Donald L. Barlett and James B. Steele, in Critical Condition (Doubleday, 2004), focused their skills as investigative journalists, on the American health care system.
The nature of our dysfunctional system is analyzed in great detail. The book should have sparked a national demand for sweeping reform in healthcare because of its shocking revelations. That it failed to produce a public outcry is an indication of the power of the healthcare industry’s control of the media.
A concise summary of the book can be found in a quote from page 73:
“This, then, is the sorry picture of health care in America. We spend more money than anyone else in the world – and have less to show for it. We have a second-rate system that doesn’t adequately cover half or more of the population. We encourage hospitals and doctors to perform unnecessary medical procedures on people who don’t need them, while denying the procedures to those who do. We clog our emergency rooms with patients who have insurance because they can’t get in to see their doctors. We stand a good chance of dying from a prescription drug taken at home. We charge the poor far more for their medical services than we do the rich. We force senior citizens with modest incomes to board a bus and travel to Canada or Mexico to buy drugs they can’t afford here. We require ambulances to drive around a city until they can find a hospital willing to accept a patient for emergency treatment. We have a system in such constant turmoil that almost everyone involved is unhappy – patients, doctors, nurses aides, technicians. Almost everyone. But for a lucky few, the turmoil is worth a lot of money.”
From 1933-1945, the governing principle of Germany’s political, social, and economic life was known as National Socialism. Its central tenet was that all individual efforts were to be subservient to the needs of German society. The individual’s goal and highest development were to be found by immersing one’s talents and aspirations into the needs of the collective.
Our culture is governed, similarly, by an organizing principle that has been called National Capitalism (National Capitalism, Global Competition, and Economic Performance, Sigrid Quack, et al, John Benjamin Publishing Co., 2000). Under National Capitalism the individual’s efforts are to be directed towards achieving profit. As the perfection of the collective was the end goal of National Socialism, the achievement of profit is the end goal of National Capitalism. Under National Capitalism, the accumulation of money (and what money can buy) becomes the guiding principle of one’s efforts. Profit frees the individual. National ‘Capitalists’ believe the society that results from pursuing profit is the highest form of social, political, and economic organization.
The inherent message of these two different forms of societal organization, National Socialism and National Capitalism, is that personal well-being and happiness are the outcomes of adhering to their respective economic principles.
It is true that National Capitalism has produced great benefits for American society. It has even become a system of organization that many other cultures seek to emulate.
The ‘genius’ of National Capitalism lies in its ability to find profit in anything. Until recently, however, healthcare was considered to be more a utility and not a desirable target for capitalists.
All this changed as healthcare began to consume an increasing share of the national budget and insurance companies, managed care firms, pharmaceutical companies, and large hospital chains discovered innovative ways of generating more and more profit from the system. The ‘corporatization’ of healthcare has become a major profit center in the workings of National Capitalism.
But in the need to generate profit from human suffering and disease, our system of National Capitalism has clashed head on with the social responsibility of providing uniform, high quality healthcare to all our citizens. Thus, the depressing abuses described by Barlett and Steele. As the reader will see, these abuses are reminiscent of those tolerated under National Socialism.
Our profit driven healthcare system functions in a cesspool of fraud. But, in healthcare, fraud is not just about the money. Healthcare fraud leads to suffering and death. Our healthcare system is not just ‘critical’ as in the title of Barlett and Steele’s book, our health care system is ‘terminal.’
Terminal Condition documents the depth and extent of fraud in American healthcare, the resulting injury and death of patients, and the extraordinary efforts the healthcare industry has gone to divert the public’s attention from the issue.
Since profit is the highest value under National Capitalism, profiting from deception – fraud – is a major component of its functioning. Donald Rumsfeld has said that “Free people are free to make mistakes and commit crimes and do bad things…” The crime of fraud is endemic in our culture.
The United States Government has a most ingenious way of attempting to get a handle on all the fraud committed against it by capitalizing on the spirit of greed in the Click for Previous Page American psyche. It does this through the False Claims Act. Individuals are encouraged to ‘blow the whistle’ where they have knowledge of fraud and are given a percentage of the money the government recoups in an action against the perpetrator (Qui Tam claim).
To give the reader some small idea of the extent of the healthcare fraud in the United States, the following is list of 36 successful cases in which the Government recouped money from fraudulent healthcare providers. Each example has hyperlinks that lead to detailed explanations of the alleged fraud. Usually the Government demands only partial repayment of the money and the alleged perpetrator is not criminally charged. Bank robbers would be envious.
Note: The acronym “PATH violation” refers to Physicians at Teaching Hospitals. Medicare/Medicaid requires that an attending physician actually be present to treat a patient in order for the hospital to be reimbursed. A violation is issued and no reimbursement is allowed when the patient is treated only by an unsupervised doctor in training.
