Quackery of a different kind than I usually write about, part 2

About a week and a half ago, I wrote about a local oncologist who was arrested by the FBI for massive Medicare fraud in which physician involved diagnosed cancers that weren’t there, gave chemotherapy to patients who either didn’t have cancer or were in remission and thus didn’t need it, and had developed a self-referral system to his own imaging facility. The story of this oncologist, Dr. Farid Fata, founder of a very large multi-location oncology practice (Michigan Hematology Oncology), made international news, which is exactly not the sort of coverage Detroit needs right now, given all the other badness happening at the moment, such as the city going into bankruptcy. It doesn’t matter that Dr. Fata didn’t practice in Detroit proper, but rather in the tony northern suburbs; his actions reflect on the region.

The scope of the misdeeds of which Dr. Fata is accused is truly staggering: Over $150 million in Medicare billing and collecting $62 million over the last three years, the percentage of which was fraudulent currently unknown. Over the last two years he billed $24 million for chemotherapy, by far the most of any oncologist in the state of Michigan (Dr. Fata did treat patients who actually did have cancer and who did need chemotherapy; so it’s hard to tell how much of his billing was appropriate and how much was fraudulent):

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The last time around, I touched on how cases like this one represent a profound failure of state medical boards. There is little doubt that, as the story evolves, the state medical board here in Michigan screwed up big time. Whether it tried to do the right thing and failed due to lack of resources or the way the law is written or whether there were other reasons, we don’t know. What we do know is that the medical board failed—and failed massively—in this case. The indications were there. The complaints were there, as we will see. The suspicions were there. But nothing happened until the feds noticed his fraudulent Medicare billing. Indeed, I wonder how he got away with his Medicare billing for so long, given that he saw 70-80 patients a day and billed the maximum level for most of them. That’s usually an enormous red flag. Indeed, at a recent meeting for families of patients of Dr. Fata, one patient’s son reported:

When Matt Fiems of Canton began taking his mother, Susan, of White Lake, to Dr. Farid Fata’s former Michigan Hematology Oncology office in downtown Rochester in 2007 for treatments for ovarian cancer, he was taken aback by the size of Fata’s operation.

“I called it Fata Incorporated,” he said. “Once you were referred, you got his diagnosis, his prescription of chemotherapy at his infusion centers.”

The operation was so large, in fact, Fiems said he and his mother had a difficult time finding a seat in the waiting room, which he said would overflow with patients on a regular basis.

“His offices were always very crowded,” he said.

There had been several complaints as well:

One person who says she spotted—and reported—warning signs is oncology nurse Angela Swantek of Shelby Township, who visited Fata’s former downtown Rochester office in 2010 while looking to work closer to home.

“Within 15 minutes of being in his office, I knew there was no way I’d be accepting a position in his office,” Swantek said, noting she observed improper mixing and administering of chemotherapy. Swantek said she notified the Michigan Department of Licensing and Regulatory Affairs about her concerns, but was told 13 months later by the department that no violations could be found.

“When I reported him to the state, my complaint was strictly about patients being mistreated,” she said. “It had nothing to do with overbilling or misdiagnoses.”

This is pretty blatant, if a job candidate being given a tour of a facility as part of her job interview can so readily spot the improper handling of chemotherapy. As noted in the previous story I cited, much of this mixing was done without a pharmacist supervising the process.

It also turns out that the medical community was also suspicious. Because of where Dr. Fata practiced, I don’t recall ever having personally dealing with any of his patients, but speaking with some of my colleagues over the last couple of weeks has been—shall we say?—illuminating. Apparently Dr. Farid was incredibly aggressive about protecting what he viewed as his prerogatives and not exactly shy about throwing his weight around on the basis of the revenue that he generated for his home base of Crittenton Hospital. If what I’ve been told is to be believed, he would chew out referring physicians if they sent patients to other hospitals or cancer centers in the area, telling them that they “owed” him a certain number of patients referred to him to make up for it and would go ballistic at his staff if one of his patients sought a second opinion. This behavior strikes me as consistent with reports in the legal complaint against him that he would berate his staff if they scheduled PET scans or other tests at facilities that he didn’t own or have an interest in. I also learned from my colleagues that apparently Dr. Fata would routinely use the threat of taking all his patients elsewhere to get whatever he wanted from Crittenton Hospital. It was an effective threat, because he brought a lot of revenue to the hospital.

