Stent Scandal: A Shocking Story, But Not News

Over the weekend, the New York Times published a head-turning tale about Dr. Mark Midei, a star cardiologist at St. Joseph Medical Center in Townson, Maryland. According to federal investigators, Dr. Midei implanted potentially dangerous cardiac stents in the arteries of as many as 585 patients who didn’t need them. A hard worker, he managed to knock off those 585 procedures in just two years, from 2007 to 2009. Medicare paid $3.8 million of the $6.6 million charged for the treatments.

The Baltimore Sun broke Dr. Midei’s story in January. In February the U.S. Senate Committee on Finance, which oversees Medicare and Medicaid, began investigating. Monday, the Finance Committee released a 1200-page report.

The report reveals that Midei was a favorite son of Abbott Laboratories, the company that manufactured the stents. Indeed, in August of 2008, Abbott celebrated the fact that the handy doctor had inserted 30 of the company’s cardiac stents into trusting patients in a single day: “Two days later, an Abbott sales representative spent $2,159 to buy a whole, slow-smoked pig, peach cobbler and other fixings for a barbecue dinner at Dr. Midei’s home.”  Employees from St. Joseph’s attended the feast.

Although St. Joseph’s has not admitted to any wrongdoing, last month it agreed to pay a $22 million fine to settle charges that it paid illegal kickbacks to Dr. Midei’s medical practice in exchange for patient referrals. In other words, it seems that the hospital encouraged the doctor to implant those tiny mesh tubes in his patients’ arteries. Certainly, hospital executive knew that they were making handsome profits on Midei’s stent procedures. This is why they paid him those “bonuses” to shepherd unwitting patients to their cath-lab where doctors can diagnose heart attacks, and quickly open arteries. Midei was a rainmaker.

Clinical guidelines generally suggest that an artery be at least 70 percent blocked before a stent is used to open it up, and St. Joseph's rules consider anything less than 50 percent blockage to be “insignificant.”  But court documents allege that some of Midei's patients were told they had blockages in the 90 percent range, while a subsequent review of their records shows blockages closer to 10 percent or less.

             Medical Journals Have Been Telling Us This for Years

But what I find most disturbing is that the story about Dr. Midei is not new; nor is it “news.”  As Dr. Nortin Hadler, author of Worried Sick, argues in his guest-post below, medical research suggests that stents have been overused, nationwide, for years, exposing patients to needless risk and exorbitant expense.

In January of 2006, an article published in the journal Circulation observed that although there has been a dramatic increase in artery-opening procedures in order to prevent heart attacks over the last 10 to 15 years, the rate of heart attacks stayed relatively constant. The findings came from two studies, one done in the U.S. and one done in Canada.

At the time Dr. Thomas Graboys, a professor of medicine at Harvard Medical School, told the Center for Medical Consumers that stents “are virtually useless, in stopping the progress of the disease itself.”  “The public is looking for a magic bullet,” Graboys warned. “Go to a non-hospital-based doctor in the community. A well-trained internist can take care of the lion’s share of people with coronary heart disease. The vast majority of people do well on medication—cholesterol-lowering drugs, antihypertensives, low-dose aspirin.”

For an expert opinion on “the best” and most persuasive of the many studies that raise serious questions about invasive heart procedures, see Dr. Hadler’s post below. 

Nevertheless, as the Center for Medical Consumers reported in 2006: “The number of people undergoing artery-opening procedures continues to rise not only because they are huge money-makers , but they are also very effective at relieving the severe chest pain of angina, which is a common symptom of heart disease.” Patients like the “quick fix” of the stent treatment for angina. Medication doesn’t work as rapidly.

Writing about the Midei case over at Kevin M.D,. Bob Wachter, Professor of Medicine and Chief of the Division of Hospital Medicine at the University of California, San Francisco, comments on the patient response: “Most of his patients were probably quite content – many had chest pain and a stent undoubtedly seemed like an appropriately aggressive, high-tech cure. ‘He put two stents in almost immediately,’ said one grateful patient. ‘I felt relief.’

“Although this patient, 66-year-old Peggy Lambdin, later received a letter indicating that her coronary artery was less than 50 percent blocked (clinically meaningless and not an indication for stenting), she was unfazed,” Wachter observes. “No one can ever tell me that I didn’t need that stent,’ she told the Baltimore Sun. ‘I feel like [Dr. Midei] saved my life.’

Moreover, I’m guessing that Dr. Midei’s complication rate was quite low,” Wacther continues, “as it usually is when one does procedures on healthy people. He probably followed all the protocols mandated by accreditors and the relevant specialty societies. (Oh yeah, except for the ones regarding professionalism.)

“The problem is this,” he concludes, “as long as the cardiologist reading the cath is the one who pulls the trigger on the intervention, we have a potential Fox/Henhouse problem.”

                                     “Gizmo Idolatry”

What may be most troubling about the Medei imbroglio is that it highlights how our infatuation with high-tech medicine tempts us to ignore medical evidence. The popularity of stents is all part of a mindset that Drs. Bruce Leff and Thomas E. Finucane have termed “gizmo idolatry.” 

