Just as Columbia/HCA drew the wrath of Congress, Tenet was slammed last week by a longtime critic of both for-profit companies, Rep. Pete Stark (D-Calif.). After noting the Redding probe and the outlier audit are separate issues thus far, Stark said in a statement, "I fear that Tenet's relentless corporate strategy to increase profits by providing and billing for more expensive medical services has improperly influenced the practice of medicine and resulted in unnecessary and harmful surgeries." Stormy weather :: Echoes of Columbia/HCA heard as Tenet overhauls management amid scrutiny of outlier payments and investor protests Modern Healthcare November 11 2002
"It's not the bad guys, the ones who are readily identifiable, where you find out and go, 'Ugh. Terrible,'" Eichenwald (investigative reporter at The New York Times) says. "The problem is the good guys, the guys who start cheating at the edges or those who start cheating and end up institutionalizing large-scale cheating.
-------------------------
That's the irony about health care fraud: criminals are only half the problem. The other half, experts say, is a medical community that has to exaggerate illness - to cheat - in order to get things done.
-------------------------
"Some doctors say, 'I hate to do it. It's not my ethics, but it's what I need to do to help my patient,'" said Mahon (National Health Care Fraud Association). Health-care industry rife with fraud ::Government swamped by $1.5 trillion in paperwork MSNBCNews Nov 12, 2002
This web page sets out to document Tenet's
arrangements with doctors and describe the link between Tenet's
policies and the services they provide. I have not previously tried
to explore the nature of the forces placed on doctors in the
corporate marketplace and their responses in any depth.
I have used the same theoretical framework I used to analyse
dysfunctional health care founders and corporate culture. I try to
explain the why and how of doctors who enter into "partnerships" with
a company like Tenet and behave like the reports indicate they
have.
To do this I have
I have also on this page examined the recent
allegations that Tenet hospitals paid kickbacks to doctors. The
particular circumstances provide fundamental insights into basic
contradictions between health care and the market system.
The press reports describing what happened in Redding illustrate what
I am saying so well that I have included large numbers of them.
Unnecessary Procedures in Tenet Hospitals
National Medical Enterprise (NME) :: The 1990 scandal
Unnecessary Cardiac Procedures
The most disturbing of all the allegations
about Tenet Healthcare is that two doctors at its Redding Hospital in
California carried our large numbers of unnecessary cardiac
procedures including coronary bypass surgery on patients who did not
have coronary disease or who did not need this treatment. These
procedures all carry significant complication and death rates. One of
Tenet's own hospitals in Florida almost lost its right to treat
Medicare patients because of failures in infection control. One
hundred and six malpractice suits were initiated because of
infections following open heart surgery. Twenty of the patients
allegedly died as a result. We do not know yet whether these
operations were medically indicated.
My view is that the allegations about Redding
hospital are very probably valid and that this problem in Tenet
hospitals is unlikely to be restricted to Redding hospital or to
cardiology. This is a reflection of the same business practices and
mirrors the same problems which occurred in National Medical
Enterprises' (NME-Tenet's previous name) psychiatric hospitals during
the 1980's and early 1990's. It is due to the same problems which I
identified in an international general hospital providing care to
travellers in 1989. Corporate policies create a context which favours
this happening.
My 1996
review addressed many of the issues
in the 1990's scandal and I will only summarise them briefly here and
provide links. I suggest opening this page in a second window. I will
include paragraph numbers
in green next to the links to this page
so that the sections can be accessed without continuously loading and
reloading. Additional information about this and quotes from a key
Wall Street Journal article are on a recent page dealing with
NME's
founders and its culture.
It is important to understand that the vast majority of things
which occurred in Tenet's hospitals in the 1980' and 1990's could not
have happened without the active participation of doctors and the
acquiescence of others - their failure to unite and attack what was
happening.
Tenets policy of treating older, sicker patients and targeting more
complex procedures was only possible with the support of the doctors
involved and the alleged over-servicing in Redding occurred by
doctors who identified with Tenet's market mission.
to
contents
This is not a problem restricted to
Tenet/NME, nor to corporate medicine. It is part of a broader problem
which can result in poor or aberrant care, but if confirmed then this
is by far the worst I have seen. It tends to occur when doctors are
isolated from criticism and the views of their peers, either
physically or mentally - even when isolated by status and high
office. Unless peers are vigilant doctors can put a barrier around
themselves and so distance themselves from the critical views of
these peers.
This tends to occur with doctors working in isolated communities, in
specialists who have few or no peers in the same specialty in their
hospital, and in doctors who use a reputation among patients and
general practitioners (primary care doctors) to buffer the views of
specialist colleagues. It can also be due to an intractable
sociopathic personality problem. There are many variations on the
theme.
While these doctors may experience inner doubts they do not
acknowledge them and often the situation they are in makes it
extremely difficult for them to do so. I have had intermittent
personal experience of doctors who behave like this and have tried to
deal with them for 30 years. The conduct is not deliberately malign.
They sometimes relate well and confidently. At other times they
create an aggressively defensive barrier which makes them prickly and
prone to anger when challenged. These doctors simply do not recognise
or accept that there is a problem. Because of their assertiveness and
drive they can achieve senior positions or good reputations.
A good example in my view is the scandal at a
National Health Service centre of excellence for cardiac surgery in
Bristol, UK. It was relatively isolated from similar centres in the
rest of the UK. The doctors were the cardiac surgery experts in the
hospital and were highly regarded. An excessive number of children
died following open heart surgery and a number of explanations were
offered for this by the surgeons. This was accepted by peers who were
not cardiac surgeons and by the hospitals administration. The doctors
accepted it themselves.
The problem was picked up by an anaesthetist, new to the hospital who
had a wider experience. He identified the problem and blew the
whistle. He was young and lacked credibility. He was subjected to the
usual treatment meted out to whistle blowers and eventually emigrated
to Australia.
An extensive investigation followed. This confirmed what had
happened. It also revealed that the doctors had been genuine people
and had about as little idea of what was really happening as Tenet's
CEO Jeffery Barbakow had about the problems in Tenet's policies and
Redding Hospital. They had rationalised and defended themselves
against this threat to their lives. I suspect we are looking at the
same sort of problem in Redding.
Doctors face constant conflicts and
uncertainties and there are many opportunities to adopt a one eyed or
closed minded approach in contrast to a reflective or open minded
one. This is particularly the case when treatment has gone wrong.
The problem is well recognised but perhaps by using different ideas
to understand it. The specialist Royal Colleges in Australia have all
had tightly integrated and cooperative structures controlling the
profession. Every effort is made to bring all specialists into the
group and have them relating cooperatively with peers. Peers monitor
each other's conduct through a variety of clinical meetings and other
processes. This is not to suggest that the process works perfectly or
that there are no failures or problems.
It is worth noting that 15 to 20 years ago
the specialist colleges and the profession were aggressively attacked
for training too many doctors. Convincing evidence was produced that
more doctors simply generated more visits and more tests, pushing up
costs. In response the numbers trained were reduced.
In spite of this costs continued to rise and specialist shortages
appeared. A new market ideology sees the situation very differently
and now the professional colleges are accused of being
anti-competitive. They are claimed to be limiting training
opportunities in order to create a monopoly enabling them to charge
more and so boost their incomes! The ACCC has imposed oversight
processes to stop them!
When professional cooperation is viewed by market theorists it is
seen to be anti-competitive (in a commercial sense) and in a
marketplace context it probably is. In Australia the profession has
been subjected to enforced competition policy. This together with the
ACCC's actions against the profession for anti-competitive behaviour
disrupt the cooperative process on which this peer monitoring
depends.
They seem unable to comprehend that health care is primarily a
cooperative endeavour by trained members of society working closely
with other members of that society and within structures specifically
developed in that society for the benefit of members of that society.
It cannot be successfully packaged and traded for the benefits of
outsiders. Illness is not something we compete for.
This is why competition policy, the ACCC, and
its new chairman Graeme
Samuel, who has so
aggressively attacked professionalism, are so dangerous for our
health system. It is why I expect we will see an increase in these
problems in the future. The medical profession will be blamed for
this. This will be in spite of all the regulation, accreditation and
oversight procedures being set in place. The US experience tells us
that these processes do not work.
The wider message is that inter-subjective relationships, bonds of
trust, and interaction between cooperating individuals cannot be
replaced by objective processes, although they are also important.
Oversight and regulatory processes should "rest lightly" and seldom
be necessary. We should not replace a civil society with a legalistic
one. The US Health system shows that we cannot control the
consequences of ideological blindness, and bad social policy with
more laws and regulations, nor is it logical to do so. In her Boyer
lectures entitled "A Civil Society" Eva Cox indicated that laws and
regulations in a civil society should rest lightly and be seldom
needed.
These matters explain why I have been a long
term advocate of integrating services rather than isolated
practitioners; of working under the umbrella of "clinics" rather than
in isolation; and very importantly a system of linked medical records
employing the full potential of technology and ongoing evaluation to
bring people together in examining outcomes.