The back cover of The Medical Racket (Avon Books, Inc., 1998) by Martin L. Gross provides a succinct introduction to the consequences of medical fraud in America:
Medical fraud siphons off vast amounts of money that should be devoted to patient care. The private system of healthcare insurance is perhaps the biggest fraud of all since it devotes over 30% of the healthcare dollar to paying administrative costs for the insurance companies. Insurance companies and all other “winners” in the medical bonanza, devote a considerable amount of money on politicians who support and perpetuate this corrupt and dangerous system.
A review of the 36 cases of alleged financial fraud shows frequent violations of Federal PATH regulations. So-called errors committed by unsupervised physician trainees are a major source of patient harm and death (see Libby Zion and Seth Speken, for example). The Government, through Medicare, pays teaching hospitals 8 billion dollars annually to provide salaries and supervision for their students. A PATH violation means that a patient had been treated by an unsupervised trainee, and most likely without their knowledge or consent.
For example, in 1996, Alan Hevesi (then Comptroller of the City of New York) cited Columbia University with “widespread fiscal mismanagement” in a major financial audit of the University’s 56 million dollar affiliation contract to staff and operate Harlem Hospital. The allegations of fiscal mismanagement were quietly settled with the University returning 2 million dollars to New York City’s Health and Hospitals Corporation. The detailed text of this audit was never released to the public, and for good reason.
We were able to obtain a copy of the 110 page document. Pages 8-10 are asummary of the findings of the Hevesi audit. In addition to the recitation of the allegations of serious financial fraud, this summary exposes the fact that patient care had been seriously compromised as a consequence of what the report refers to as a “fiscal theft” of service. Pages 17-19 document instances of “double dipping” in which Columbia Presbyterian Hospital attending physicians with part time assignments at Harlem Hospital received salaries from both the City of New York as well as Columbia University for overlapping hours. That is, they were supposed to be working at one facility when they were actually at the other. They were paid twice for working at two facilities at the same time (p.8) This meant that one or the other facility and its patients were being defrauded of the scheduled time the fully trained physician was supposed to be present. Clearly the community had been put at risk or harmed by the absence of these attending physicians. These physicians were neither present to supervise house staff nor to deliver patient care.
The Hevesi report dealt with Columbia University’s fraud of Harlem Hospital and consequently the health of the African American community of Harlem in New York City. Pages 52-55 document specifically how the AWOL “double dipping” Columbia physicians had a direct impact on patient care at Harlem Hospital.
As noted in the Hevesi report, it is an accepted standard of graduate medical education that medical trainee house staff who read x-rays in an emergency room are to have these x-rays re-read by fully trained radiologists within 24 hours. Serious and consequential decisions are made on the basis of these x-rays and safe practice demands that a fully trained physician be required to check the work of the trainee. There were numerous indications in the Hevesi audit that this practice was being ignored, most likely because the “double dipping” supervising physicians were not even present in Harlem Hospital. In other words, patients who arrived at the emergency room of Harlem Hospital were having medical decisions made on the basis of x-rays that were being read by students. A likely consequence is that many errors were made by these students.
The Hevesi audit clearly shows that Harlem Hospital was being substantially run by students. For example, there was evidence that nearly 75% of x-rays were not being re-read by trained radiologists. (Page 8) This means that the activities of students with patients were being marginally supervised, if at all, by experienced physicians.
The Hevesi audit was never released to the public, but a copy was provided to the New York Times (2/11/1996). The New York State and City Government had these details, the New York Times had these details, but the public did not. By what right was this information about the dangerous conditions within their Hospital withheld from the Harlem community?
It was significant that when non-medical auditors looked at the medical delivery situation within Harlem Hospital, they uncovered the fact that the financial improprieties of Columbia University were not limited to billing, but also extended to patient care.
The public knew none of this. Columbia simply made a statement as reported in the New York Times that it would improve the “internal controls” of its operation at Harlem Hospital. There is no comprehensive regulatory system to guard against such abuses as exposed in the Hevesi audit and report. Each individual state has a medical board to oversee healthcare delivery but the system is weak, understaffed, not up to the task, and often corrupt. Medical disciplinary boards often lie to protect negligent providers. Yes, the boards may investigate complaints, but they do not provide oversight and supervision of healthcare delivery. Medicine, so the story goes, is trusted to regulate itself.
And so, without a regulatory system in place, there was no way for the public to know whether any changes that Columbia University announced were fundamental or just cosmetic. There was no way for the public to know just how dangerous the situation was.
It will be of interest for the reader to know that in December of 2006, Mr. Hevesi resigned his position as Comptroller of the State of New York rather than face indictment and possible prison time for fraud. He admitted to the unlawful use of a State car and driver for his own personal purposes at a cost to the State of well over $200,000.