Back in June of 2006, a few months before I began HealthBeat, I wrote a post about our use of stents for The Health Care Blog. It was titled: “Tech: Is Newer Better? It’s a Coin Toss.” Below, an excerpt :

 “Last week The Annals of Internal Medicine roiled the medical world by publishing a study suggesting that the drug-coated stents produced by companies like Boston Scientific and J&J may not be quite as miraculous as first advertised. (You will find the abstract here) Following a two-year study, researchers at the Cedars-Sinai Medical Center in Los Angeles are now suggesting that the ‘putative superiority’ of drug-coated stents is founded on questionable premises.’  Or as The Wall Street Journal put it, the clinical trials of drug-coated stents (mostly funded by manufacturers), may ‘have exaggerated their real-life advantage.’ [Dr. Midei was using a new generation of drug-coated stents.]

“Stents, you may remember, are those tiny metal scaffolds that cardiologists use to prop arteries open after they have been cleared of fatty deposits. Since they were approved in the early 1990s, manufacturers have made a fortune peddling the devices which, they say, can prevent a future heart attack while avoiding riskier and more invasive bypass surgery.  Today, stents are used in 85% of all coronary interventions in the United States.

“Before turning to the new Cedars Sinai study, it should be said that THCB has long harbored doubts as to whether these cunning devices represented the best solution for quite so many patients. Back in 2003, THCB quoted a Stanford study which suggested that, over the long term, patients with multi-vessel disease would achieve better outcomes, at a lower cost, if they opted for the bypass operation. In 2005 THCB questioned the cost-effectiveness of the new, improved “drug-coated” stents that are designed to prevent the growth of scar tissue inside the artery. . .

Yet “drug-coated stents have become wildly popular, thanks in part to what The Annals of Internal Medicine describes as ‘aggressive marketing’ and the unbridled expectations of patients. Wall Street likes them too. At $2300 a pop (vs. a mere $700 for the uncoated, bare-metal variety), the newer stents are far more profitable. Despite the hoopla, nine months ago THCB was once again forced to ask ‘Are Stents A Waste of Money?’ after reading about a study of 826 patients, published in Lancet, which suggested that the drug-coated stents made by J&J and Boston Scientific aren't cost-effective for all patients and should be restricted to those at highest risk for heart attack.

“A second 2005 study, published in The New England Journal of Medicine, added to the uncertainty about the widespread use of stents by reporting that patients suffering minor heart attacks do equally well with drug therapy. ‘In a study colliding with established practice, recovery from small heart attacks went just as well when doctors gave cardiac drugs time to work as when they favored quick, vessel-clearing procedures,” the NEJM reported. "The surprising Dutch finding raises questions over how to handle the estimated 1.5 million Americans annually who have small heart attacks – the most common kind. Most previous studies support the aggressive, surgical approach. . . .  Meanwhile, just last fall, Dr. Eric Topol, chairman of the cardiology department at the Cleveland Clinic, warned Consumer Reports: ‘Unfortunately, the extensive use of such stents is far ahead of the data that can be cited to support them.’

 “But it’s not just that manufacturers over-estimated the benefits; they underestimated the new risk that the coated stent introduces. For after reviewing outcomes research, Cedars Sinai’s clinicians found that the drug-coated stents increase the danger that a blood clot will form inside the stent– months, or even years after the procedure. Such clots can be life-threatening. . .

“The stent story illustrates a major problem in our money-driven health care system. When a product is very profitable, it is promoted to the skies—and, in such cases manufacturers tend to put the very best face on their clinical research. A startling study published last month in the Journal of the American Medical Association comparing clinical trials funded by for-profit entities to clinical trials funded by nonprofit entities underlines the point: it seems that that the industry-funded trials were far more likely to report positive findings.

“Finally, most patients (and even many physicians) tend to assume that, when it comes to medical technologies, ‘newer’ means ‘better.’ This is why, when asked to participate in a randomized clinical trial, some patients refuse, fearing that they will ‘miss out’ on receiving what they assume is the newer, better product. Yet the odds that the bleeding-edge therapy represents an improvement over existing technology are only about 50/50. As Americans we tend to believe in what’s new—as if medical science progressed in a straight linear fashion, one breakthrough after another, from Madame Curie to me. As a result, we pay more—and more—and more—as drug makers and device-makers flood the market with ‘new, improved’ products.”

In Money-Driven Medicine: The Real Reason Health Care Costs so Much, I quote Kaiser Permanente CEO George Halverson who points out that few modern researchers are willing to risk betting their own money on their newest products or procedures. In some cases, he reports, when health care plans have been asked to cover a new, as yet unproven treatment, they have said: ‘Try it. If it works, we’ll pick up the bill. If it fails, then it’s your cost, not ours.’

Researchers virtually never take the bet because they ‘know that most research fails,’ says Halvorson. “So having their personal incomes tied to the actual success of their unproven care isn’t at all attractive. There is some irony in the fact that the same researchers who enthusiastically extend hope to individual patients are, almost without exception, far too practical about the actual value of their experimental care to risk their own income.”


I wrote that post in 2006.

