeballing a live X-ray image of their arteries, taken during a cardiac catheterization procedure. But recent data suggest that those estimations weren't very good. A report published this summer in the Journal of the American Medical Association claimed that half of the non-emergency stent procedures in the United States may be either medically questionable or outright unnecessary.
Midei, however, considered himself a master at the diagnostics and the procedure, his friends said.
"I do think that Mark reached a stage in his life where he believed that he was very, very attuned to a patient and their needs, and he knew when somebody needed to be fixed," said Brinker, Midei's mentor.
Midei's skills attracted the attention of MedStar Health, which owned several hospitals in the area. It proposed a $25 million merger with MACVA in 2007 — as long as Midei and was part of the deal, which meant he would have to leave St. Joseph.
The Towson hospital fought back, offering Midei triple his MACVA salary of about $500,000 and a full-time job on St. Joseph's staff.
"It came as a complete surprise to me," he said of the offer, and made him "feel like a baseball star."
"I loved the people at St. Joe, the patients at St. Joe," he said. "It had become my identity."
Midei called MACVA Chief Executive Hank Yurow to resign, and Yurow exploded, knowing that the loss of Midei would scuttle the merger.
"He said he would sue me into the Stone Age, he was going to destroy me personally and professionally," Midei recalled last week.
Yurow, who did not respond to messages from The Sun, eventually expressed regret in a court deposition for his comments, though Midei's supporters still wonder if the CEO, since retired, harbored animosity and retaliated.
Less than a year after Midei joined St. Joseph in January 2008, an anonymous complaint was sent to the Maryland Board of Physicians, which oversees physician licensing, listing the medical record numbers for 36 St. Joseph patients and the dates they received stents from Midei.
The tipster wrote "to report medical fraud in regard to the unnecessary procedures by Dr. Mark G. Midei in St. Joseph hospital, Towson, Maryland," according to the November 2008 letter. "He has performed stent procedures in the coronary (heart) arteries which have insignificant blockages."
A second letter, listing an additional 41 procedures, was sent to the board in late April 2009.
"The allegation was fairly sophisticated," Midei says in hindsight. "It had to come from somebody with access to information at the hospital."
Around the same time, according to hospital records, "several MACVA physicians" told an employee of St. Joseph who had several stents implanted by Midei that his procedures were unnecessary.
Under other circumstances, that might have triggered an internal review of Midei's work and a correction plan that allowed him to keep working under supervision, doctors have said in court testimony.
But St. Joseph was already under scrutiny, making officials more cautious.
'Under the bus'
The CSA surgeons had taken their MACVA kickback complaints to the federal government, eventually filing a whistle-blower lawsuit against 55 defendants, including St. Joseph, which was accused of collusion and forced to replace its leadership team in early 2008.
While looking into the alleged extortion, federal investigators caught wind of the allegations against Midei.
The prosecutor in charge of the case pressured St. Joseph to initiate a thorough review of Midei that met Department of Justice specifications, according to minutes from the hospital's Medical Executive Committee.
It felt like the "government was in the room," one doctor would later testify. "There was this underlying concern ... that there was another entity that was looking at how we dealt with this and what we did."
Midei's attorney, Stephen Snyder, says St. Joseph officials threw Midei "under the bus" — snitching on him in hopes it would earn them leniency in the kickback case.
St. Joseph declined to comment for this story.
Hospital leaders asked Midei to take "paid time off" in May 2009 while St. Joseph investigated. A staff doctor found that the employee complaint, initiated by MACVA analysis, was valid. A consultant also found instances of unacceptable stenting after reviewing about 15 cases, though his analysis was later deemed incomplete.
Yet another review, by four members the American Medical Foundation that looked at 157 cases over a weekend, found that one-third of them did not meet the standard of care and nearly one-quarter of the cases were so far off that they merited "special review."
"Particularly troubling is Dr. Midei's practice of repeatedly over-estimating the severity of lesions visualized during numerous cardiac catheterizations," a hospital committee noted in a confidential investigative report.
Midei commonly found an artery to be 80 percent to 90 percent blocked, while the four AMF reviewers each found less than 50 percent blockage in many cases. In some instances, the reviewers saw less than 30, while Midei saw more than 90.
Investigators later interpreted that to mean Midei purposely inflated the degree of blockage to justify unnecessary stents.
When he appeared before a hospital committee to defend his decisions, Midei admitted that the percentages he recorded seemed high. He explained that he must have unknowingly defaulted to using the figures of 70 percent, 80 percent and 90 percent to represent mild, moderate and severe blockage, the report states.
He later came to believe that the differences between the blockage assessments could be attributed to the medical exams under review. The recorded images were of a much poorer quality than those available live on the day of the procedures, he said.
The figures Midei noted on patient records were "reflective of [his] judgment of that blockage at the time," he said last week. He also pointed out that great variance among reviewers is typical, especially when it comes to mid-level blockages.
"The notion that we in the cath lab, have a very precise method for mathematically determining the degree of obstruction is false," he said. "It's subjective."