When this crime was uncovered, Mr. Hevesi wanted the same deal he had given Columbia University 10 years previously. That is, he wanted to be able to just return the money and go back to business as usual with the rationale that his fraudulent behavior was “just an aberration.”
This time, however, there was a prosecutor who was not buying Mr. Hevesi’s argument. Hevesi was given a deal to either resign or face indictment.
So it was that 8 years after the Hevesi audit, a whistleblower came forward at the same prestigious New York City medical center to ‘blow the whistle’ on a particularly egregious example of endangerment of public safety.
At the Allen Pavilion division of the New York Presbyterian Medical Center, the Chairman of the Department of Obstetrics and Gynecology concocted a double-billing Medicaid scam that ran for more than 10 years (most likely with the approval of the “higher ups”). A summary of the Federal complaint provides complete details. The essence of the scam was that bills were sent to Medicaid claiming that a physician had performed a delivery when in fact there was no physician present at all and the delivery had been performed by a midwife or medical trainee.
When the alleged fraud was halted, the Columbia University’s hasty press release announced that it was discontinuing the midwife deliveries because the population was “high risk.” One midwife was told, “…85% of the patients were at risk, and that we were no longer eligible to assist…in the delivery room.” Prior to the exposure, the Hospital had deemed the same population, “low risk.”
Beyond the alleged financial crime involved, what makes the scam so abhorrent is the fact that the delivery process is always fraught with multiple dangers. Midwives were delivering babies in a “high risk” minority population from September, 1990, through January, 2001, without the immediate on site availability of a fully trained attending obstetrician who could quickly deal with the serious emergency a difficult delivery presents for both mother and child.
The Allen Pavilion serves a predominantly minority (Dominican) population in upper Manhattan. Absent any meaningful New York State regulation, the University felt they could get away with this scheme without detection. There has been no investigation of this decade long abuse to learn how many babies were damaged or how many mothers were injured by Columbia University’s alleged Medicaid fraud. (The reader will note we use the phrase “alleged fraud.” Columbia University paid $5,100,000 in December 2002 to settle the allegations but did not confess guilt. Therefore, the University’s fraud is considered “alleged.”)
The goal of this scheme was to maximize the University’s profit by submitting a double-bill to Medicaid. The University directed its attending physicians to sign charts long after a delivery was performed by a midwife – this could be from the next day to weeks or even months later. To cover their tracks, the University had to convince ‘phantom’ doctors to sign charts as though they were present in the delivery room when they were not. It was the job of the whistleblower who exposed the scheme to find doctors and bribe them with $50 per chart for their signatures.
So once again, our dysfunctional healthcare system sanctioned an operation that for over 10 years placed human life at risk for what was for them the more important goal of profit.
These fraudulent activities at one of the world’s most prestigious medical centers, the New York Presbyterian system, was just one of many dangerous abuses that have occurred in New York State.
Why would the Medical Center take such risks by engaging in acts that are obvious crimes? One clue can be found by examining the salaries of the executive staff of the Medical Center.
As reported in the New York Times, the CEO of New York-Presbyterian Medical Center, Dr. Herbert Pardes, “received more than $4.3 million in compensation in 2004, plus $1.2 million in contributions to his employee benefit plan.” Dr. Pardes is clearly one of the winners in the National Capitalist model of healthcare. His most recent salary is up to $5.9 million dollars annually. His lavish lifestyle has gained him media attention. Search “Pardes” in the highly recommended site: “Where the Money Goes” for more information. ( At “search WTMG” enter “Pardes”)
As reported in the New York Sun , following are a sample of salaries earned by executives and executive physicians at New York Presbyterian Hospital in 2003:
|Excecutive Staff Member||Salary|
|Executive Vice President Dr. Michael Berman||$1,700,000 plus $1,400,000 in “benefits”|
Senior Vice Presidents:
|More than $750,000 plus $150,000 in “benefits”|
|Steve Corwin, M.D.||$950,000 plus $181,000 in “benefits”|
|Chief Financial Officer, Phyllis Lantos*||$852,000 plus $225,000 in “benefits”|
* Note: Ms. Lantos was formerly Vice President for Financial Services at Montefiore Medical Center for 20 years during a time of major alleged financial fraud by that Hospital. . Her “financial skills” now are being put to use at Columbia University
And that’s not even counting the practicing physicians at New York Presbyterian Hospital. The following income for a sampling of physicians at the Hospital was reported for 2002:
These figures probably understate the current salaries at New York Presbyterian Medical Center as of 2007. For example, it was recently reported that a clinical professor of dermatology received $3,721,741 in 2004.
It should be noted that New York Presbyterian Medical Center is but one division of Columbia University (the Hospital is actually a joint operation of both Columbia and Cornell Universities). Dr. Pardes holds the title of Vice President for Health Affairs at Columbia University.
Yet the president of the entire Columbia University with all its undergraduate and graduate schools, Lee C. Bollinger, received only $611,000 in 2005.