Monday, the Times’ story acknowledged that “Prosecutors, malpractice lawyers and state medical boards are only now waking up to the issue . . .The Texas Medical Board last month accused a widely known cardiologist in Austin of inserting unnecessary stents. In September, federal prosecutors accused a cardiologist in Salisbury, Md., of performing unnecessary stent surgeries, and last year a Louisiana doctor was sentenced to 10 years in prison for inserting unneeded stents. . . ”

The Times went on to quote Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic: “What was going on in Baltimore is going on right now in every city in America.” Nissen added that he “routinely treats patients who have been given multiple unneeded stents. We’re spending a fortune as a country on procedures that people don’t need.”

I would love to see the Times expand on these comments by exploring the larger national problem. Ideally, the nation’s paper of record would launch an investigation by looking into the use of stents in its own backyard—Manhattan.

                 Why the Delay in Acting on the Problem?

 Why has it taken so long for state medical boards to “wake up?

I am afraid that many hospitals have resisted the news for one simple reason:  procedures that involve stents are extremely lucrative. In 2007 Business Week told the story of how stents rescued New York’s Mt. Sinai hospital:

“The 2,000-doctor hospital was struggling in March, 2003, when Dr. Kenneth L. Davis took over as chief executive. During the previous six months, Sinai had lost $50 million, partly as the result of tougher caps on Medicare reimbursement rates.  . . . While trimming costs, Davis also decided to build up practices in high-margin specialties. ‘Interventional cardiology was one of myriad areas where we were eager to facilitate growth,’ Davis explains. Dr. Samin Sharma, Mt. Sinai’s “King of Stents,” ran a cath lab which was central to this campaign, performing procedures that typically brought in as much as $20,000 a piece for the hospital.

“Sharma convinced his bosses that to capitalize fully on the stent boom, Mount Sinai should turn his cath lab into a 24/7 operation. At a cost of $400,000 a year, he figured, the hospital could put enough doctors and nurses on call to do emergency angioplasties late at night and on weekends. Soon the lab was averaging 15 off-hours patients a month. Interventional cardiology became a key revenue source for Sinai. By the end of 2006 the hospital's total patient revenues had grown 41%, to $1.2 billion. Cardiology services, excluding surgeries such as heart bypass, contribute 15% of that, most of which comes from Sharma's cath lab.”

This is one of many such stories. Two years ago, a physician at another prestigious Manhattan hospital explained to me why his hospital didn’t offer palliative care: “The COO would rather put the money into expanding the cath lab; it’s far more profitable.”

Let me add that I don’t think that most doctors who recommend procedures using stents are motivated by greed. As Dr. Hadler points out in his guest post, there are many ways for physicians to rationalize their use. Professional pride plays a role: doctors who implant stents firmly believe that they are helping their patients.

Since 2007 Study, Use of Stents Has Dropped, but Many Remain Undaunted

Not everyone has ignored the research. The Baltimore Sun notes that “after a landmark 2007 study in the New England Journal of Medicine concluded that stents were often not beneficial,” enthusiasm waned. “In 2009, Medicare paid ‘just’ $3.5 billion for stent procedures nationwide, down from about $5 billion a year before the 2007 study” was released.  According to the Sun: “The 2007 study didn’t find that stents are worthless, just that not implanting a stent can often be as good — and avoids the real risks of complications or even death from the procedure. But hospitals can’t bill $12,000 for deciding not to implant a stent, even if that’s the best thing for the patient.”

Some physicians remain clearly undeterred by the research.

For example, the Sun reports, "Dr. Midei’s [use of stents] increased, by his own estimate, 50 percent, to about 1,200 a year.” 

As for Mt. Sinai’s Stent star, Cardio Brief, a blog for cardiologists and other cardiovascular health care professionals, heard from Dr. Sharma just last year, shortly after the Brief reported that Columbia University cardiologist Jeffrey Moses had earned  $2.5 million in 2006-7, vaulting him to 8th place in the Chronicle of Higher Education’s Hit Parade of individuals receiving the “highest total compensation at private colleges, 2006- 2007.” Apparently Dr. Sharma was miffed. He got in touch with the blog to point out that “he performs 1,500 complex coronary interventions each year, which apparently is an American record,” Cardio Brief noted. “Sharma also wanted to let us know that the Chronicle's list failed to include Sharma’s own salary of $2.75 million which would have put him ahead of Moses.”

              Health Care Reform Legislation Points to Solutions

Bob Wachter recalls that when the Midei scandal broke, a reporter asked him “Why didn’t peer review catch this?”

Peer review is improving Wachter says, but cases like Dr. Midei’s don’t trip any alarms. Patient who think he saved their lives don’t complain. Still, there are ways stop them.

“Obviously, the Mideis of the world could be caught by requiring that every cath undergo an independent second reading,” Wacther adds. His point is that the physician who diagnoses the need for stents shouldn’t be the one who also performs the procedure. “Some insurers in New Jersey now require such readings before they authorize a stent, and at least one SoCal Kaiser hospital mandates that each cath be presented at a conference before a treatment decision is rendered, analogous to what many tumor boards do for cancers.”

No doubt many of the New Jersey insurers’ customers—and some physicians—object to the requirement. But this is an example of how insurers can add value to health care, not by trying to make treatment decisions themselves, but by calling for more collaboration. If a second doctor must sign off on the reading, this could stop a serial stenter in his tracks. It’s one thing to close your eyes when a colleague is wheeling one patient after another into the cath lab, quite another to associate your name with his activity.