Unfortunately in the corporate marketplace these processes open the
system further to abuse and misuse. In 1990 NME used
this sort of computer based system
(5.6)
for its admission practices to ensure that almost everyone, coming
for "evaluation", who was insured was admitted to hospital.
What I have said so far seems to support
Tenet's claim that the problems lie with the doctors rather than with
the corporation. This is very far from the truth. What Tenet and
NME's policies have done has been to create a context which fosters
and supports the development of these problems, and obstructs the
professional processes which normally control them.
The framework of interpretation I have used
to understand corporate medicine is an attempt to develop a
non-judgemental process which can be applied. This does not mean that
there are no real criminals or that people should not be blamed or
punished when they take advantage of a vulnerable system. It is
simply that this does not help us to understand what is happening or
help in dealing with systemic problems. When the problems are
widespread then it is the system that needs review. It is also the
system that fosters criminals.
I am trying to bridge the gap between broad social ideas of how
communities behave and ideas about how individuals behave - how they
interact and influence each other to create dysfunctional cultures
and ideologies.
Individuals essentially have no choice but to build their lives in
whatever situation they find themselves. They can do this as active
participants, passive participants, opt outers, or as rebels. Most of
us choose the first two. Groups develop and maintain the ideas they
use to understand their situations and what they are required to do
there. They interact to develop cultures and ideologies. The way they
behave depends on the way they respond to conflicts in the situations
in which they find themselves - and there are always conflicts of
some sort.
This framework I use emerged while living and working with different
cultural groups under apartheid and when dealing with doctors who
were not practising the sort of medicine they should have been. In
both situations I was privy to their differing understandings and
explanations. One could only understand these differences by looking
at the context of these different lives and the conflicts there.
This is not to exonerate or excuse. Humans behave humanly in whatever
context they find themselves. Market culture is not an exception and
I have applied these ideas to market leaders and market cultures. I
am going to apply them to tenet's doctors.
I have written a page about this
theoretical approach
and used it to analyse corporate conduct. I based the paper I
gave in 1996 about Tenet/NME on
these ideas (1)
and on a US paper by Annas which used the
similar idea
of "metaphors" (1.1)
to explore issues in the USA. I have examined Sun
Healthcare in this way
and
most recently HealthSouth which
illustrates the psychology of the sort of leaders who emerge well.
Tenet is a better illustration of the ongoing cultural
behaviour which I discussed
there. I will not repeat the theoretical arguments and ideas
here.
Doctors are not immune to the sort of forces
to which senior executives respond in the marketplace. They develop
groups and subcultures with explanatory systems to support the things
which they do - often in response to a wider culture. If they are
required to do unsavoury things by the wider culture then it is
likely that a proportion of them will do so and find ways to make
this legitimate. This is well illustrated by the human
experimentation on Jews in the Nazi concentration camps and by the
way sections of the medical profession cooperated with and supported
apartheid medicine in South Africa. In fairness the medical
association officially opposed apartheid and doctors in some
hospitals were among the first to openly rebel and abolish apartheid
for patients.
There is at this time a great deal of public unhappiness about the
medical profession, more so in the USA, and particularly its lack of
openness and accountability in handling failures in care. There is
certainly substance to this. I hypothesise that much of this is the
hangover of a deeply entrenched paternalism in medical thinking and a
culture which supports this - much as apartheid was a hangover from
colonialism. I simply do not have the information needed to explore
this idea further. It is not something I have been directly involved
in.
to
contents
Specialists working in corporate hospitals
and in Tenet hospitals in particular have to develop their practices,
and build their reputations there. This is a marketplace profit
centred environment and this soon becomes the "self evident" way
medicine is practised. More importantly Tenet/NME and the hospital
does exert a very considerable influence on the career of the doctor.
Each hospital is likely to have fostered a hard core of senior
medical staff who relate to management and identify with the
corporate ideology. They act as role models and also have power in
the hospital. I will use my own observations, the 1990's scandal, and
the 2002 scandal to explore the problem of corporate doctors.
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contents
I am limited in the comments I can make of my
experience of an international National Medical Enterprises hospital.
I withdrew some of the allegations I had made and gave undertakings
as part of a settlement. I stress that the comments made here relate
entirely to the way the hospital operated and I make no allegations
about care by the hospital or by its specialists in December 1988. I
refused to give undertakings in regard to anything else. It is a
matter of public record that two other doctors who provided services
in the hospital were suspended from practice by the Medical Council
in 1991 following a complaint.
I acted strongly because I believed I had identified the sort of
dysfunctional situation which I have alluded to in the first section
above, and that this was because medicine was being practiced
primarily for profit.
I was concerned that a potentially dangerous situation existed. In my
letter when I drew my concerns to the attention of the head of the
country's health department in June 1989, and also in a subsequent
complaint itself I stressed that the doctors in the hospital were
kind, considerate, confident experts in their fields and related
well. They were unaware of any problems in the hospital and
identified fully with the way the hospital operated.
It is also worth noting that the equipment in this hospital was
superb - the very best. The whole place was very impressive. They
lacked for nothing that money could buy.
Most of them (doctors) related well. They were kind and empathic. Some offered real friendship.
--------------------------------
One is forced to the conclusion that there is something wrong with the environment - - - - . Somehow a pathological medical social group has arisen which is able to isolate itself from its colleagues. It is able to build a set of ideas and presuppositions, a perceptual set unchallenged by outside norms.
-----------------------------
There is evidence to suggest that the structure of medicine in this hospital is such as to isolate the group from other groups and to limit critical interaction among peers. This has enabled them to create the illusion - - - - - - and they seem to believe this themselves. Complaint to Medical Council March 1990
One of the observations I made was that each
specialist operated as an expert in his own narrow field and did not
encroach on or dispute the expertise of that of others treating the
same patient. It was almost as if this was an invasion of the others
personal space.
I knew the hospital was run by an American group, but knew nothing of
it, and had no real knowledge of corporate medicine. I thought that
it was an aberrant group out of touch with the main company. The
Australian Medical Association later became involved and wrote to
NME's chairman and CEO, Richard Eamer. They did not receive a reply
until NME entered Australia late in 1991 and were put under pressure.
I only learned of NME's US scandal in October 1992, much of it
similar to "rumours" I had heard.
The local government in this country put up a
brick wall and it required intervention by the Australian Medical
Association, the international airlines and the Australian Federal
government before the issues I raised were addressed. During this
period I spoke to many people who had had dealings with the country
and the hospital. The information I received was all hearsay and
unconfirmed but in June 1991 I wrote to the Medical Council and
indicated that with so
much smoke there was likely to be a
large fire.
Among the hearsay stories which I dared not repeat at the time was
that insured patients were needlessly flown in by air ambulance from
neighbouring countries whose doctors were paid for referrals. These
patients were admitted for prolonged periods and extensively
investigated. One of the concerns was that these were sometimes
invasive cardiac procedures which were not risk free. I understood
that these matters were to be raised at a meeting of insurers in the
UK but do not know if this happened.
I stress that there is no actual evidence that this happened in this
country but in the light of what is now happening in California it is
relevant. I also heard that in-transit patients were needlessly
admitted from the local airport, sometimes pulled from their planes,
and kept in hospital as large bills were generated.
I subsequently traced and spoke to some of these patients and from
what they told me I believe this was so. Other stories were similar
in nature to the allegations made by Dr Pearce. He wrote about the
widely held perceptions in the medical community that Redding doctors
were "wild"
and "cowboys" - pointers to real
problems. Similar broad remarks about care in 1990 suggested that my
concerns about systemic problems in this international hospital were
well founded.
Note that this hospital was sold to a local company in 1995 and I am
not aware of any unacceptable practices by that company.
Subsequently in 1993 allegations were made by a doctor at this hospital that during the 1980's the company's senior staff had pressured him into a contract trading monetary benefit for patient admissions. The hospital denied the allegations but declined the opportunity to give evidence and say what actually happened. The contract which the doctor claimed he was pressured to sign would have put pressure on him to operate on many more patients, including those who may not have needed surgery.
In 1992 the company was also found to have
paid bounty for and then flown
psychiatric patients from Canada to the USA
(5.8)
where their profit potential was exploited. NME was convicted of
paying doctors and bounty hunters for patients in the USA. We need to
consider whether some of the same things may have happened in
2002?
I feel that in this analysis I am now entitled to draw attention to
these "rumours" to show that there may well be a continuity of
business practices not only through its psychiatric hospitals but
through its general hospitals in the 1980's. When the scandal in the
USA broke these people were brought back from the international
division into senior positions on the basis that they
were not
tainted by these practices. The
problems and the culture which gives rise to them appear to be deeply
ingrained and go back a long way. In 2000 a Tenet university hospital
in the USA was again trying to reward
doctors for doing more procedures and
this was legal.