Professor Bollinger cannot bill Medicare, Medicaid, and private health insurance but the hospital and its key staff can. It is an understandable conclusion that to pay for such inflated salaries, corners must be cut somewhere and chances must be taken. Taking the Allen Pavilion midwife scam as a model, for over 10 years a high-risk population was knowingly placed at further risk. The hospital’s profits, to a large extent coming from public money, enriched the coffers of doctors and the executive staff. While the Medical Center is described as a not- for- profit institution, there is certainly a lot of money being generated.
The life of anyone who exposes financial and quality care abuses in healthcare can be difficult. When Dr. Kyriakie Sarafoglou, formerly of Weill Medical College (one of the teaching divisions of New York Presbyterian Medical Center) exposed the fact that the pediatrics department was allegedly misusing a 23-million-dollar grant from the National Institutes of Health, she was demoted, denied tenure, pressured to see a psychiatrist, and eventually had to move to another state. The NIH grant was supposed to go for the development of a children’s center for the treatment of childhood AIDS and other illnesses. Little of that money seems to have gone for that purpose. The consequence of depriving the children of the care this program was supposed to provide them was never reported.
The case is interesting to read. Four armed marshals sat in a vehicle parked outside the Weill Medical College while Federal officials served the subpoena. The allegations were eventually settled with the repayment of $4.4 million in 2005. There was no investigation of the remaining $18.6 million of the grant. As quoted in the Wall Street Journal, “The Cornell (New York Presbyterian) case exposes what some scientists call a dirty little secret of university medical research: the misuse of taxpayer’s funds. The NIH last year funneled $20 billion to campus researchers, an amount that has doubled since the late 1990’s. Now, a “string of multimillion-dollar settlements by leading universities is showing how vulnerable the system has become to abuse.”
As one of his last acts in office, New York State Governor George Pataki announced that his final budget would propose a new State agency to “battle theft” in Medicaid. This was welcome news, but came at the end of a 12-year administration that progressively weakened the capabilities of any of the existing agencies that were mandated to unearth just the types of abuse taking place at the Allen Pavilion and the Weill Cornell Medical College
In March of 2005, it was announced that U.S. Attorney Christopher J. Christie was investigating allegations, denied by the University, that it had intentionally submitted fraudulent claims to the Medicare program totaling over $1,400,000.
In the case of UMDNJ, however, the Federal attorney did not stop there. A detailed investigation is ongoing into the overall operations of the University and has already found potentially provable criminal conduct. UMDNJ currently has a Federal monitor and is operating under a Federal deferred prosecution agreement.
UMDNJ, including the prestigious Robert Wood Johnson School of Medicine, has over 4500 students in its various schools as well as a full-time faculty and staff of over 11,000. It is the Nation’s largest healthcare university. The various hospitals and clinics have over 2 million patient visits annually.
On December 29, 2005, Mr. Christie announced that the University had defrauded the Government out of at least $4,900,000 in the “purposeful over-billing of Medicare.” It was reported that the Hospital administration had sanctioned this over-billing “for years.” The scheme involved billing Medicare for services by attending physicians who were not personally involved in cases. Bills were submitted to Medicare for work that interns had performed without any supervisors in violation of the Federal PATH regulations.
As reported in the New York Times of 12/29/2005, “Federal prosecutors are investigating allegations that university officials padded the payroll with patronage employees, curried favor by making contributions to elected officials and politically connected charities, doled out hundreds of millions of dollars in no-bid contracts (on some of which no work appears to have been done), and awarded huge salaries and bonuses to top officials.” An editorial in the New York Times reported that $700,000,000 in “no-bid” contracts was made in a 5-year period to “politically connected recipients, some of which did little or no work for the money. Jobs were filled by patronage. School funds were siphoned off for campaign contributions to elected officials. Lavish perquisites and bonuses were given to administrators. The board was riddled with conflicts of interest.”
In response to his investigations, Chistie told the hospital administration that he had sufficient evidence to criminally charge the University. He demanded that a Federally hired monitor assume control of the finances of the university as a precondition to avoid indictment.
The point of this discussion of crime in the nation’s largest healthcare teaching university is that there is a direct link between financial criminality and patient harm. Who knows how many people were injured or killed by the lack of appropriate supervision of house staff? What is certain is that the administration of the UMDNJ treated the Medicare/Medicaid budget as though it were a private bank from which it could make withdrawals at any time. Ultimately this involved stealing already limited financial resources from the poor and elderly.