Under health care reform, doctors are more likely to be looking over each others’ shoulders. There will be incentives to join Accountable Care Organizations where doctors or doctors and hospitals work together, and all share in the financial rewards if they are able to avoid waste. Under the Affordable Care Act (ACA) bonuses will encourage doctors to move away from fee-for-service, and toward working on salary (as doctors already do at multi-specialty clinics such as Kaiser or the Mayo Clinic) or accepting “capitated” payments.

In Massachusetts, Blue Cross/Blue Shield, which owns about 45 percent of the private insurance market in the state, already has moved to a combination of capitation and  bonuses for higher quality care. BCBS pays contracting groups of doctors to provide all care, including inpatient services, for its members. The payments are risk-adjusted for age, gender, and health status. Any savings the physicians achieve remain with their group, unless they share the risk with a hospital; in the latter case, part of the savings flow back to the hospital.

Physicians and hospitals also can receive bonuses of as much as 10 percent by doing well on nationally recognized process and outcomes measures. The Massachusetts Blues program is the first major global capitation effort on the East Coast in a decade. Capitation has remained more common the West, where HMO penetration remains greater.

The Centers for Medicare and Medicaid is determined to move away from “fee- for service” payment because we know that inevitably, it leads to more procedures, yet   earlier this year, the Commonwealth Fund reported that “physicians and industry leaders [feel] that cost reductions of 20 percent to 30 percent are achievable under well-constructed global payment models” which pay doctors a lump sum to keep patients well. Meanwhile “patient care suffers in the fee-for-service environment.”  Medicare will not force physicians to give up fee-for-service, but those who cling to being paid “piece work” are less likely to be eligible for the bonuses that reward collaboration and better outcomes.

Under the Affordable Care Act doctors who create a “medical home” also  will be rewarded if they are able to keep their patients healthy and out of the hospital, while avoiding invasive treatments. For heart patients, medication, and diets like Bill Clinton’s “plant diet” are likely to be favored.

In addition, the Medicare Payment Advisory Commission (MedPAC) has suggested that when Medicare spots high volume combined with high profits margins, this is a place to look for overtreatment. The Accountable Care Act allows the Secretary of HHS to lower fees for “overvalued medical services.” One would expect that she will take MedPAC’s advice and that especially in light of the Senate Finance Committee report, as well as legal action in a number of states, procedures involving stents would come under scrutiny.

Finally, as I reported earlier this year, a more proactive Food & Drug Administration has announced that it plans to begin requiring drug makers and device makers to disclose details about their clinical trials—providing detail on their failures as well as their successes. Greater transparency will make it much harder for those who manufacture stents to paint a rosy picture of risks versus benefits—the FDA aims to make sure that these companies are not hiding information about risks.

                          Reform Will Mean More Team Work

Wachter goes on to suggest that team work can also reduce medical errors—including overtreatment. Many at the hospital must have known what Midei was doing, he suggests, but looked the other way. “Cardiologists don’t perform caths on desert islands – they are assisted by cath techs and nurses.  In my experience, these folks become as adept at reading cath films as any physician. If the allegations against Midei are true, it strains credibility to think that no one in the lab knew that inconsequential lesions were being read as tight stenoses and treated with stents.

And what about hospital administrators?” he asks. “While it is possible that no St. Joe’s leader knew precisely what was happening, I’m guessing that some did but chose to look the other way: the pressure to steer clear of the golden-egg-laying goose must have been intense. Perhaps the fact that the hospital’s CEO and two other senior executives resigned after the case broke provides a clue as to who knew what when.

“Cases like this one are terribly troubling,” he continues, “not just because they harm individual patients but because they do violence to the trust that is so fundamental to the physician-patient relationship.

But these cases also force us to consider the kind of culture that could allow such a fraud to take root and go on for years – a culture that likely prized the hospitals’ and physicians’ financial health over the clinical health of their patients. If the allegations are true, the penalties should be severe, not only for Dr. Midei but also for leaders who knew – or should have known – what was going on, yet remained silent.”

Under reform, “accountability” is likely to extend beyond the individual patient-doctor relationship. Physicians and hospitals that work together—and are paid as a team—will become accountable for each other.

22 thoughts on “Stent Scandal: A Shocking Story, But Not News

  1. Yes, but physicians rarely go to jail for malpractice.
    Even in Redding, California, where a doctor performed hundreds of unnecessary bypasses and angioplasties, he did not go to prison.
    Part of the problem is that in these cases, the doctor may well have thought that he was helping the patients.
    The physician himself becomes part of a mass cultural delusion about the efficacy of certain procedures. People are thanking and congratulating him– patients, their relatives, the hospital, etc.
    He may well believe he is saving lives.
    Though of course there are extreme cases where a doctor is consciously over-treating, but I suspect those are very rare.

  2. whilst I’m enthusiastic about CMS moving toward capitation, I’m not holding my breath. In the meantime, simply releasing payment information would help the press and public target such excess, as the WSJ piece on prostate care indicates.