There were articles in the early 1990's
describing problems in NME's general hospitals in the USA but these
were never followed up by investigators. They feed concerns that the
stories surrounding this international general hospital and my
assessment had substance and I am justified in drawing attention to
them. The problems were not isolated to an "infected appendage" - its
psychiatric hospital - as the companies COO Michael Focht claimed in
Australia in October 1994.
In the dispute described above the doctor, a surgeon was being
pressured to enter into a contract to guarantee a specific number of
admisions in return for reduced or even free rental. This was a
surgeon and if he undertook to admit more than the patients he had
referred then he would be under considerable pressure to perform
uneccessary operations.
As is well illustrated in the extract below this seemed to be
standard company practice at the time.
Investigating Other Areas
-------------------------------
Twice in two years the company's general hospital division has been slapped with cease-and-desist orders from the FTC, which charged some National Medical hospitals with making "false and misleading" claims in advertisements for patients.
---------------------------------
Four former executives of the general hospital division say in interviews that national Medical has routinely offered inducements to doctors for patient referrals, and compensated for them by charging insurers at a higher rate than their not for profit competition for a broad range of treatments and services. The executives also say the company has forgiven big loans to doctors in exchange for patient referrals. - - - - government officials concede the law is weakly enforced and such practices are fairly widespread.
------------------------------------
In the 1980s, so many of the rents in the dozens of medical buildings National Medical operated next to its hospitals were well under market value or altogether free that the buildings operated at a loss, says Mr Amaral, the former chief financial officer - - -. Abiding Suspicion: Allegations Of Fraud, Malpractice Still Haunt Operator of Hospitals The Wall Street Journal January 8, 1993
For instance, Pete Alexis, who oversaw Tenet's operations in Texas, admitted to conspiring to pay between $20 to $40 million in bribes to psychiatrists, psychologists and others in exchange for patient referrals.
-----------------------------------
In 1997, Tenet agreed to pay about $100 million to approximately 700 former patients who contended that the company and some affiliated doctors wrongfully imprisoned them in psychiatric hospitals in order to obtain their insurance benefits. Risky Business: The Tenet Story* SEIU (Nurses Union) Research document Jan 1999
My 1996
analysis of the US market
place, NME's business practices, the resulting scandal in psychiatry
and substance abuse, and the way doctors were manipulated is on this
web site. I will summarise matters affecting doctors here and provide
links.
None of the misuse and exploitation of patients and little of the
Medicare fraud could have been accomplished without the active
participation of doctors in the hospitals. The company took control
of the admission of patients by its marketing, its health assessment
clinics, its help phone lines, its purchase of patients from doctors
and other agencies, and the employment of bounty hunters.
The company set up a "programmatic" system of care designed to
maximise length of stay and the amount of treatment given. The
hospitals controlled doctors' incomes by allocating the patients to
doctors who supported its programmatic system and handed the patients
over to untrained staff who provided the care. Those who complied
were richly rewarded and given positions of power in the hospital.
Those who did not starved. In effect the company bought the use of
the doctors degrees.
Doctors favoured by the hospitals received
numerous perks - secretarial services, house loans, research grants.
They were promoted as experts in particular fields and were sent on
lecture tours. Many identified with their new expertise, even though
much of this was illusionary. At the same time audit, clinical
accreditation, critical clinical presentations, and collegial
meetings were probably downgraded or subverted helping to isolate and
secure (rather than challenge) each specialist in their claimed
expertise. These review processes did not generate profits and would
have provided a venue for "disruptive" physicians. Critical
discussion and criticism creates uncertainty and self doubt. It
destroys the self confidence of the isolated specialist - the sort of
self confidence which is so successful in the marketplace.
Like management and company executives many
doctors must have adopted corporate thinking or at the very least
went along with it - in spite of their training and responsibilities
to patients. A medical subculture would have developed within the
larger corporate culture in order to accommodate the conflicts. One
way was to trivialise and joke
about (5.14)
what was happening by using terms like "howdy rounds", "wave
therapy", and "charting parties". Whistle
blowers (5.16)
would have been a particular threat to
all this and the response of Tenet and the profession to medical
whistleblowers has been strong.
When local doctors would not cooperate the company sometimes brought
in doctors
from outside (5.15)
and put them into controlling positions.
Some were poorly qualified. An example was Dr Bowlan. He was the
doctor who provided a medical certificate in 1991 in order to kidnap
a teenager he had never seen. A policeman believed the boys family
rather than the hospital and this led to exposure of the
scandal.
Dr. Timothy Mark Bowlan, a psychiatrist at a Tenet hospital in San Antonio, pleaded guilty to making false claims, theft of public money and forgery. Bowlan admitted forging documents to obtain a Texas medical license. He was sentenced to five months in prison and three years of supervised release. Risky Business: The Tenet Story* SEIU (Nurses Union) Research document Jan 1999 citing the Houston Chronicle March 24th, 1997
Note that the cardiologist in the Redding
case was not a properly qualified and registered specialist. This
extract from my 1996 critique is almost prophetic and I reproduce it
here. Redding Hospital's administrators backed the doctors when they
were told what was happening.
NME strategies for attracting doctors with large practices were highly regarded. It spent large sums of money to purchase the latest equipment which would attract doctors.
--------------------------------
NME promoted a policy of product differentiation to attract referrals. Hospitals advertised highly specialised units in their hospitals to draw patients and increase profits. Doctors were promoted as experts and lecture tours were arranged for them. The possible consequences of turning doctors who have been in busy practices for several years into overnight superspecialists using the most sophisticated equipment in order to meet corporate business objectives must be considered. Would administrators tolerate interference by colleagues or quality assurance committees when these doctors who bring in the well insured patients are found to be deficient and out of date in the specialised area into which they have been pushed. From 1996 paper (click here) . (3 )
With the introduction of corporate medicine
the power of clinicians in the hospitals was
eroded
(2.1)
and some of their clinical functions in the hospitals were
appropriated.
Stock analyst's reports about NME describe corporate policies and
often quote from corporate statements. Not only do they tell us NME's
policies but also provide an insight into corporate thinking and how
to get doctors
to comply with the corporate mission.
(3)
Internal documents show how NME sold its money
first approach to staff (4.1)
and the way its financial success and marketing created an
illusion of
quality.
(4.2) Monthly reports to the CEO reveal
the importance management attached to involving
physicians (4.2)
in the corporate agenda. NME's
culture
(5.4) was nurtured by its success.
No one seemed to question its startling admission
practices (5.6)
where administrators and untrained staff replaced doctors, and where
children
were targeted
(5.7)
because they were more profitable.
Patients were kept for the full duration
of their insurance
(5.9), exploited
for profit (5.10),
and Medicare
defrauded
(5.11). NME exerted tight control over
all staff and a clinical focus was grounds for
dismissal. (5.12)
Evidence given in public inquiries
graphically describes the way NME came to control doctors and
secured their
compliance. (5.14)
Diagnosis and care were tailored to
profit requirements with unfortunate consequences
for patients. (5.15)
In 1997 after my paper was published Tenet settled a case brought on
behalf of over 600 patients, mostly children for US $100 million.
Although bound to secrecy by the settlement agreement some young
adults were able to graphically describe how they were mistreated as
children before the agreement became operative.
Elsewhere on these recent pages I have looked
at the lack of change in the company's board and senior staff and
the
persistence of NME's culture beneath
a façade of caring and social responsibility. These people did
not believe that they had done anything seriously wrong and made no
attempt to examine the validity of their marketplace belief system.
NME's statements
when it changed its name
(5.18)
to Tenet Healthcare are particularly interesting.
Tenet's new policy of partnerships can be seen to be presenting its
old policy of bringing everyone else on side and getting them to see
things its way, but coated in icing. The commitments to integrity
were as John Bedrosian had acknowledged in evidence given in 1992/3
simply "singing to the choir. Doctors were very much targets in its
"partnership" policy. Note the absence of any mention of patients or
citizens when referring to benefits below.
Successful partnerships require that the parties share certain beliefs; that they hold philosophies, expectations and standards in common. And That's exactly what the word "tenet" conveys. Our new name says that we have strong values and beliefs and that we will seek out others with similar views for the benefit of both. Company Release 1994/5
In hindsight there can be little doubt as to
whose beliefs, philosophies, and standards partners were expected to
adopt if they were to be successful.
Focht who was president of the international division at the time of
the un-confronted
allegations of trading in patient
admissions and involved in the misinformation
given to Australian authorities. He
was made COO of Tenet and placed in charge
of its integrity program on the basis
that he was far removed from the scandal. He was brought back from
retirement by Barbakow to help sort out the 2002 scandal.
Ford, his vice president who allegedly participated in dealings with
the doctor was promoted to a senior position before returning to the
international arena as an international health consultant and
director (with other past NME staff) with Vista
Healthcare in Singapore. Soon after
Tenet made noises about re-entering the international market and it
is likely Ford was acting for them.
