"I can tell you confidently that what happened over there couldn't happen over here," says Union Memorial's Debra Schindler. "Every one of our doctors gets checked — his records, his cases reviewed. Even our chief of the cath lab gets his records checked." (Catheterization labs are where patients have stents installed.)
Perhaps what St. Joseph officials delicately describe as "stent procedures that may have been medically unnecessary" were confined to that hospital. But I doubt it. On Sunday, The Baltimore Sun reported that state officials have identified potentially questionable stent-implant rates by other, unidentified doctors. Even at St. Joseph, the internal inquiry is curiously narrow.
It is the duty of the state not to take any hospital at its word. The biggest shock in this scandal isn't that one doctor is alleged to have subjected hundreds of patients to unnecessary medical jeopardy and pocketed thousands of dollars in unwarranted fees. The biggest shocks have been the lack of safeguards against unneeded stents at St. Joseph, the possibility that similar vacuums exist at other hospitals and the apparent inability of the medical-industrial complex to police against unnecessary procedures.
Dr. Robert Wachter, an expert on health care quality, says on his blog that he was "thrown back on my heels" when I asked him recently why standard safeguards hadn't flagged irregularities at St. Joseph.
Apparently he and other experts in patient safety haven't thought much about the hazard of "successful" but unnecessary procedures.
"Cases like Midei's don't trip any alarms" even as they generate outsized fees for the hospital and the doctor, writes Wachter, medical professor at the University of California, San Francisco and chief of medicine at UCSF Medical Center.
Doctors who scan arteries are generally the same ones who implant stents — so there are no extra eyes at the time of diagnosis. At St. Joseph, doctors reviewed each other's work afterward, but Midei, as head of the department, got to pick the cases, according to a state investigation. In any event, reviews at most hospitals are focused on complications and mortality — not on whether procedures were needed. (St. Joseph says it has fixed its system, and Midei has said he expects to be exonerated.)
The emergence of alleged earlier cases at St. Joseph makes a comprehensive state review even more imperative. St. Joseph has confined its investigation of Midei to cases going back two years, saying complications from older, unnecessary stents would have appeared by now.
But patients and their lawyers are requesting expert reviews of older cases handled by Midei — and finding what they say are unneeded implants. It's surprising that St. Joseph isn't doing its own analysis of the earlier cases and contacting patients directly.
"If the hospitals don't give them the information, lawyers will," says Briggs Bedigian, a lawyer handling malpractice cases against Midei and St. Joseph. "We're in the position of being the police force for the medical profession, and that's a shame."
The real medical police should be the Maryland Department of Health and Mental Hygiene. Officials there appear to be on the job after a slow start. Del. Peter A. Hammen, a Baltimore Democrat who is chairman of the House health committee and appears to be the only elected official who cares about this, asked the department in February whether other hospitals were implanting unneeded stents.
Now the department is working with the Maryland Health Services Cost Review Commission to see whether other doctors have been installing suspiciously high numbers of the devices, says Hammen.
Until 2009, Midei held privileges to practice at Union Memorial, said Schindler, the spokeswoman. Doctors from MidAtlantic Cardiovascular Associates, from which Midei had a bitter split a few years ago, work there now. The federal agency that investigates Medicare fraud has subpoenaed Union Memorial, MidAtlantic and St. Joseph for documents on unspecified business practices. (A MidAtlantic spokeswoman declined to comment.)
For years, Union Memorial has reviewed the medical necessity of its stents and randomly sent cases for review to its sister institution, Franklin Square Hospital Center, Schindler said.
The multimillion-dollar motive to install unneeded stents is indisputable. The opportunity seems to be ample. And as the cost of all medically "necessary" procedures threatens to break the health care system, policymakers should spare no resources to identify and stop the unnecessary ones.