The November 17, 2006 issue of the New York Times reported on one scheme at UMDNJ where cardiologists were recruited with “no-show” jobs as part-time clinical associate professors. They were paid $150,000 or more yearly “solely for referring their patients to the university hospital.” The Federal prosecutor, Herbert Stern, reported that the hospital was “feverishly bent on increasing the number of heart procedures at the school…”
Mr. Stern went on to allege that when these allegations were first raised, the interim President of the University, Bruce Vladek (formerly director of the Medicare and Medicaid program during the Clinton Administration, and who is being paid $525,000 annually to clean up the mess at UMDNJ) had actually attempted to cover up the cardiology kickback scheme. From the New Jersey Star Ledger on 11/12/06, “…(the report) set off a maelstrom of activity by Vladekand others to discredit its conclusions.”
Six million dollars was allocated to just 18 cardiologists by UMDNJ to ensure the success of this big business venture. On 11/17/2006, it was reported that over a 4-year period the University took in nearly $36,000,000 in illegal Medicare and Medicaid payments for 2,733 cardiac procedures on hundreds of patients. The unanswered question is: how many of these procedures were really necessary and were patients exposed to unnecessary risks so that the Hospital could make more money? How many died, as they did at the Tenet Redding California Hospital, where the Federal inspector found 167 deaths among Medicare patients who had up to 50% unnecessary cardiac procedures during a 3-year period? The amount of injury and death to non-Medicare patients at the Tenet Redding California Hospital is uninvestigated and unknown.
Our final point of this discussion of UMDNJ is a question. Of the many cases of alleged fraud we have discussed above, in how many would similar abuses be found were there to be a vigorous criminal investigation of the hospitals?
Finally, here is an example of an egregious scheme concocted under National Capitalism to keep the dysfunctional healthcare system profitable.
A great shock often awaits the uninsured when they go to pay their medical bills. More often than not, the bill a patient without insurance is expected to pay the hospital is much higher than the bill an insurance company would have to reimburse the hospital for the same service. For the uninsured patient, the hospital will use the full panoply of collection techniques. These include referring the unpaid bill to a collection agency and going to Court to seize the assets of the uninsured patient. More than 50% of all personal bankruptcies are due to an inability to pay medical bills.
In New York State, after collection efforts are abandoned (presumably leaving many impoverished and on welfare, having lost all their money trying to pay their medical bills), the hospitals then turn to a fund set up by the State to pay uncollected patient debt. Shamelessly, hospitals often defraud the State by presenting charges that are 100% (or even more) higher than the amount of money they actually spent in providing the care.
Mismanagement, corruption, and fraud pervade the United States healthcare system. Comprehensive improvements have yet to occur, since effective regulation is thwarted by politically powerful interests who benefit from the system as it functions now.
Regulation, or rather the absence of regulation, is what connects our dysfunctional, fraudulent healthcare system and patient harm. Hovering in the background of all the cases of fraud we have discussed is the sad fact that, for all too many providers, delivering high quality healthcare has not been the primary concern.
The quality of care in a system so riddled with fraud and corruption is bound to be poor. In fact, the World Health Organization found that the United States healthcare system ranks only 37th in overall quality when compared with other nations. There is a conflict between the need to provide quality care to patients and the ever-increasing financial benefits to those who make their livelihoods from healthcare. The vast sums of money that the stakeholders (insurance companies, drug companies, managed-care companies, hospital administrators, physicians, politicians, and the like) are able to amass has prevented the development of the type of high-quality, well-regulated healthcare the people need. A fundamental tenet of National Capitalism–that when each individual is pursing his or her self interest, this will eventually lead to general improvements for all–does not apply in healthcare. The result of our unregulated, money-driven health delivery system is much more serious than just its financial abuses.
The final common pathway is iatrogenic patient injury and death. So-called “errors” are rampant. Each and every American is either the victim of a malpractice, is related to, or knows someone who is the victim of medical malpractice. Conservative estimates have the rate of medical malpractice deaths at around 100,000 annually. Other estimates range to over half a million.
Lucien Leape, M.D., a professor of Public Health at Harvard University and retired pediatric surgeon, published what is still the most comprehensive study of medical malpractice in the United States (see A Measure of Malpractice, Harvard University Press, 1993). In response to Dr. Leape’s landmark statistical analysis, in which he documented that upwards of 100,000 people lose their lives each and every year to medical error, the American Medical Association developed the National Patient Safety Foundation whose mission it is to study and improve the safety of patients in the healthcare system. The NPSF quickly announced that it was “system dysfunction” that was at the root of medical error. But in our opinion, the NPSF has basically been an attempt of organized medicine to preserve the status quo of the American healthcare system, particularly its financial structure, while tinkering at its margins.
Organized medicine is most concerned that the public be convinced that it is able to manage its own shop and effectively deal with the problems in healthcare delivery without government intervention and regulation. By far the most elaborate initiative in this regard is that mounted by Dr. Donald Berwick, founder of the Institute of Healthcare Improvement (IHI).