Brown, allegedly a very active participant in promoting this contract
involving patient admissions was promoted to a position where he had
responsibility for liaising with doctors
to
contents
1994/5
"Unless restrained and enjoined, Defendant will continue to engage in acts, practices and courses of business as set forth in this complaint or in acts, practices and courses of similar object and purpose." Securities and Exchange Commission (SEC) vs NME. "Complaint for permanent injunction"1994/5
In 1994 the Securities and Exchange
Commission (SEC) was well aware of the cultural continuity and the
likelihood that Tenet would offend again. In spite of this it did not
seek to change management, nor address the resilience of the culture.
Injunctions, integrity agreements, ethics committees and public
expressions of
moral intent (5.19)
do not change the way people
think. (5.20)
This is illustrated by an angry outburst by one of Tenet's lawyers
because Tenet was being
treated as a criminal organisation.
This sort of change can only be accomplished by changing the context,
and then dismembering the company by distributing its staff among
those who find its practices abhorrent.
Tenet's naïve new policy of pushing up prices, targeting complex
and risky procedures, and cutting costs announced in 1999/2000 does
not differ much from its earlier policies. It set out to equip its
hospitals with the very best equipment to attract doctors and their
patients - much as its policy of product differentiation had done
earlier.
We do not know what its partnerships with doctors involved but in the
marketplace these are going to be commercial partnerships. Tenet's
new wealth was obtained from outlier payments generated from complex
cases and complex procedures. It was eager for doctors to perform
more of these procedures and it obviously supported those who did so.
Doctors who were eager to advance their careers and their standing in
the hospitals would have been under pressure to do so. Administrators
would have gone out of their way to encourage them and support
them.
There are also indications that Tenet is targeting doctors incomes to
encourage admissions. A hospital has been raided and a charge of
paying
kickbacks has been made. Other
hospitals are being investigated.
There are some indications that the unneeded heart procedures scandal
was simply the continuation of a long process of encouraging doctors
who made money for the company and discouraging those who did not -
with little regard for the consequences.
It must be asked whether unnecessary procedures have also been encouraged in the other areas of complex care, neurosurgery, orthopaedic care, and more specifically lucrative spinal surgery. The SEIU union's 1999 research document "Risky Business The Tenet Story" describes some concern about a new spinal surgical procedure promoted by a doctor who had developed a large following in one of Tenet's hospitals by performing it. I do not have details but it sounds like a precursor to the 2002 scandal.
But the legitimacy of this physician's new spinal procedure was challenged in a series of malpractice and fraud lawsuits filed in Los Angeles accusing Dr. AAA and another doctor, Dr. BBB, of conspiring to perform unnecessary spinal surgery that had no medical or scientific basis. Risky Business: The Tenet Story* SEIU (Nurses Union) Research document Jan 1999
It seems that NME's successful
monitory
rewards and penalties approach
(5.14)
to doctors was very much alive. It
resurfaced in 2000. Particularly revealing is a report in 2000 from
the university teaching hospital in St Louis in Illinois. This was
soon after Tenet embarked on its new aggressive money making
policies.
Physicians pay was to be increased or decreased on the basis of their
performance in seeing more patients and performing more procedures.
For some strange reason this is not considered as paying kickbacks
which are accepted as a threat to care. The term kickbacks is
narrowly restricted to paying doctors for referrals. As the Redding
scandal shows paying a doctor to do more procedures is much more
dangerous.
That this new strategy came directly from Tenet's board is clear. The
policy was introduced by the university's president, Lawrence Biondi,
who was also a member of Tenet's board and who sold the university's
hospital to Tenet.
I do not know how this eventually worked out but the consequence of
this approach can be seen in the 2002 cardiac scandal. The extracts
describe what was planned and speak for themselves. One wonders about
the quality and skills of doctors who applied to replace those who
left or resigned from senior positions in protest. Would these be
less qualified or out of state doctors like those at Redding or those
in Texas in 1991, appointed because of their willingness to meet
corporate goals rather than their skills and responsibility to
patients.
Being a physician in America usually means you're well paid, drive a nice car, enjoy the respect of others and sometimes have power over life and death. At St. Louis University Hospital, it also means you could get a yearly 20 percent pay cut, every year, for as long as you don't meet your quota.
Of course, they don't call it a quota; rather, they refer to it as meeting the requirements of your "performance supplement." It works like this: A medical-faculty member's minimum "base" salary next fiscal year will be 80 percent of what his or her salary was last year. To recover that missing 20 percent, the faculty member must meet certain goals. Those goals usually involve seeing more patients, performing more procedures or both, thereby producing more revenue. The chairman of each department sets the goals; the medical-school dean approves them. If those goals are not met at the end of fiscal year 2001, the faculty member takes a 20 percent income hit. The same is repeated the next year.
-----------------------------------
- - - (doctors says)- - "That destroys the principle of tenure. The idea behind tenure is to give professors freedom of expression, academic freedom, without fear of retaliation. That's lost now.
-----------------------------------
It's no wonder there is reluctance to speak up. The chairman of internal medicine no longer heads that department, the health-science center's largest, because of his opposition to the pay plan. The director of the physicians' University Medical Group stepped down as a result of the flap. Several other chairmen are leaving, and, for a variety of reasons, some top doctors -- including two renowned cancer specialists -- have left. That the new compensation plan includes incentive bonuses for faculty physicians who really crank out the patients and procedures seems to be overshadowed by the threat of a pay cut.
------------------------------
Thanks to St. Louis University president Lawrence Biondi, S.J., the university took in $309 million from Tenet by selling the hospital. The move was criticized by Archbishop Justin Rigali, who opposed the idea of selling the not-for-profit hospital to a for-profit chain. But Biondi and others were convinced that the hospital would eventually become a money pit.
------------------------------
Though the stock price and profits are up, a Tenet spokesman in April estimated that the company lost $100 million nationwide on physician practices. Perhaps Biondi, who serves on the Tenet board of directors, has picked up a few lessons on how to put a cap on physician costs.
-------------------------------------
Biondi, who is nicknamed "Father Capone" for his Italian and Chicago roots and for his, well, assertiveness, appears to think the medical faculty needs to pull its own weight.
--------------------------------------
It appears the archbishop was right to oppose the hospital sale, but it appears it's not the indigent getting screwed -- yet. Who'da thunk it that the first collateral damage from the sale would be SLU physicians? Prescription for Resignation : Upset over a new pay policy, docs are checking out of St. Louis University Hospital Riverfront Times October 11, 2000
A single press report suggests that Tenet may have been leaning on doctors to increase their bottom line by keeping patients in hospital longer than necessary. I do not know what evidence was given and how reliable this is.
Among hospital chains operating within California, Tenet Healthcare -- the nation's second-largest for-profit health system -- has the highest average charge for injuries and illnesses that most often bring elderly patients to hospitals, a recent Bee analysis of hospital financial data found.
The committee is expected to hear from doctors who say they were told to keep patients hospitalized longer than necessary. The committee also will explore whether the for-profit hospital chains tweaked rules to pad patients' bills. Legislators to eye billings by hospitals The Sacramento Bee December 5, 2002
On the 30th of October the FBI
raided Tenet's Redding Hospital in California and the offices of a
cardiologist and cardiac surgeon. It was alleged that the two doctors
had carried out large numbers of cardiac procedures that were neither
indicated, nor necessary, some on patients with normal hearts. In
view of Tenet's past history and current business practices it is
likely that the allegations will prove to have substance. For the
purpose of this analysis I will assume that they do.
This raid occurred the same day as an analyst picked up the outlier
problem and Tenet was notified of a Medicare audit. Tenet delayed 24
hours before disclosing the raid and a week before disclosing the
audit. Its shares dropped precipitously.
With so many thousands of patients each of which will inevitably
raise conflicting arguments and opinions prosecuting this problem in
the courts will be a nightmare. It will require many thousands of
hours and disputed analysis on each patient. This is why cases
involving multiple clinical cases are so seldom prosecuted. It will
be interesting to see how this is dealt with.
The investigation apparently began months ago and was led by Redding FBI agent Michael Skeen. FBI Special Agent in Charge Michael Mason said that both doctors were suspected of "health care fraud, making false statements about health care and conspiracy to commit fraud," the Record Searchlight article said.
-----------------------
In the 70-page affidavit for a search warrant, federal agents detailed their investigation and interviews with other cardiologists, who said they had suspicions as far back as 1995 about the unusual volume of heart procedures the doctors logged at the hospital.
Skeen's affidavit said one cardiologist told him a Eureka man had an angiogram that revealed no coronary artery disease, yet Moon had referred him for a bypass. The cardiologist said the bypass had been unnecessary.
----------------------------
The doctors said they ran across dozens of patients who had been diagnosed by Moon and operated on by Realyvasquez, but they couldn't find evidence of damaged hearts.