  3. NG —
    Just to clarify —
    As long as a doctor has obtained a signed consent, they are pretty much immune from assault charges, unless of course they engage in sexual or other illegal activity with a patient. As Maggie says, doctors who engage in inappropriate care are guilty of malpractice, a violation of contract (civil) law, not criminal law.
    If it can be demonstrated that a doctor was willfully negligent or engaged in fraudulent behavior, many, perhaps most, malpractice policies have clauses that obsolve the insurance company of responsibility, potentially leaving the doctor responsible for the entire cost of settlement or judgements themselves. In practice, this is rarely invoked except in cases involving falsifying records after the fact, perjury, and other similar things, but in theory it could be in some cases. Court findings of fraud or willful negligence also expose the doctor to potential punitive financial damages, in addition to the usual compensatory damages. Malpractice insurance generally does not cover punitive damages.
    In addition, of course, doctors are subject to investigation and censure by their hospitals, potentially leading to loss of privileges (the right to work in the hospital) or other lesser sanctions, and by state medical boards, potentially leading to loss of license or other lesser sanctions.
    Finally, if there is a finding that a doctor willfully or fraudulantly billed for false charges to Medicare, Medicaid, or private insurance, the doctor would be liable for a judgement of insurance or Medicare fraud. That can result in criminal charges and in permanent or temporary loss of the right to bill Medicare for services.

  4. VA–
    You are correct-you if you make physical contact with your victim, that’s battery.
    But doctors can go to jail for malpractice–typically if they are found guilty of fraud and malpractice.
    A doctor who knowingly performs unnecessary surgery– or hospializes patients who don’t need to be hospitalized– is bilking the insurer while harming the patient, and can go to jail.
    Intent is very important.
    Of course very, very, very few doctors ever intend to harm a patient. But some do set out to over-charge insurers, Medicare or Medicaid, and sometimes the patient suffers the “collateral damage.”
    I’m not an attorney, so I don’t know whether a prosectuor has
    to prove intent, or whether there are cases where criminal negligence could put a doctor in jail.
    Ordinarily, though doctors are not imprisoned for malprctice because society acknowledges that we all are human and even the very best doctors make mistakes.

  5. Maggie,
    I have a different take on this.
    First, my own experience goes like this. I had quintuple bypass surgery in 1999. I was told that I probably had a small heart attack sometime in the past and never realized it as there was some minor heart damage. I was put on maximum medical therapy after the surgery and have been on it ever since. I take a beta blocker, an ACE inhibitor, a statin, an anti-spasmodic drug and a blood thinner plus baby aspirin. After six years, an angiogram following new complaints of chest pain found one artery that was 85% blocked and a stent was inserted on the spot which took only an incremental 15 minutes or so beyond the time for the angiogram by itself. While I occasionally have some chest pain from time to time, it’s minor and the medical regimen continues and will continue indefinitely.
    I was glad to get the stent at the time of the angiogram rather than have to come back for a separate procedure. If a second doctor had to sign off to confirm the need for one or more stents, it would delay treatment and add to the patient’s anxiety. If the first and second doctor each worked for the hospital with their compensation tied, at least in part, to the hospital’s revenue and profit, I’m skeptical how many times the first interventional cardiologist would be overruled.
    Instead, when payers, including commercial payers as well as Medicare and Medicaid notice that a particular doctor and/or hospital is performing an unusually large number of procedures of any type, timely unannounced post-procedure audits should be performed by experts hired and paid for by the payers. If clearly unnecessary procedures are being done, especially when claiming that a blockage is much greater than the film shows it to be, the consequences for the doctor should be swift and severe including prosecution for fraud and, possibly, loss of his medical license. If hospital compliance departments want to perform their own audits as well, more power to them.
    With regard to the studies that claim to show that there is no benefit from stents regarding either life expectancy or preventing future heart attacks or strokes, they don’t speak to the quality of life implications of reduced chest discomfort. Chest discomfort, especially if it occurs at rest and not during or shortly after eating is not only stressful, it can be perceived as life threatening. By contrast, pain from, say, arthritis, is both annoying and can negatively affect quality of life, but it’s not life threatening. That’s a huge difference to those of us who live with heart disease.
    Finally, the new reform driven approach to pay hospitals modest bonuses if they meet certain quality standards is not likely to be as effective as you think or imply. Hospitals that don’t do procedures don’t get paid. For capitation or bundled payments to work, they would need probably to be assured of total revenue equal or at least close to what they are generating today. For most hospitals, 60% of their costs are fixed and 40% are variable. It’s not that easy for them to reduce costs in the short term.
    As an aside, I recently met with the CEO, who is also a physician (OBGYN), of a large hospital system in the NYC metropolitan area and the CFO of a well known hospital system in Pennsylvania. Both said that they could not make money if they had to take Medicare rates from all comers even if there were no uncompensated care.

  6. Barry —
    Your story is a good example of why anecdotal results don’t mean much.
    It is true that people with angina often get faster relief from stents than medical treatment, but it is also true that medical treatment is usually successful at providing relief from angina after a short interval, an interval that can usually be bridged successfully with use of morphine and nitrates. On the other side of the coin, stent patients have much higher incidence of problems related to stent failure, re-stenosis, and delayed stent complications, plus face the risk of acute complications, including death, during the procedure.
    In fact, in most stent patients the stent most likely is responsible for the pain effects for only a fairly short time, at which point the maximal medical therapy they are almost always on as well takes over and carries most if not all of the weight.
    Studies still do suggest that stenting is the preferred treatment in either acute heart attacks or in unstable angina, but the studies are very convincing, as shown elsewhere on this and the related thread, in showing that there is no real advantage and most likely a slight disadvantage to managing both standard angina and non-symptomatic coronary artery disease with stents instead of medical therapy alone.

