Embarrassing Light on Unnecessary Procedures

It's instructive to compare two items of news coverage for this story:
http://www.baltimoresun.com/health/bs-md-senate-stent-report-20101205,0,2116790.story
http://www.nytimes.com/2010/12/06/health/06stent.html

First, the basic story outline: Dr. Mark Midei trained at John s Hopkins to become an interventional cardiologist. He co-founded MidAtlantic Cardiovascular Associates, a practice with dozens of cardiologists that handled much of the cardiac business in the private hospitals in Baltimore. Dr. Midei became such a big shot that when MidAtlantic planned a $25M merger with Union Hospital in 2007, his continued membership in the practice was crucial to the deal. That led St. Joseph Hospital in Towson, just outside Baltimore, to worry about losing too much of its own lucrative cardiology business. St. Joseph offered Dr. Midei a $1.2M salary to ditch MidAtlantic and come on board with them exclusively. Dr. Midei took the offer, the merger deal collapsed, MidAtlantic sued, and the former CEO of MidAtlantic was recorded as saying he'd "spend the rest of [his] life trying to destroy [Dr. Midei] both personally and professionally."

All that soap opera is merely prelude to what is really important. As to destroying his career, Dr. Midei took care of that himself, with a little help from St. Joseph and Abbott Laboratories, maker of one of the cardiac stents that he used.

Ensconced at St. Joseph, Dr. Midei soon became the darling of his new employer and also of Abbott due to the steady high volume of stents that he inserted (the procedure takes half an hour or less and nets a cool $10-12,000). He reached his height in August, 2008, when he implanted 30 stents in one day. Top execs at Abbott sent him special congratulations at this accomplishment. Abbott also paid for plush cookouts and barbecues (including one whole, slow-smoked pig) at his 7000-square-foot house on 30 acres of rolling hillside. They also showered him with research money and VIP trips.

Apparently neither St. Joseph nor Abbott was worried about the obvious difficulty of finding as many patients that truly needed cardiac stents as fast as Dr. Midei seemed to be lining them up. St. Joseph had a system of quality review of its procedures, whereby the head of a department would select which cases were to be reviewed. Dr. Midei was head of cardiology. For some odd reason he did not select any of his own cases as requiring review.

Eventually there were complaints to the state medical board and a Federal investigation. Finally St. Joseph felt enough pressure to start its own investigation. When that study showed that over the previous two years, nearly one-third of the stent implantations were judged unnecessary, St. Joseph removed him from his duties and eventually revoked his hospital privileges. That led many former patients to sue both the doc and the hospital, and Dr. Midei to sue St. Joseph claiming they were trying to make him the fall guy to evade their own responsibility.

Abbott's response to that little kerfuffle? They decided to hire Dr. Midei on as a consultant--"It's the right thing to do because he helped us so many times over the years," wrote one exec in an e-mail (one of about 10K documents obtained by Sen. Max Baucus's Finance Committee). In early 2010, when a Baltimore Sun columnist wrote about the case and allegations of widespread unnecessary stenting, Abbott's vice president of global marketing, sent an internal message: "Don't you have connections in Baltimore????? Someone needs to take this writer outside and kick his ass! Do I need to send the Philly mob?"

Despite such touching concern, Abbott soon decided that the publicity around Dr. Midei made him too hot to handle. They cut short his VIP trip to Japan (for which they paid him $30,000), where he was extolling the wonders of Abbott's Xience V stent. Now, the best Abbott can say about the guy is, "Dr. Midei has been a highly regarded physician in his field, with whom Abbott had consulted in the past. Our affiliation with Dr. Midei ended early this year."

OK, so why did I suggest you compare the two articles? The Baltimore Sun, as appropriate for a home town boy, focuses on the saga of Dr. Midei, but leaves the unwary reader with the impression that he might well be a relatively isolated case. The New York Times, with veteran medical/business writer Gardiner Harris, does a much better job of showing the big picture--that this sort of abusive overuse of well-reimbursed procedures is widespread in cardiology particularly. Harris for instance quotes Dr. Steve Nissen of Cleveland Clinic: "What was going on in Baltimore is going on right now in every city in America....We're spending a fortune as a country on procedures that people don't need." And in it up to their respective eyeballs are the unholy trinity of greedy docs, greedy hospitals, and drug and device makers willing to pay huge kickbacks for sales volume.

The political implications of which version you buy into are huge. If you see things the way the Times puts it, you realize that measures like the "doc fix," either allowing Medicare fees paid across the board to physicians to be cut by 23%, or saving docs from that hit, is clearly the wrong way to go about seeking health care cost savings. We will somehow have to garner the political will to identify the stent type procedures--the unnecessary, nonbeneficial procedures that place patients at serious risk for harm, and that cost a ton, without making anyone live any longer or better. Whichever specialty that procedure is a big cash cow for will scream bloody murder about "the government getting between you and your doctor." So the best possible solution (as I wrote in the New England Journal of Medicine last January, http://www.nejm.org/doi/full/10.1056/NEJMp0911423) would be for us docs to assume real leadership and identify those wasted procedures ourselves and quit doing them before waiting for the Feds to come and get us.

Then we just might be worthy of being called a "profession" once more.