------------------------------
Skeen said in his affidavit that a cardiologist told him procedures by the two doctors escalated in the early 1990s -- around the same time Redding Medical Center "began to aggressively posture to become known as a top-ranked heart center." He noted that in one two-year period, the hospital spent $2 million on advertising. Two Redding heart surgeons suspected of fraud, unnecessary surgeries The Times-Standard November 02, 2002
In an affidavit made public Thursday, FBI Agent Michael Skeen said the two doctors, who practice at Redding Medical Center, performed an unusually heavy volume of heart catheterizations and other coronary procedures, of which as many as half -- based on the opinions of other doctors -- may have been unnecessary.
-----------------------------------
The FBI affidavit stated that the two doctors derived enormous income compared with other physicians, noting that Realyvasquez ranked as the top Medicare biller in a list of 50 physicians of a similar specialty in the Northern California region.
Moon was ranked No. 2 among doctors of a similar specialty.
----------------------------
In one instance cited in the affidavit, a woman evaluated by a cardiologist in August was found to be in "relatively good health and not suffering from any coronary artery disease."
She went to Moon for a second opinion, and she received a heart catheterization that same day, according to the affidavit. Moon further told the mother that she needed immediate bypass surgery, which she subsequently received at Redding Medical Center, the affidavit stated.
----------------------------
Tenet, which operates 113 acute-care hospitals nationwide, including 40 in California, has openly pursued a strategy of treating sicker patients and increasing the volume of high-acuity specialties, such as cancer and cardiology. Tenet's Stock Hammered on News of Probe ::Two doctors are under investigation over possible billing irregularities and unneeded procedures. LA Times November 1, 2002
Skeen (FBI affidavit) estimated that one-quarter to one-half of the patients underwent unnecessary cardiac procedures and 167 died. Sudden impact :: Tenet reeling after federal raid at Calif. hospital Modern Healthcare November 4, 2002
Trading of Tenet Healthcare Corp. stock was halted today after it plunged 22% to $32 per share from $38.97 per share on news of a federal raid at Tenet's 188-bed Redding (Calif.) Medical Center. Search warrants were executed on the hospital and the offices of its director of cardiology and director of cardiac surgery. The raid was carried out by some 40 agents and inspectors from the FBI, HHS, the IRS and the U.S. attorney's office in Sacramento. According to affidavits filed in U.S. District Court in Sacramento, investigators were seeking evidence of false billings and unnecessary angioplasties, coronary bypasses and heart catheterizations. Tenet Calif. hospital subject of government raid Modern Healthcare October 31, 2002
It is unclear what degree of civil or criminal liability the 113-hospital chain, based in Santa Barbara, Calif., faces.
----------------------------
Government agents carted away hundreds of boxes of evidence from quality assurance, medical records, cardiology, catheterization laboratories and the hospital's storage center.
Moon and Realyvasquez have not been charged in the case.
--------------------------------
Teplitzsky, who has no connection to the case, said government prosecutors take a dim view of healthcare organizations whose compliance programs don't work. Sudden impact :: Tenet reeling after federal raid at Calif. hospital Modern Healthcare November 4, 2002
I would like to paint a hypothetical
situation which my reading of the available material supports. It is
an attempt to reconstruct the situation and I may not get everything
right.
This was Tenet's most successful and most profitable hospital. The
company, the hospital's administrators and even the doctors would
have been intensely proud of their performance and the success which
accompanied it. They were all supremely confident and flushed with
success.
I very much doubt that anyone would have considered the possibility
that this success was built on deceiving patients. The doctors may
have known it but I believe that they are unlikely to have actually
confronted this themselves. It would have been compartmentalised and
ignored. The behaviour of all the parties suggests that no one wanted
to know and no one looked. The reality was too frightening so they
denied it.
Tenet staff from its chairman down to junior staff in the Redding
hospital would have been boosted by this success and supremely
confident. They were on a high. They had no doubts about what they
were doing. Their marketplace views were unchallengeable. Marketplace
success and increased status in the community was validation enough.
A host of red flags simply went over their heads.
As in 1991 it was a single index case which
blew it all open. Of all people the doctors and the hospital picked a
medical ethicist, hardly the person to deliberately deceive. Instead
of quickly recovering the situation by addressing it they ignored all
of his efforts to tell them that there was something wrong -
incredible stupidity. This is not the way someone who knows that he
is a criminal responds. The administration must have had supreme
confidence in their doctors.
The ethicist went for a routine heart check because of a family
history and must have been advised to have an angiogram. He was then
told that he had heart disease and was in need of urgent bypass
surgery. Friends suggested that he should go to Las Vegas for this as
they could provide support. The surgeon there told him his heart was
normal. Multiple other opinions confirmed this. He repeatedly spoke
to the hospitals administrators and told them of the problem. Instead
of looking into this the administrator advised him to follow the
Redding cardiologists advice. Instead he took his concerns to medical
bodies and then to the FBI. He also lodged a Qui Tam court
case.
Last June, shortly after his 55th birthday, John Corapi got the bad news from Dr. Chae H. Moon, director of the cardiology department at Tenet Healthcare Corp.'s Redding Medical Center. Corapi had splits in his arteries, according to Moon's June 11 report. His recommendation: bypass surgery.
-------------------------
Authorities are investigating whether the doctors performed unnecessary heart procedures on hundreds of patients. No charges have been filed against either man. Heart Patient Sues Tenet, Physician :: Lawsuit follows public disclosure of FBI probe. Hospital chain executives try to reassure investors and analysts as shares sink. LA Times November 2, 2002
Now, a malpractice lawsuit filed in Shasta County (Calif.) State Court by the Rev. John Corapi accuses Redding's director of cardiology, Chae Moon, M.D., of professional negligence, battery, conspiracy and fraud and names Tenet and the hospital as co-defendants. Corapi was among the informants who led the FBI and other federal agencies to raid Redding's offices last week for documents related to cardiac procedures and patients. Add malpractice case to Tenet hospital's woes Modern Healthcare November 4, 2002
"I'm a lecturer in medical ethics," Corapi said.
--------------------------
"I was scrambling to draw up a will," Corapi recounted in an interview here late Sunday night. "It was a traumatic experience."
Eventually, after the 55-year-old Corapi developed suspicions about his diagnosis by Redding's Dr. Chae Moon, he took his concerns to his health insurer, to the California Medical Board and eventually to the FBI.
-----------------------------
In Corapi's case, rather than agree to the immediate bypass surgery recommend by Moon, he called to seek the advice of a friend in Nevada who had convinced him to have his heart checked out in the first place. The friend suggested that he come to Nevada to have the surgery. He went to a cardiologist in Las Vegas, expecting to soon land on the operating table.
------------------------------
In time, four other Las Vegas cardiologists concurred that there was nothing wrong with his heart and that he did not require a bypass operation. All of the Nevada doctors reviewed the results of tests performed by Moon.
Corapi said that he asked the Nevada doctors if it could have been a simple mistake by Moon or a difference in judgment. The answer he received, he recounted, chilled him: He was told there was no way to look at his tests and legitimately conclude that he needed immediate surgery.
"This was black and white," Corapi said. "It wasn't an error."
Armed with the far different conclusion of the Nevada doctors, Corapi returned to Redding Medical Center looking for answers and an explanation. What he says he got from the medical center's Chief Executive, Hal Chilton, was a strong defense of Moon's diagnosis and another hard sell that he needed the surgery and could be accommodated that very afternoon.
Corapi said that he returned to Nevada again seeking the reassurance of his doctors there, and they again confirmed that surgery was unnecessary. Corapi said that he again contacted Chilton by telephone and that Redding officials again tried to convince him that the surgery was needed.
--------------------------
Barr said that he probably would consult with several cardiologists, adding that those who had contacted him seemed to indicate that "if you went into that [emergency room] complaining about pain anywhere from your chest to your abdomen they would try to do" a heart examination "on you." Priest's Heart 'Trauma' Triggers Tenet Probe :: Consultant will review allegations. Firm also will investigate. LA Times November 5, 2002
After receiving a physical examination as he turned 55, Corapi decided to have his heart checked because his father suffered from coronary disease, his attorney said.
At the suggestion of a neighbor, he ended up at Redding Medical Center with Dr. Moon, and after being examined "they were telling him if he didn't have surgery he was going to die," Barr said. Suit seeks cut of funds in probe of surgeons The Sacramento Bee December 11, 2002
Did Tenet know? - it should have known
As in the past Tenet frantically tried to
distance itself from the allegations claiming that care was the
responsibility of doctors and that the investigation was of the
doctors and not of Tenet. This is disingenuous. Tenet has a
responsibility to set in place monitoring and oversight processes and
ensure that they work. It should discourage and not encourage
unnecessary treatment. Perhaps it simply did not want to know and was
struggling to comprehend what had happened itself.
The ethicist was not the only one who had warned the hospital.