On June 14, 2006, Dr. Berwick announced that IHI’s “100,000 lives” campaign had succeeded. Eighteen months previously he had enlisted the cooperation of 3,100 hospitals in following a 6-step plan to reduce the amount of lethal medical error. These simple steps included preventing respirator pneumonia, preventing IV-catheter infections, stopping surgical-site infections, responding rapidly to early warning-signs, making heart-attack care absolutely reliable, and finally stopping medication errors. In June, 2006, Dr. Berwick announced that that lives of an estimated 122,300 people had been saved who would otherwise have died had his advice not been taken.
The publicity surrounding these findings certainly was designed to convince the public that organized medicine can successfully fix its own problems without government intervention.
Several observations, however, are in order:
Dr. Berwick has even acknowledged that there is no verification (see #2 under Terms and Conditions) that the data reported to IHI is in fact truthful. Others have also questioned his claims.
The essential message of the Joint Commission on Hospital Accreditation, the National Patient Safety Foundation, Dr. Berwick’s Institute for Healthcare Improvement, and several other groups that include CAPS, Sorry Works, etc., is that the healthcare industry can regulate itself. The healthcare industry – that is, physicians, pharmaceutical companies, for profit and not-for-profit hospitals, healthcare insurance companies, and HMO’s – are a vast guild that is highly profitable for a select few. They are the winners in the race for profits under the healthcare component of National Capitalism. Vast sums are spent on assuring that the right politicians are elected who will not tamper with this system. For any meaningful tampering, that is, honest regulation, might severely limit their profits. Vast sums are spent convincing the public that “American Medicine is the best in the World.” Sadly, the facts are exactly the opposite.
Organized Medicine wants the public to believe the old-time image of the doctor as the caregiver who puts saving lives as the highest goal (not profit). One of the messages of the healthcare industry is that nothing should come between the doctor and his patient. This is a way of saying, “no regulation of healthcare.” Dr. Berwick has been one of the most vociferous in advancing this line. He has suggested, for example, that doctors must be free to break rules. This is equivalent to claiming that doctors must be free to make their own rules. We know of one case to illustrate the point that surely there are medical rules that must not be broken. In this case an 11-year-old-child, already febrile and septic with both streptococcus and staphylococcus bacteria, was rushed to the operating room, without a pre-op x-ray or blood work, to have his infected ankle incised and drained. A chest x-ray taken in the operating room after the first of several cardiac arrests disclosed that he had bilateral pneumonia. Hours later, after several more arrests, he died. A chest x-ray prior to the surgery would have quickly alerted the physicians to transfer him to the intensive care unit where he could have received intravenous antibiotics before any surgery was even contemplated. The need to have an x-ray and blood work prior to surgery is an example of what should be known as a “medical law”, the transgression of which would be not just an “error” but a “medical crime.” Organized medicine certainly does not want to hear this. One of the criminal law’s chief purposes is to provide a warning to others not to engage in behaviors that can cause injury and death.
The doctors in the above case were reckless in not obtaining blood work and a chest x-ray prior to surgery. These doctors should have been charged with the crime of reckless endangerment. While such physician behavior in Germany would lead to a criminal charge, criminal indictment for medical recklessness rarely occurs in the United States. It is unknown what percentage of medical malpractice involves recklessness to a degree that criminal penalties should be invoked as a deterrent.
But make no mistake about it. In the pursuit of profits, there can be a sinister side to physicians, a side that borders on murder. One example of this can be found in a case in Long Island, New York, at the North Shore University Hospital, a Division of the North Shore Long Island Jewish Health System. This Hospital is another ardent supporter of Dr. Berwick’s Institute of Health Improvement.
From 1993 through 2001, 10 patients at the North Shore University Hospital developed Hepatitis C after being on the cardiac service of that hospital. Eight of these patients had their surgery performed by one surgeon, Dr. Michael Hall. It emerged in a medical malpractice lawsuit (Beatrice Putter, etc., et al v. North Shore University Hospital, et al) that “…correspondence from the Nassau County Department of Health (the hospital is located in Nassau County, Long Island, New York) to the New York State Department of Health reflects that the hospital infection control director and other appropriate individuals knew for several years that the surgeon had been infected with Hepatitis C.” The surgeon was diagnosed in 1989 and Mr. Putter’s cardiac surgery was in 1993.
There was no treatment for viral Hepatitis C at the time Mr. Putter and the others were infected. Hepatitis C often leads to Cirrhoses of the liver and death. Yet because the heart surgeon was talented and a high earner on the cardiac service (he is now chief of service), for the sake of profit, the hospital did not stop him from performing surgery even when his infection was disclosed to them. Certainly his surgeon’s illness was not disclosed to Mr. Putter. Profit was more important than life. The knowing and willing placement of patients at risk of death, in our opinion, constitutes second degree murder. This risk was well beyond simple error and certainly not “system error” as Dr. Berwick would have us believe.