A similar examination of any other practitioner's work would turn up comparable discrepancies, he claimed. He added: "It's unimaginable that anybody has gone through the kind of scrutiny I have."
Midei was formally suspended on July 8, 2009, and allowed to resign in November of that year after signing a form releasing St. Joseph from any potential claims. The hospital said it would provide a cursory letter of reference if asked, and Midei believed he would be able to get on with his life elsewhere.
But then St. Joseph began sending 585 of his former patients letters alerting them that their stents may have been unwarranted.
The letters drew national attention from media and malpractice lawyers and quickly quashed any hope Midei had of finding work. Within a few months, the state launched an investigation into unnecessary stenting, as did the U.S. Senate Finance Committee, which oversees the Medicare and Medicaid programs.
In June 2010, the Board of Physicians filed professional charges against Midei, beginning the process that would strip him of his medical license.
In November 2010, St. Joseph paid the federal government $22 million to settle claims of a kickback scheme with MACVA, which has since been dismantled, and to repay federal Medicare funds it received for Midei's so-called questionable stents.
And in December of last year, Midei went before an administrative law judge to fight the board charges.
He enlisted the help of Dr. William O'Neill of Miami, an expert cardiologist who was paid $10,000 a day for his time. O'Neill said he helped develop the stenting guidelines and found Midei's work appropriate based on clinical indicators.
But his opinion didn't sway the judge, who, after reviewing the evidence recommended to the board that Midei's license be revoked.
At the same time, the Senate committee released its findings, suggesting that Midei was too cozy with stent maker Abbott Laboratories, which may have "indirectly encouraged" his stent use. Abbott praised Midei's high stenting rate in a congratulatory email and once threw a pig roast at his home.
Midei calls the implication "ludicrous."
"I didn't derive any benefit," he said, adding that it was a hassle to "clean up after 100 people" following the party.
At times, the condemnation was more than Midei could take. On April 27 of this year, the same day he was scheduled to address the board about the license revocation recommendation, he was rushed to an alcohol and drug treatment facility for a month's stay, according to court records.
"Unfortunately, he has a broken heart," lawyer Snyder told the board at the time, explaining Midei's absence.
Midei declined to discuss the incident in detail, saying only that he "never ever had a problem with substance abuse that preceded any of this." He would neither "confirm nor deny" that he has a problem now.
"I was a leader, I was respected, I spent close to 30 years building a reputation that came crashing down," Midei said. "It's harmed my confidence, it's harmed me gravely financially. I can't find a way of providing for my family."
Abbott offered him a position for a short time until the media attention became too much to bear. He also tried working abroad in Saudi Arabia, but it was culturally uncomfortable for his wife.
He's now living near family in Ohio, where his medical license is still active, though it's set to expire in July, according to online records. He's hoping to set up a consulting business there, while Denise stays behind to sell their Maryland house, which is listed for $1.9 million.
"It's hard for me to be in Baltimore," Midei said. "I can't go to the grocery store without running into a patient. I can't go to church; I'm being sued by my neighbors, my secretary, many doctors I've treated over the years, friends. So it's just unimaginable."
He's filed a lawsuit against St. Joseph, alleging that it used him as a decoy to deflect attention from the kickback scheme between the hospital and MidAtlantic, and his lawyer plans to file a memorandum Monday supporting his request for judicial review of his case.
"One of the reasons why we've gone through this is the belief that what I've done is good work, quality work, and a belief that it's important to fight the injustice of it all," Midei said. "I don't think Baltimore, and I don't think St Joe, is as good or as safe a place with me out of practice."
January 2008: Dr. Mark Midei leaves MidAtlantic Cardiovascular Associates to become a full-time employee of St. Joseph Medical Center, leading a former colleague to vow revenge against him.
November 2008: The first of two anonymous letters is sent to the Board of Physicians claiming Midei was placing medical unnecessary stents in patients.
April 27, 2009: Several MidAtlantic cardiologists inform one of Midei's patients, a St. Joseph's employee, that his stent was unnecessary. The man reports the concern to hospital staff.
May 12, 2009: St. Joseph sends Midei home on "paid time off," during an investigation of his work.
July 8, 2009: St. Joseph suspends Midei's practice privileges.
November 2009: Midei resigns from St. Joseph, and the hospital begins sending letters to roughly 600 patients telling them they might have had unneeded stents implanted in their coronary arteries.
Oct. 22, 2010: Midei files a $60 million lawsuit against St. Joseph alleging that it made him into a "sacrificial lamb" to deflect the attention of civil investigators looking into a separate kickback scheme between the hospital and MidAtlantic.
Nov. 10, 2010: St. Joseph agrees to a $22 million fine to settle kickback claims and repay Medicare funds received for questionable stents placed by Midei .
Dec. 6, 2010: The U.S. Senate Finance Committee releases a report questioning whether stent maker Abbott Laboratories "indirectly encouraged" unnecessary stent procedures.
July 13, 2011: The Maryland Board of Physicians revokes Midei's medical license.
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