Doctors, including a cardiologist working in the hospital had taken
the matter up with the hospital administration. In addition to this
there were concerns among other doctors in the town, doctors who
worked at the competing not for profit church run hospital in
Redding. This was conveniently dismissed as petty jealousy because of
Redding's success. Dr Pearce describes these doctors as having a
reputation among other heart specialists across the country of being
"wild" and "cowboys". He doubts that Tenet could have been unaware of
this.
Large numbers of people seem to have known or suspected . The HMO's
knew and were making huge losses as a result. Instead of reporting
this and initiating action they simply closed up shop in the region.
This is the marketplace.
The behaviour of hospital administrators is reminiscent of what
happened in Bristol in the UK. They simply put their heads in the
sand because they did not want to know.
"This is an investigation of doctors, not the hospital or Tenet," said Harry Anderson, a Tenet spokesman. He said the company had no prior indication that there was anything out of the ordinary occurring at Redding Medical Center.
In the FBI affidavit, another cardiologist at the hospital that he took his suspicions about the two doctors to the hospital's chief executive and chief financial officer last spring. (6 months earlier)
The affidavit said the cardiologist believed that both hospital administrators were aware of what was going on and looked the other way "because Moon and Realyvasquez produce tremendous revenue for the hospital." Tenet's Stock Hammered on News of Probe ::Two doctors are under investigation over possible billing irregularities and unneeded procedures. LA Times November 1, 2002
Barr and other lawyers in Redding, who reported receiving dozens of calls Friday from former patients of Moon and Realyvasquez, said they found it hard to believe that Tenet officials missed red flags.
"Other cardiologists in town have complained" about the two doctors, said Robert Simpson, who has been a lawyer in Redding for 22 years. How could Tenet deny knowing of problems "when they have two doctors in Redding, a small regional center, producing more income than doctors in large regional centers?" he asked.
-----------------------------
According to state filings by Tenet, the Redding hospital generated pretax net income of $94 million in the 12 months ended June 30 -- the highest among Tenet's 40 hospitals in California. Mercy Medical Center, the other hospital in Redding with slightly more beds, reported pretax net income of about $5 million in the same period. Heart Patient Sues Tenet, Physician :: Lawsuit follows public disclosure of FBI probe. Hospital chain executives try to reassure investors and analysts as shares sink. LA Times November 2, 2002
According to unnamed government witnesses cited by the FBI in the affidavit, hospital medical staff members were concerned about the high volume of procedures and told hospital administrators they believed many were unnecessary and put patients at risk. A physician witness interviewed by government agents reported that the hospital's chief executive officer seemed unsettled by the news but initiated no review, Skeen said.
------------------------------
"Our initial review found no failings," Anderson said. "We're taking this very seriously. But we want to emphasize that hospitals have to rely on the professional judgment of their doctors, since they make all the necessary medical decisions, not us." Sudden impact :: Tenet reeling after federal raid at Calif. hospital Modern Healthcare November 4, 2002
One thing most everyone will agree on is that for years there have been whisperings in the community and elsewhere about whether Redding Medical was being overly aggressive with heart procedures. In fact, in recent years HMO firms and some medical groups pulled out of the Redding area, saying they were losing too much money because the filing of health-care claims was off the charts.
"Redding is the highest cost of care per population in all of California," said Steve McDermott, chief executive of Hill Physicians Medical Group. McDermott said his doctors group pulled out of Redding at the end of last year, after losing almost $1 million last year serving 22,000 HMO members there.
Blue Shield of California said it would stop providing HMO service to members of the California Public Employees' Retirement System in the Redding area as of early next year. According to a 2000 report prepared for the California Healthcare Foundation, the Redding area had the highest rate of bypass surgeries in California, at 13.55 procedures per 1,000 enrollees -- more than double the statewide average.
-----------------------
Mercy Medical also has a cardiology department, but the hospital's profit is just a fraction of Redding Medical's. And some doctors say a bitter rivalry between the hospitals is behind much of the criticism against Redding Medical and the two doctors. Redding's Spotlight Turned Into an Unwanted Glare :: Town is divided over investigation into doctors LA Times November 6, 2002
Although Redding is a relatively small hospital, with 238 beds, it is one of the company's most profitable -- largely because of the high-volume cardiology program the two doctors established.
Among other sources of revenue, Redding Medical Center receives an unusually large share of outlier payments because the hospital performs many specialized and costly heart procedures. U.S. to Audit Tenet Hospital Bills :: Focus will be on large Medicare payments. Meanwhile, state seeks to curb Redding doctors. LA Times November 7, 2002
When the story broke hundreds of patients, particularly those who had not had symptoms prior to invasive procedures began to think about what had happened to them. Many went to lawyers. One lawyer has about 500 past patients wanting to take action.
Now, Haggard said, he's convinced that the fear he has long harbored in the back of his mind is completely warranted. "I suspected when it was done to me that I didn't need" an operation, he said. "There's a very good chance I may be a prime example of what Dr. Moon did. The whole thing has made me mad. I'm just waiting here for the FBI to contact me."
--------------------------
He said his misgivings were heightened when the drummer in his band, the Strangers, also checked into Redding Medical Center about three years ago. Biff Adam was back from the road, feeling a little weak and complaining of some chest pain, when he went to see Moon.
After some tests, Adam remembered in an interview Monday, the doctor delivered the bad news: The left muscle in his heart was badly damaged. Moon "went up to my wife and said, 'Your husband needs a heart transplant,' " Adam recounted. "She almost passed out."
Adam said his family doctor in Redding, Morris Ballard, suggested that he get a second opinion. He did, from Dr. Robert Pick, who wound up treating Adam not with surgery but with a drug called Coreg, which lowers blood pressure. "That straightened me out," Adam said. "I didn't need a heart transplant -- that's for damn sure." Haggard Says Heart Didn't Need Fixin' LA Times November 6, 2002
The affidavit presents a far more chilling scenario, which is that Moon violated the ancient medical oath to "first, do no harm." One case briefly detailed by the FBI: A 59-year-old male received bypass surgery and, four years later, is still too weak to work. A cardiologist who reviewed the man's records for the FBI "found, at most, evidence of a relatively minor problem," the affidavit says. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
This is one of those situations where protection of the public should take precedence over the rights of the individual, at least until the situation is resolved. This could take months if not years. In November 2002 the Californian Medical Board moved to have the doctors suspended from practice. The court however chose to protect the rights of the doctors who had not been charged with a criminal offence and rejected the move. The council tried again in June 2003. The cardiologist had stopped practising as he could not get medical insurance. In july 2003 he agreed to temporay suspension of his medical licence..
On Wednesday, the California attorney general's office, acting on the request of the state medical board, said it would seek a court order to prevent the two doctors, Chae Hyun Moon and Fidel Realyvasquez Jr., from practicing medicine pending the outcome of the probe. U.S. to Audit Tenet Hospital Bills :: Focus will be on large Medicare payments. Meanwhile, state seeks to curb Redding doctors. LA Times November 7, 2002
November 2002
As part of the petition, there was a declaration from Vincent Yap, chief of cardiology at Kaiser Richmond Medical Center. "It is my strong professional opinion that neither Dr. Moon nor Dr. Realyvasquez can safely practice medicine, and each poses a threat to patients," he wrote. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Shasta County Superior Court Judge Monica Marlow ruled that the California Medical Board's evidence against cardiologist Chae Hyun Moon and heart surgeon Fidel Realyvasquez was insufficient to stop them from practicing.
-------------------------------
- - - - FBI and the Medical Board describe as the doctors' approach to patients. Moon and Realyvasquez "were able to carry out their scheme by lying and/or misleading and in some cases scaring patients," the board wrote in its court petition. Redding Doctors Keep Licenses :: Medical Board fails to win the suspension of two heart physicians at a Tenet Healthcare facility. LA Times November 14, 2002
The head of the cardiology department at Tenet Healthcare Corp.'s Redding, Calif., hospital, who faces a federal investigation of allegations that he performed unnecessary procedures, is suspending his practice because he is losing his medical malpractice insurance. Tenet Cardiac Doctor to Suspend Practice LA Times January 29, 2003
June 2003
The California Medical Board has accused a doctor, suspected of performing unnecessary surgeries, of insurance fraud, gross negligence, dishonest or corrupt acts and incompetence, a board official said Thursday. Ex-Tenet Doctor Faces Hearing on Alleged Fraud, Misconduct LA Times June 6, 2003
The former director of cardiology at 188-bed Redding (Calif.) Medical Center has agreed to a temporary suspension of his medical license pending the outcome of a federal probe into his practice.
--------------------------------
Moon stepped down as Redding's cardiology director and suspended his medical practice earlier this year because he couldn't obtain malpractice insurance coverage. Doc in Calif. probe accepts license suspension Modern Healthcare July 3, 2003
Not surprisingly lawyers saw the opportunities for litigation and were soon advertising their services. Large numbers of past patients were soon lodging law suits. Some lawyers now have up to 500 patients on their books. Other lawyers representing shareholders took action against Tenet and its CEO claiming that the company was or should have been aware of what was happening and the consequences.