Nearly 3,000 people died in the World Trade Center collapse and the Nation has been transfixed and fearful ever since. The leaders of healthcare such as Drs. Berwick, Leape, and O’Leary have acknowledged that over the years millions have died unnecessarily from bad healthcare, and yet there has been scarcely a ripple heard from the public. This lack of mass reaction is a tribute to the skilled use of the science of public relations to shape the public’s beliefs about the state of their healthcare. An example of the skillful use of public relations techniques is Dr. Leape’s comment to the NPSF that he wants “to desensitize people” regarding medical errors and “get them to realize” that errors arise out of a “defective system.” In our opinion, the NPSF, IHI, and other such operations have been primarily designed to “desensitize” and defuse public anger. While these organizations give lip service to the need to repair a defective system, they have yet to publicly embrace the fundamental reform and restructuring of healthcare that can only take root under a single payer system.
“You cannot fool all of the people all of the time,” said Carl Sandburg, quoting Lincoln. (The People, Yes, Harcourt Brace & Company, 1936). To date Organized Medicine has been successful in doing just that. But there are indications that this massive cover-up may be coming undone. The recently released Michael Moore movie “Sicko” graphically displays just how dysfunctional our healthcare system really is. The decisions of politicians under National Capitalism to support the healthcare monolith may quickly change once the public understands that the greed of the few has placed lives at risk.
The financial fraud and patient-care abuses that are rampant in healthcare require a system of regulation analogous to the manner in which the Federal Aviation Administration oversees the airline industry. Each state has a degree of medical regulation carried out by their medical boards; but the system varies in its effectiveness and is subject to local political pressures. The state medical boards are incapable of fighting the vast amount of abuse exposed in this document.
The push on the part of Federal prosecutors to go after fraud and corruption is, in its own way, actually a step towards imposing national regulation on the healthcare industry. Regulation is what the healthcare industry fears most. The multitude of Qui Tam suits, just a few of which we report above, suggests that the government is aware that something must be done. Unfortunately, this “regulatory” approach hinges on the willingness of a whistleblower to come forward. Much crime is still well hidden because no one is willing to blow the whistle. Only a fraction of healthcare fraud is ever discovered.
Since its inception in 1965, the Medicare program has had an initiative devoted to the “quality problem“. There are now 51 taxpayer-funded contractors, called Quality Improvement Organizations (QIO’s), in 50 states that are supposed to assist healthcare providers in improving the care to Medicare beneficiaries.
Their mandate has been to monitor all phases of the Medicare program on the local level. The fiscal and quality-of-care abuses uncovered by the Qui Tam suits all occurred in spite of the existence of the QIO’s.
In March, 2006, the Institute of Medicine issued the Medicare’s Quality Improvement Organization Program: Maximizing Potential, a report very critical of QIO’s as they now function. This followed a series of articles in the Washington Post in July, 2005, that discussed findings from the John’s Hopkins Bloomberg School of Public Health that concluded that hospitals working with QIO’s were no more likely to show improvement than hospitals that did not take part in the program.
It is beyond the scope of this paper to go further regarding Quality Improvement Organizations. It is sufficient to note that recent developments suggest that Congress has gotten the message. All the money spent on healthcare has not bought United States citizens a first-class healthcare system. What it has bought is a system riddled with fraud, and a system that all too often maims and kills.
Senator Charles E. Grassley, former Chairman of the Senate Finance Committee, has initiated a broad reform of the QIO program. He also drafted part of the Deficit Reduction Act, signed into law in February, 2006, that requires healthcare employees to “…ferret out fraud and report it to the government…” (see New York times, 12/24/06). This same article noted that in the fiscal year ended 9/30/06, more than $3.1 billion dollars was recovered by the Government in fraudulent claims, 72% of which was from healthcare fraud.
The various articles in http://www.citizens-for-medical-safety.com present a broad vision for healthcare reform. There is a long-overdue need in the United States for a well-regulated, Federally financed healthcare system – a system with regulators to enforce the practice of safe medicine. Our healthcare system must be based on the sanctity of human life as the highest value, not the focus on profit that is central to the workings of National Capitalism.
A Federally financed healthcare system (“single payer”) is needed before an effective regulatory system can be put into place (we have suggested a National Medical Board under which the 50 State Boards are subsumed and which would then implement regulatory reform.) Dr. Don Sloan’s recently published book, Practicing Medicine Without a License: The Corporate Takeover of Healthcare in America (Caveat Press, 2006), provides the most comprehensive guide to the ways in which corruption has led us into the current healthcare morass. The book presents a powerful argument as to why single payer financing is urgently needed in the United States.
Of course, the healthcare industry is “tooling up” to ensure that powerful politicians are brought into line and never back such a system. It was recently reported, for example, that the health insurance industry has already funneled over $1,000,000 into Senator Hillary Clinton’s campaign coffers.