  7. Barry–
    The research shows that
    stent procedures offer relief from the pain of angina for a while–but not forever.
    It’s fast, but a band-aid fix.
    Drugs and a change of diet
    can help the patient for a much longer period of time.
    And as Pat S. points out in his comment, pain-relieving drugs can help patients until the other medications kick in.
    As for whether hospitals can make money on Medicare-or lowered Medicare payments– sse the Medicare Payment Advisory Commission report which I have referenced in the past showing that
    most hospitals do turn a profit on most Meidcare patients.
    As for hospital CEOs at overpaid hospitals in NYC and PIttsburgh who tell you they couldn’t surive on Medicare paymtents? (I’m pretty sure I know the hospitals you are referring to) What did you think these CEO’s would say?
    As for Medicare paying hospitals less: this will begin quite soon. Medicare will be penalizing hospitalis with excessive readmissions, and, each year, they will be cutting annual increases to all hospitals by 1%.
    Medicare wants to put hospitals under some fianncial pressure because MedPAC reserach shows that when hospitals are under financial pressure, they learn to become more efficient–and, in fact, beginning making a profit on those Medicare reimbursements.
    As Pat S. points out, in his comment, anecdotes (or stories you hear from people with an ane to grind) are one thing; MedPAC’s well-documented analysis is another.
    These CEOs are making 7-figure salaries as a reward for running a hospital as a revenue center (as opposed to a patient-care center).Of course they will say that the government isn’t paying hospitals enough.
    Pat S.
    Yes–tand hank you.
    But in your last paragraph I think you mean “but the studies are NOT very effective” ???
    If so, let me know, and I can go in and make the fix.

  8. Pat –
    Do you have any data on the percentage of stent placements that go into patients who are either asymptomatic or have stable angina? I don’t understand why and under what circumstances asymptomatic patients would ever be sent to the cath lab in the first place. Conversely, I also wonder how many patients who receive stents would have been better off for the longer term with a CABG.
    Maggie –
    The PA hospital system is based in Philadelphia, not Pittsburgh. The CFO said their current margin on their Medicare business overall ranges from 0 to -10%. They make decent money on the surgical procedures but the medical admissions, as a group, are more problematic from a financial standpoint. He also said that in the two years prior to this year, their costs per adjusted admission grew 3.5% with the comparable number for this year at 2.0%. Meanwhile, Medicaid pays them less than 70% of their costs with more payment reductions coming due to state fiscal pressures. If Medicare payments rise only 1% or so while their costs continue to go up at 2%, it’s a formula for continued cost shifting to commercial insurers.
    The main area where all hospitals have the potential to get better is in reducing 30 day readmission rates and they are all working on that. ACO’s certainly have the potential to do a better job with care coordination, especially if decent electronic records are in place and used. The trend toward more hospital employed physicians makes it easier to consolidate vendors and standardize operating room protocols. At the same time, they could lead to even greater concentration of market power which could result in healthcare costs even greater than they would have been under fee for service even with global payments, bundled payments for surgical procedures or partial capitation.
    The powerful hospitals will vigorously resist value based insurance design though BCBS of Massachusetts is moving ahead with the introduction of a tiered in network insurance product on January 1, 2011. While I strongly support that approach, I suspect that, in the end, we may well wind up with an all payer system but Medicare and, especially, Medicaid will have to pay more than they do now. That’s a heavy lift in the current fiscal environment.

  9. Barry–
    As you know, a profit margin turns on the cost of operations.
    MedPAC has found that the cost of operations at a great many hospitals is much, much higher than it needs to be.
    This is because they are terribly inefficient.
    Just one example: they have three or four ORs that are all very busy during the morning and more or less empty in the afternoon.
    This is becuase many surgeons prefer to operate in the morning, and if these surgeons bring in business, hospital administrators do their best to please them.
    These hospitals need only two ORs.
    As for hospitals having greater market power as phyisicans abd hospitals consolidate, the government pays more and more hospital bills, “the makket” is not going to determine prices.
    Government (taxpayers) already pays more than 50% of all health care bills in the U.S.
    Going forward, govt’s share will grow (as more people age into Medicare, and as as Medicaid and SCHIP expand).
    Note what happened this year when the Secretary of HHHS negotiated with Medicare Advantage insurers on prices: next year, premiums will be 1% lower than they were this year, and Sebelius insisted that they slash co-pays for extremely expensive drugs for cancer, MS, etc.
    In other words, governmetn is beginning to regulate prices.
    (Medicare Advantage insures will be pushing back, refusing to overpay drugmakers, hospitals, etc.)
    The Affordable Care ACt also cuts increases in payment to hospitals and nursing homes by 1% a year–every year. This provision is designed to put pressure on hospitals to become more efficient.
    As MedPAC reserach show, when hospitals are under some financial pressure, they find a way to cut waste in what it costs them to deliver care.