On Friday, in Redding, three more people filed lawsuits against Tenet, Redding Medical Center and the two doctors, Chae Hyun Moon and Fidel Realyvasquez Jr. All three plaintiffs claimed fraud, and one blamed the death of a 74-year-old man, Cecil Josefsson, on an allegedly unnecessary coronary bypass surgery performed this year at Redding Medical. The suit was filed by the man's son, Peter Josefsson, who, through his lawyer, declined to comment. Shares of Tenet Fall on Cuts in Ratings LA Times November 9, 2002
Lawyers are running ads in the local paper and on television, trolling for victims. One local firm says it will file more than 100 suits all by itself. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Defendants actually knew that the quality of Tenet's profits were inflated by, among other things, wrongfully inducing patients into undergoing unnecessary and invasive surgeries. Tenet's key profit center was and is Redding Medical Center ("RMC"), a 238-bed, general hospital located at 1100 Butte Street, Redding, California 96001. Defendants knowingly or in conscious disregard for the truth engaged in a scheme to cause patients to undergo unnecessary invasive coronary procedures.
-----------------------------
Interviews conducted by the two Redding doctors with patients and/or other physicians revealed that many of the surgery patients were falsely told by Dr. Moon that they suffered from a serious heart malady and that they would soon die without surgical intervention. Tenet healthcare KMSlaw.com December 2002
Unconscious people in an unconscious hospital in an unconscious company in an unconscious marketplace in an unconscious country in an unconscious civilization?
My view is that in Tenet, its hospital, and
its doctors we are looking at one of the most extreme examples of the
disconnectedness from reality which the Canadian John Ralston Saul
describes so well in his Massey lectures published as "The
Unconscious Civilisation". It is a world distanced from reality by
abstractions. The meaning systems have become more important and
vital for the lives of those in the system than the reality which the
abstract meaning systems fail to represent. Because they are not
attached to reality they can be readily changed to accommodate the
immediate needs of those who need to use them.
Abstractions are of course the way we humans grasp reality. Without
them we would not be human. For us they are more important than
reality because we cannot exist as humans without them. As I have
argued elsewhere we have no choice but to live our lives and we must
have abstract meaning systems to do so. There is no other way. When
there are barriers to the process of living our lives we will develop
unreal abstractions which enable us to do so. We will doggedly defend
them regardless of their tenuous links to reality.
No abstraction perfectly represents reality and ideally abstractions
change to accommodate more closely to reality. The farther the
abstraction is from reality, the more we have to employ closed minded
or one eyed strategies to shield out the contradictions.
Ultimately the conflict between reality becomes so great that actions
become too harmful for society and it all implodes. For NME this
first happened in 1991. As in 2002 they were like stunned mullet.
They had set up a solid barrier between themselves and the real world
out there in the hospitals. They were totally impervious to what was
happening. They accepted every possible explanation except the real
one. They saw it as a media beat up. Instead of visiting the
hospitals to see what was happening when they flew to Texas they went
straight to public relations firms - then went home to their comfort
zone in California! Three months later there had been no changes in
the hospitals.
The imperative for those in the company to hold on to and live out
these abstractions was not removed by the criminal pleas. They
responded by feeling that they had been victimised. This was perhaps
the only way these people could protect themselves and live out their
lives and so realise their ambitions. There was perhaps no other way
for them. The abstractions endured, then flourished and finally it
all imploded again in 2002.
Redding hospital represents the last cog in the corporate chain. The
hospital administrators and the doctors are the unconscious
individuals whose unconsciousness builds the culture and ultimately
our civilisation. It is one of the unconscious subcultures which
makes up this bubbling unconscious civilisation which Saul describes
so well. Like the marketplace this unconscious civilisation then
props up leaders blinded by their abstractions but I am not going to
start on that!
In the confused and struggling people in this hospital we should see
ourselves. In imposing their certainties and protecting them they are
responding and behaving as we all do in our lives.
Technologically mankind took a giant step through space and
technology barriers in the 20th century. Perhaps there is
an even greater barrier to step through in the 21st -
ourselves.
I will fill in the gaps with my own understanding of what I think
probably happened.
Redding hospital in a relative backwater is the product of Tenet's
market policy and its partnership (marriage) with consenting doctors.
It is the real consequence of the abstractions. If we believe
something to be real, however false it is, then it is real in its
consequences. If those abstractions which create the baby do not
approximate reality then the real baby which is born is likely to be
a grotesque monster.
Redding was proof of Tenet's revival and its success. Here was a
hospital where Tenet's policy of generating profits by targeting
sicker patients, complex cases and partnering with doctors to provide
more services was proven. It was widely recognised as a centre of
excellence for heart disease and Tenet poured more and more money
into it. Tenet was about to double the hospitals size when the
scandal broke.
Redding seems to be a small city, not the sort of place where you
would expect to find a high level specialist hospital. That it became
one was because of the marketing skills of its administrators and the
personality of its doctors.
It is a reincarnation of some of NME's psychiatric hospitals in the
late 1980's and early 1990's. In evidence to the US house of
Representatives hearing "The Profits of Misery" in April 1992 Mr Lou
Parisi, a fraud investigator from New Jersey gave
evidence. (4.2)
He indicated that a situation had
developed where " some hospitals and substance abuse centres can
achieve a reputation for professionalism and a high level of patient
care and that reputation is only a facade" He could have been talking
about Redding.
This hospital and its administrators were intensely proud of what
they had accomplished. They had followed Tenet's policies to the
letter, buying in the latest equipment, attracting doctors who would
use it heavily, marketing their facilities to the public and reaping
the financial benefits of all their effort with high pricing and
outlier payments.
Their success spoke for the quality of the service they were
providing. They and the doctors they supported enjoyed stature in the
hospital, in the company and in the community. It would have been
obvious that other doctors who complained about the doctors were
simply jealous of their success and the support given to
cardiology.
The hospital's marketing seems to have been little different to that
used in the
1990's scandal (3).
The reports suggest that it was designed to create anxiety and
encourage patients to come for cardiac screening, a new industry with
great potential. The risk was that in the market enthusiasm and the
eagerness of the doctors to meet the "demand" large numbers of
anxious people would be treated for something they did not have. This
happened in 1990 and the allegations suggest that it happened again
in 2002.
There is a marked similarity in the way these doctors emerged and the
way the market selects and fosters
dysfunctional people and personalities
as leaders. In much the same way Tenet at least seems to select and
foster doctors with similar characteristics. They are not mainstream
members of the profession and the hospital is not interested in their
qualifications or abilities. They would probably have been
nonentity's in a critical university hospital. Tenet is interested in
their marketplace performance. It is interested in their patients and
the money they bring in. It will help and encourage those who produce
these goodies.
The situation in Redding is a consequence of Tenet's policy of
partnership with doctors - doctors who are able one way or another to
identify with its values and norms. They might well have difficulty
in finding skilled and well qualified doctors who will do so. These
would have no need of Tenet's assistance to build their lives and
would not go along with Tenet's practices. That one of the doctors is
not a qualified cardiologist, not even a qualified internist would
not concern Tenet's businessmen. They are doctors and they are the
source of patients. If they bring a profit they must be good. This is
the way they thought in 1990 and they still do. Many businessmen are
self made men and perhaps critical of academia and academic
institutions. In the 1990's Tenet/NME fired people because they were
"too clinical". Could medical critics have been denigrated as
"too academic"?
The second doctor is a board registered cardiac surgeon but does not
seem to be widely recognised as a leader by his own profession.
Tenet turns these doctors into leading experts widely admired and
trusted by the community. This is done by marketing. Success in
bringing in and treating patients is evidence enough of expertise and
standing. What is more they all identify with the illusion they have
created. Little wonder that they defend it and reject any suggestion
that all is not what it seems.
There is a report which indicates that a complaint of unnecessary
surgery was made against one of these doctors in 1992. A complaint
like this would normally alarm everyone in a hospital. This does not
seem to have rung any bells with this hospital or caused it to take
note of all the red flags a few years later.
The many press reports tell the story far better than I
can.