In signing up for the “100k lives Campaign” of the Institute of Healthcare Improvement (IHI), hospitals were told that “Each participant, and not IHI, is responsible for the truth, completeness and accuracy of any and all submitted data submitted by such participant to the Campaign, and all such information is used in the Campaign “as is” by IHI without verification.”
In other words, Dr. Berwick is telling the public that the healthcare system can be trusted. But given all the documented iatrogenic injury, death, and fraud in the system, can this assertion be believed? Is there any other institution in our culture — for example the airline industry, the automobile industry, service providers such as the police, fire and utility industry, the insurance industry, the financial industry, etc — where the public would be content with accepting the word that they were “doing the right thing?”
No. What the public needs and wants is for physicians like Dr. Don Berwick (who earned over $500,000 for his entrepreneurial efforts) and Dr. Herb Pardes (who makes over $6,000,000 a year) to become part of a national medical regulatory system. The Institute of Healthcare Improvement, the National Patient Safety Foundation, the Government’s Agency for Healthcare Reform and Quality, and others have developed valuable insights into how medical care can be safely delivered. Now, these insights must be mandated and not be, as they are now, voluntary. It is as though in healthcare regulation currently there are Ten Suggestions rather than Ten Commandments.
There is a conflict between “We, the People” and National Capitalism. On the one hand our Constitution directs us to improve the “common good”, and on the other, it gives us the right to “…pursue happiness.” More often than not, the pursuit of happiness means the pursuit of the wealth of National Capitalism.
Nowhere is this conflict more evident than in the working of our healthcare system. While attempting to “provide for the common good” with high-quality healthcare, it is also a major source of jobs and, for the privileged few, unimaginable wealth. But the system is dysfunctional and riddled with massive corruption and danger.
In the conflict between “We, the People” and the National Capitalists, the Capitalists have the upper hand with their control of the media. The media furthers their agenda. For example, whenever the concept of Single Payer healthcare financing is mentioned in the media, the coupled message is always presented, “It’s not politically possible.”
What does this mean: “…not politically possible?” It means that the National Capitalists will spare no expense to convince our politicians that their support or even mention of the concept of single payer is dangerous to their political futures. And the media will always dismiss any real discussion of the merits of Federally financed healthcare.
Carl Sandburg’s “The People, Yes” had an idealistic notion of the American experience. Sandburg’s vision of America was that the People would eventually choose leaders and a government that would work for them. Quoting Lincoln, once again, “A Government that would “…do for them what they cannot do for themselves.”
But there is a darker vision for America’s future. Martin Mayer, in They Thought They Were Free (The University of Chicago Press, 1955), notes that upon returning from a defeated Nazi Germany he thought, “What I was not seeing was German Man, but rather Man.” American Man is still Man and we are capable of behaving in ways no less base than the Germans under National Socialism.
The descent into the Nazi years was gradual and incremental for the German people. As is true in the United States in our time, the German citizen was plagued with economic insecurities and the fear of foreign dangers (in their case, Communism, in our case, Radical Islam.) Governed by this fear, the nation of Germany threw morality out the window.
As the reader has seen in Terminal Condition, morality is often thrown out the window as our healthcare system serves to enrich the few at the expense of suffering patients. So what if millions of people do not have insurance, we are told; millions more do and therefore it’s all right.
They Thought They Were Free talks about this denial of responsibility: “Responsible men never shirk responsibility, and so, when they must reject it, they deny it. They draw the curtain. They detach themselves altogether from the consideration of the evil they ought to, but cannot contend with. Their denial compels their detachment” (p76).
The “…denial of responsibility” by our politicians does not mean they are Nazis. But it does mean that in an issue that literally affects millions upon millions our leaders are exhibiting dangerous symptoms of Nazism. In the healthcare issue, there is a conversion of the extremes between National Capitalism and National Socialism. Economic considerations in both systems can have a value even more important than human life.
The question for our time is just how serious this “symptom” is? Once again, it is instructive to re-read the recollection of a German who lived through the Nazi years in They Thought They Were Free (pp167-168)
“…we were decent people – and kept us so busy with continuous changes and crises and so fascinated, yes fascinated by the machinations of the national enemies, without and within, that we had no time to think about these dreadful things that were growing, little by little, all around us. Unconsciously, I suppose, we were grateful. Who wants to think?
To live in this process is absolutely not to be able to notice it – please try to believe me – unless one has a much greater degree of political awareness, acuity, than most of us had ever had occasion to develop. Each step was too small, so inconsequential, so well explained or, on occasions, ‘regretted,’ that, unless one were detached from the whole process from the beginning, unless one understood what the whole thing was in principle, what all these ‘little measures’ that no ‘patriotic German’ could resent must some day lead to, one no more saw it developing from day to day than a farmer in his field sees the corn growing. One day it is over his head.”