The idea that you can visit a doctor and become worse, seems like an outcome belonging to medieval times, but an investigation in The New York Times shows how profit incentives can drive hospitals to recommend more excessive procedures for patients even if the procedures are unnecessary and risky. In today's case, the spotlight is on HCA, the country's largest for-profit hospital chain, which still has quite a lot of explaining to do.
Through internal documents and interviews, The Times' Reed Abelson and Julie Creswell found that cardiologists at HCA hospitals could not justify a number of procedures that in many cases badly injured and extended the hospitalization of patients. For instance, at one hospital, doctors were performing half of all cardiac cauterizations, an invasive diagnostic test, on patients without significant heart disease. (That happened 1,200 times.) At another hospital, "43 percent of 355 angioplasty cases, where doctors performed invasive procedures to open up a patient’s arteries, were outside reasonable and expected medical practice." As an example of the kind of damage unnecessary cardiac procedures can cause, Abelson and Creswell cite an internal memo where a 44-year-old man went to the emergency room complaining about chest pain and wound up with a punctured blood vessel and near-fatal irregular heartbeat after doctors undertook procedures an outside expert said might not have been necessary. Fortunately he survived: “They shocked him twice and got him back,” Dr. Aaron Kugelmass is quoting as saying in a testimony. An incentive in all of this is the amount the hospitals can charge to Medicare: about $10,000 for a cardiac stent and about $3,000 for a diagnostic catheterization, making it one of the most lucrative aspects of its business. "HCA has more than 100 catheterization labs across the country and the one at Lawnwood [hospital] was a financial juggernaut. It accounted for 35 percent of the hospital’s net profits, according to financial documents."
So what's HCA's response to all of this? Jumping the gun a little bit, the company made its case to the public before the Times story even came out on its website yesterday. It's basically a two-pronged response. First, is that HCA hospitals are performing fewer cardiac catheterizations than they used to as per this chart:
The company doesn't really explain the reduction in procedures but notes that there is a "debate within the cardiology community" across the country about what procedures are medically necessary.
Second is to point out that HCA hospitals have a pretty good record on patient care outcomes compared with other hospitals. "One of the most widely-accepted sets of clinical quality measures is the 'Core Measures,'" the site notes. "More than 90 percent of HCA hospitals are in the top quartile nationally on Core Measures, and more than 80 percent are in the top 10 percent." It adds that it received about 20 million visits to its facilities just last year, so you know, not everything is destined to turn out perfect with those numbers.
What's left unanswered is some of the staggering statistics coming out of some of HCA's hospitals. Why are half of all cardiac cathetizations at one of its Florida hospitals, a $3,000 procedure, done on patients without significant heart disease? And what explains the 43 percent of clogged artery angioplasties that were deemed "outside reasonable and expected medical practice" at another HCA hospital? Brushing those aside and saying overall, most of its hospitals run really well is a copout for HCA.
It's possible the company is still preparing more statements as more reporting comes out. In a conference call yesterday, HCA CEO Richard Bracken said "the Times may be preparing more than one story about the company and that the newspaper had also asked about wound-care practices, treatment of uninsured patients and emergency-room procedures," Bloomberg's Alex Nussbaum reports. While that may be the case the company's posture appears to be to remain tightlipped at the moment. Following yesterday's release, it said "The Company undertakes no duty to update or further comment on this matter." Yesterday, market analysts also wondered whether Mitt Romney could be dragged into this given that Bain Capital is HCA's largest shareholder. That's yet to be seen because Romney left the company as CEO and chairman years ago. But clearly, HCA still has some work to do to explain to potential customers how it justifies the level of cardiac procedures at some of its hospitals.