Dr. Moon is the Director of Cardiology at RMC. Dr. Moon is neither board-certified in cardiology nor in internal medicine. Dr. Realyvasquez is the Chairman of the Cardiac Surgery Program at RMC. Dr. Realyvasquez is a board-certified cardio-thoracic surgeon. Dr. Realyvasquez is one of only two known cardiac thoracic surgeons at RMC. The other RMC cardiac thoracic surgeon is a junior associate of Dr. Realyvasquez. Tenet healthcare KMSlaw.com December 2002
According to the Redding Medical Center's Web site, the hospital performs about 200 heart catheterizations a month and 700 open-heart surgeries annually. Residents of Redding said the hospital frequently advertises its California Heart Institute as a highly rated center with low morbidity rates. Heart Patient Sues Tenet, Physician :: Lawsuit follows public disclosure of FBI probe. Hospital chain executives try to reassure investors and analysts as shares sink. LA Times November 2, 2002
Complaints against Tenet doctor date back a decade. The San Francisco Chronicle reports on a 1992 complaint to the California state Medical Board over unnecessary heart surgery performed by one of the Redding Medical Center doctors now under investigation. SEIU web site Saturday, November 16, 2002:
Tenet added that the company plans to extend its internal review to other hospitals that have a high volume of specialized services, such as cardiology and neurology. The company has been pursuing a strategy to build up these programs, and some analysts have questioned whether that may have fostered a culture of aggressively treating patients at Redding and other hospitals. By handling more critical and complicated cases, Tenet has received an unusually large share of special Medicare reimbursements, which also have come under scrutiny. Priest's Heart 'Trauma' Triggers Tenet Probe :: Consultant will review allegations. Firm also will investigate. LA Times November 5, 2002
But in the last decade, the town became a magnet for a different kind of visitor. Patients from as far away as Sacramento, the Oregon border and eastern Nevada have descended on Redding, drawn by Redding Medical Center's growing reputation as a leading center for heart surgery.
In 1993, the 238-bed hospital, owned by Tenet Healthcare Corp., embarked on an ambitious plan to build a heart institute. Two years later, a five-story medical wing rose up in the center of town, intensifying a rivalry with Redding's other hospital, Mercy Medical Center, and setting up what would become an economic boon for Tenet but also for the town.
The two hospitals "are a real key component of the economy here," said Doug Latimer, Shasta County's chief administrative officer.
But now, Redding Medical has put an unwanted glare on this town of 88,000 on the Sacramento River, which appears deeply divided about the hospital and the two doctors who built up its cardiac practice and now are being investigated for allegedly performing numerous unnecessary procedures and surgeries.
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Today, Redding Medical Center is a thriving medical center with a strong local marketing campaign replete with billboards, advertisements and even a "put a little love in your heart" campaign in 2001. At the entrance, patients and visitors are greeted with free peppermints and chilled bottled water. A Yamaha player piano plays softly in the background in the lobby, where the private and soundproofed patient consultation rooms are located.
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Just about everyone in town seems to know someone or is related to someone who was operated on by Moon or Realyvasquez. Redding's Spotlight Turned Into an Unwanted Glare :: Town is divided over investigation into doctors LA Times November 6, 2002
For all the advances in technology, cardiac care can still be as much art as science. Redding Medical was home to the best machines and receptive to the latest ideas. To his admirers, and there are still many here, Moon saw further and knew more. He prevented heart attacks, extending the life and health of many patients.
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In this former logging community turned vacation jump-off point, Moon is a more personal matter. The Redding Medical Center draws patients from the entire northern half of the state, and Moon is its star. Everyone, it seems, knows someone who's been a patient or who works for the hospital. It's the most dominant building downtown, except for the jail, and was going to get even bigger. Before the events of the last two weeks, the 238-bed center was to double in size.
In a search for more business, Redding Medical recently mailed out fliers that showed a trim woman with a basketful of healthful groceries.
"After grocery shopping, a few errands and one load of laundry, a 42-year-old woman collapsed of a heart attack," the flier warns. "And you thought heart disease was just a man's problem."
The "lifestyle risk factors" listed are very broad, including "increasing age."
Such an approach can save lives, but it's also ripe for abuse. When does aggressive prevention cross over into unnecessary operations? It's a question many of Moon's former patients are being forced to ask themselves. Some are emerging with their faith intact. Some are uncertain what to think. And some are filing lawsuits. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
The press reports give a fascinating insight
into the doctors and their lives. We can see here the doctor
equivalent of Richard
Scrushy, Andrew
Turner and perhaps Richard
Eamer. There are some gaps and I will
fill these with hypotheses - describing the sort of people and the
sort of behaviour which I have seen myself so it is possible. I may
well be wrong. I am trying to show how and why situations like this
arise because I don't believe this is isolated. There may be other
better explanations which fill the gaps in the press reports.
It is I think relevant that the cardiologist
and possibly the surgeon were not educated in the USA. In some
developing countries 30-40 years ago education was primarily by rote
learning. This is a cultural problem and in fairness this has
improved enormously over the last 40 years. I have called this the
"form" of learning rather than its substance. It does not equip
students for success in the Western world.
These students do not learn to think, understand or challenge so are
unable to handle the vast quantities of knowledge which they acquire
- however erudite and impressive they seem. They can accumulate a
long list of degrees. Good medical practice depends much more on
knowing how to use knowledge than on having it, and on knowing when
you don't have the knowledge yourself. Medicine carried on without
understanding simply results in the outward "form" of medicine rather
than its "substance". It looks very impressive to everyone except
those with real understanding. It is disaster prone.
It is like the child who can't yet write but who scribbles a letter
to its mother. The child believes that it is writing a letter and
unless you can read and write yourself you might think so too. The
child knows what writing a letter looks like and how to make marks
with the pencil. It acts out the process and believes that this is
what it is doing. It does not yet possess the abstractions which
enable it to understand the nature of writing.
I have had experience with postgraduate doctors in training who have
had a university training like this. Lovely people they may be but
there is very little you can do to help them. Even doctors who have
had this background in their schooling remain deficient. I have seen
it in doctors who subsequently got their medical degrees at the best
of United Kingdom universities and hospitals. I have struggled to
confront and challenge this in foreign students at our university and
it has been traumatic for them. I have seen this in successful
doctors in private practice, but these are doctors who have also
isolated themselves.
All of us have strengths and weaknesses. These doctors need a niche
working with others where they can realise strengths but be protected
from their weaknesses. The lost art of management is not about
creating ever bigger incentives but in recognising and understanding
people. It comes through organising the system so that people and the
system can together realise their potential through strengths while
protecting the system from weaknesses.
We know that the cardiologist obtained his education and basic
medical training in Korea in the period 30-50 years ago and he may
have received the sort of education I have described. The surgeon
very probably had some of his schooling in Mexico but his medical
training was in the USA.
Moon, 55, was born in Seoul, the son of an orthopedic surgeon and a volunteer for the Korean Red Cross. He studied medicine at Yonsei University, one of the preeminent schools in the country.
His goal was to be a surgeon like his father, he told the Redding Record Searchlight in a lengthy interview in 1994, but back trouble made it impossible to stay on his feet for hours at a time in the operating room. After coming to the U.S. in 1972, he decided to specialize in heart disease, the leading cause of death. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Both doctors received their specialist
training in the USA. In the cardiologist's case his training was in
two different centres and it seems that he never properly completed
this. He was never board certified in internal medicine or in
cardiology. He then flitted through several other posts before ending
up in Redding.
It would be very interesting to find out more about this doctor's
training and what his mentors really thought of him. I would
hypothesise that he was assertive, confident and resentful of
criticism. He went his own way. He would have been a skilled
technician, much more so than his seniors and would have used this to
boost his ego and counter criticism from his mentors whom he probably
considered inept.
His failure to complete his training and become board certified may
have been because of their failure to support him. He then flitted
about for a bit. This may have been his choice, because he did not
fit in, or because those who trained him would not support him in his
ambition to be a cardiologist. Tenet did - perhaps they saw his
potential in the marketplace. Instructions
to NME staff (5.5)
interviewing potential employees in the 1980's were headed "Look for
a Shark". These might have been current at this time.
One of the problems created by our present system is that the right
of individuals is supreme and they are protected from wrongful
dismissal. They must commit a series of frightful bloopers to earn
dismissal and when trainees are properly supervised this is
prevented. They have the right to appeal a decision to terminate
their training. Specialists in charge of training cannot remove
trainees from the program because they think the trainees personality
is likely to lead to problems for patients in the future. Some of us
have tried to find other reasons to do so in people like this. The
second problem is that we are sometimes wrong in our assessment.
There seems little doubt that these two doctors were skilled
technically and that their results were good. They should have been
excellent if, as alleged they were operating on healthy people with
no disease.
Moon trained in New York, moved to Cleveland and then made a rapid transit of Orange County, working in seven hospitals in little over a year. In 1979, he arrived in Redding, which he said reminded him of Korea: clear skies, mountains, quiet. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Tenet would have inherited NME's practices.
NME targeted doctors who already had or who were likely to develop
big practices and formed partnerships with them. They spent large
sums of money supplying the latest and best equipment for them to
use. They then turned them into overnight experts sending them on
lecture tours and marketing their expertise.
Would they have done so if these people were conservative doctors who
were more selective than their peers in carrying out invasive
procedures? I suspect they would have pushed out these doctors
(called economic credentialing) and brought in the others. This is
illustrated by the events in St Louis described
earlier.
The problem I see is that some doctors accepted this imposed
expertise uncritically and then hid behind the credibility and
authority which this sometimes illusionary expertise gave them.
To maintain this illusion audit, peer review and