  10. Barry–
    Pat didn’t say that “asymptomiatic patients” undergo stent procedures.
    He said that patients suffering from angina–who have never had heart attacks- undergo these procedures.
    This is true.
    And, research shown that while angioplasty with stents offers them quick relief from pain, over the long term, their angins often comes back.
    Medication and change of diet, on the other hand, is much more likley to lead to long-term relief from angina.
    More imporantly, when patients undergo angioplasty with stents, long-term repeated reserach shows that their chances of suffering a heart attack–or dying from a haert attack– are NOT REDUCED..

  11. Barry —
    Non-symptomatic patients end up in cath lab because of results of other tests — ecg, stress ecg, nuclear cardiology, lab tests, and these days especially coronary artery CT. These tests are advocated as screening tests and are obtained for things like clearance to begin exercise programs, “executive” physicals, family history or other risk factors, or just plain general prinicples. When they have positive findings, the logical next step is to send the patient to cath. Part of this is pure overkill, and part of it is due to some physicians’ desire to locate patients with the so-called “widowmaker” lesion — significant stenosis in the left main coronary artery — before they suffer severe or life threatening events.
    The result goes: screening suggested for one reason or another > abnormal results in screeing > cath > abnormal cath findings > stenting. It is a good example of the problem of accidentally creating disease by the doctor boxing themselves in with testing that was not needed in the first place.
    I have no idea of what the percentages of people who are non-symptomatic who end up getting stents, but simple angina is the most common cause of heart cath and stenting in many centers.
    I personally once had a stress ecg — clear back when I was in my late 40’s — as a screening test at the urging of my doctor despite being asymptomatic at the time. Fortunately, it was negative and everything ended there.

  12. Maggie —
    Actually, I did say that asymptomatic patients undergo cath and stenting, under the circumstances that I outlined in my answer to Barry. The problem is that some, probably many or most, cardiologists believe that once they discover what they consider to be a significant stenosis they more or less HAVE to treat it to prevent it from causing the patient problems down the road.
    As to the sentence: it may be awkward because of the parenthetical phrase, but what it says, minus the aside, is:
    “the studies are very convincing in showing that there is NO real advantage and most likely a slight disadvantage to managing both standard angina and non-symptomatic coronary artery disease with stents instead of medical therapy alone.”
    (caps added to “no” for empnasis.)

  13. Pat –
    Thanks for the explanation of how non-symptomatic patients wind up in a cath lab. It makes perfect sense. In my own case in 2005, there were some symptoms and a stress test showed a significant adverse change from my prior stress test a year or so earlier.
    I understand that stent placement is a lucrative procedure for both the hospital and the interventional cardiologist. I wonder, though, what role defensive medicine plays in the equation as compared to how decisions about how to treat screening test findings are determined in other countries. I could see where formula based protocols might be developed here that would call for a stent if the percent blockage is above X depending on where it is – maybe a lower threshold for the Left Main or, perhaps, the LAD as compared to one of the distal branches. Even if the interventional cardiologist knows that the patient has stable angina or is non-symptomatic, if the percent blockage is above the threshold, and he doesn’t put a stent in, what if the patient has a heart attack in the next week / month / year? The path of least resistance in our litigious culture is to insert the stent. Oh, and by the way, it pays well too. If the docs in other countries perceive, correctly, that, as a practical matter, they are unlikely to ever be sued, even if the screening results are positive, the patient may not be sent to the cath lab if he/she is non-symptomatic or has stable angina. My sense is that defensive medicine may be an important part of the equation that determines interventional cardiologists’ practice patterns in the U.S. even though its effect cannot be specifically determined or quantified.

  14. “This is pretty much what happened in one notorious case,that of Shasta Regional Medical Center in the small town ofRedding, California. There, two rogue cardiologists, Chae Hyun Moon and Fidel Realyvasquez Jr., headed a team that performed extraordinary volumes of unnecessary and recklessly dangerous heart operations. In the end, both would lose their licenses, and each would pay a $1.4 million fine in lieu of federal criminal prosecution. Yet for years before, their building reputations as top-notch cardiologists brought in patients from all over Northern California. In gratitude, the hospital pampered them with department chairmanships and perks. Dr. Moon even enjoyed occasional use of the hopital’s emergency helicopter to fly to golf tournaments.
    Our Lady of Lourdes Regional Medical Center in Lafayette, Louisiana, provides another example of how high-volume rogue surgeons can escape scrutiny for years, either because hospital administrators don’t know, or profit from pretending not to know, how dangerous they are. At Lourdes, there were rumors for years that one of its surgeons, a Dr. Mehmood Patel, was performing vast amounts of unnecessary heart operations. Yet it wasn’t until one of Patel’s fellow doctors at last secretly sued him in federal court under a special whistleblower law that the hospital revoked his admitting privileges. The hospital subsequently agreed to pay a fine of $3.8 million but still denies it had any way of knowing about the safety or effectiveness of Dr. Patel’s care.
    As the number of specialists in a community grows, many people cut out visits to their primary care physicians altogether. Instead, they skip from one specialist to another according to what body part gives them reason to complain that day, all the while gathering more and more bottles for the medicine cabinet.” Phillip Longman “Best Care Anywhere”

  15. run 75441-
    Yes, the Redding story eptiomizes what has been happening.
    I interviewed some of the victims of Redding when I wrote Money-Driven Medicne. Very sad stories.
    And I do blame the hospitals. While looking at overtreatment, Dartmouth researchers realized that Redding was doing an extraordinary number of bypasses and angioplasties. Dartmouth helped expose the problem.
    Dartmouth is on the ohter side of the country. Administrators at the California hospital should have realizled that something unusual was going on.

  16. Barry —
    This is the usual complicated stew of motives for performing tests and procedures that are not scientifically warrented. The main issue, in truth, is probably that the doctors believes that they are doing the right thing, based on their grasp of the science and their personal feelings about what they are doing, possibly influenced by personally not having kept up on the science and by the continued insistence of academic doctors with career stakes and of reps from supply, equipment, and drug companies that the evidence against the procedures are flawed, incomplete, or don’t apply to a brilliant person like themselves who gets far better results than the people at institutions where the research is done . It is very very hard for doctors to admit to themselves that something they have been doing for a while is now demonstrated to be of little value or even potentially harmful. The rest of the complicated motives behind this, ranging from the desire of their hospitals to keep expensive equipment paying for itself to personal prestige to the financial rewards to the feeling that if they don’t do something they might be sued all enter into the mix, but the first is the main thing.
    The interesting thing is that the article in the Times suggests that the tide has turned and that doctors are actually at greater risk of litigation from DOING the procedure than from NOT DOING it. This is relatively unusual in medical circles, although there have been some spectacular cases of litigation for performing a procedure that is useless or causes harm. The most spectacular was the case of retrolental fibroplasia causing blindness in infants who had been given too high of levels of oxygen in intensive care nurseries, usually because of prematurity. A small group of unfortunate pediatricians who had been somewhat behind the curve on the issue ended up being sued by the children when they reached adulthood, 18 to 21 years later. In many cases, the malpractice insurance that was in force for the incidents had been acquired two decades earlier and had cash limits that were way too low for the settlements and judgements that were being given, leaving the pediatricians, many of whom had already retired, to pay 7 figure awards out of their own pockets. That lesson influenced a lot of doctors from my generation, who saw all this happen early in our careers, but lessons that don’t quite fit with personal ego and ambition have a tendency to be forgotten after a while, especially by younger people who did not see the events first hand.

  17. Pat –
    Thanks for the very thorough and nuanced explanation. It makes a lot of sense as usual. I think it’s encouraging that doctors may be starting to perceive greater litigation risk from doing this procedure as opposed to not doing it. In the meantime, with modern data analytics, I think both public and private payers could more aggressively audit some of these cases to confirm medical necessity, especially when they notice unusually large numbers of procedures being performed by a given institution or a specific physician or group.

  18. I have been researching, investigating, speaking & writing on the ugly reality of physician misbehavior for more than a decade. I’ve seen it from the inside and out.

    What any cursory investigation reveals is truly jaw-dropping:

    1. NO other profession injures & kills more citizens unnecessarily;

    2. No segment of professionals escape more appropriate discipline upon being found guilty

    3. 2,500+ doctors are found responsible of Felony-level crimes each year – another 5,500 convicted of “lesser” bad behavior.

    4. Health Care almost never reports its own miscreants to authorities, as they are mandated by law to do.

    The Nat’l Practitioner Data Bank holds files on a whopping 1/4 million physicians – just since 1985. A shocking number of them fall into the categories of “Dangerous” or “Questionable.”

    And that 250,000 is considered an extremely low number, by those who understand the scope of the misbehavior.

    As a society, we are getting exactly what we tolerate – which as of this writing, includes skyrocketing health care costs, and almost exactly 500 innocent deaths . . . per day.

    We are being enormously group-stupid in not bringing the roof down on the bad boys of medicine.

    • Patrick–

      Thanks for the comment–I am afraid you are entirely right.

      Why don’t doctors police themselves and blow the whistle on bad doctors?

      I’ve read that the “hazing” experience of med school causes doctors to bond with
      each other: “anyone who has gone through this deserves to be a doctor.”
      That hazing–which includes being humiliated by people who are supposed to be
      training you– makes doctors extremely sensitive to criticism.

      These things may be true of many–though not necessarily most doctors.

      A more practical reason is that doctors are concerned about being sued if they try to
      blow the whistle on other doctors. (We need better laws protecting whistle-blowers).

      Finally–and I am afraid this is a major reason– a great many hospital CEO’s protect their
      “rainmakers” –and this includes doctors who bring in revenues by doing too many surgeries (even when
      they are very tired), too many unnecessary and expensive tests, etc. Often, if they’re moving too fast and
      doing too much, they make mistakes. If a colleague tries to bring this to the attention of the administration,
      he may find himself in trouble. The politics inside hospitals can be ugly.

      I wonder if you might want to write a guest post about this?
      Click on “Contact Maggie” on the blog’s home page.

  19. Hello, I got over to your post via Reddit. Not some thing I regularly read through, although I appreciate your views nonetheless. Many thanks for putting together something worthy of reading!