Unfortunately, as a story from last year from a local magazine demonstrates, Dr. Fata is not the only doctor apparently got away with bad behavior for a long time, with the state medical board doing, in essence, little or nothing about it:

But enforcement is getting less, not more, strict.

Wolfe notes that the rate of serious discipline — revocations, surrenders, suspensions, and probation/restrictions — was 20 percent lower in 2010 (2.97 actions per 1,000 physicians) than the peak rate in 2004 (3.72 serious actions per 1,000 physicians), with considerable evidence of under-disciplining physicians.

“At this point, with all that’s been written, I would think they’d [state medical boards] be hyper-aware of protecting patients,” says Bill Heisel, contributing editor/blogger for Reporting on Health. “They will usually plead poverty and say they don’t have the money and people to go after doctors.”

Wolfe agrees. “Most states are not living up to their obligations to protect patients from doctors who are practicing medicine in a substandard manner,” he wrote in 2011 at the posting of Ranking of the Rate of State Medical Boards’ Serious Disciplinary Actions, 2008-2010, on Public Citizen’s website.

Michigan ranked 38th in the study, and has ranked from 37th to 40th since 2003 (with the higher the number, the worse the showing).

I’ve written about this before in the context of various “complementary and alternative medicine” (CAM) quacks who practice with seeming impunity, whom state medical boards have been unwilling or unable to shut down. Examples include Dr. Rashid Buttar in North Carolina and Dr. Rolando Arafiles in Texas. (And don’t even get me started on the Texas Medical Board and Stanislaw Burzynski.) Then there’s Dr. Mark Geier in Maryland and multiple other states. The only good thing about the Geier case is that, once Maryland finally after decades pulled his medical license, the other states where he was licensed to practice medicine followed suit reasonably quickly because losing your license in one state can be a grounds for pulling it in other states. Sadly, Michigan is far from alone, as this recent story in USA Today, Dangerous Doctors Allowed To Continue Practicing, shows:

Despite years of criticism, the nation’s state medical boards continue to allow thousands of physicians to keep practicing medicine after findings of serious misconduct that puts patients at risk, a USA TODAY investigation shows. Many of the doctors have been barred by hospitals or other medical facilities; hundreds have paid millions of dollars to resolve malpractice claims. Yet their medical licenses — and their ability to inflict harm — remain intact.

The problem isn’t universal. Some state boards have responded to complaints and become more transparent and aggressive in policing bad doctors.

But state and federal records still paint a grim picture of a physician oversight system that often is slow to act, quick to excuse problems, and struggling to manage workloads in an era of tight state budgets.

When I write that I believe that there should be one standard, a science-based medical standard, for determining what treatments fall within the standard of care, I mean it for all doctors. While it is true that I write about this issue mostly in the context of protecting the public from CAM practitioners, it goes far, far beyond that. I also mean it with respect to all doctors. To me, it is the same issue if a CAM doctor is prescribing drugs that can’t possibly help but can definitely harm or a cancer doctor in Michigan is prescribing chemotherapy drugs to patients with advanced cancer who can’t possibly be helped by them but whose quality of life in their remaining months or weeks can definitely be destroyed by them. The issue is to protect patients from the bad behavior of doctors.

There are three main points where bad doctors can be shut down. (At least, that’s the way it’s supposed to be.) The first, of course, is licensure by state medical boards, but, as we have seen, the oversight by these boards is frequently quite lax. True, it’s not lax in all states, but at the very best it can be described as highly variable. The second is credentialing by hospitals. In general, however, it’s hard not to be credentialed by a hospital where you want to practice, particularly if, like Dr. Fata, you did your oncology training at Memorial Sloan-Kettering. Often, if a physician is denied credentialing at a hospital, it is not uncommonly for reasons other than medical training and skill, such as rival physicians not wanting to let a competitor in on their home turf. Yet, apparently a local hospital did deny Dr. Fata privileges, as reported above. The problem is, if you’re a physician with an active practice, hospitals are highly unlikely to deny you credentials unless the evidence that you practice substandard medicine or engage in unethical or illegal activity is impossible to ignore. Take the example of Crittenton Hospital, which basically appears to have let Dr. Fata do whatever he wanted, as long as he kept that sweet, sweet money flowing. The final point of impact is being credentialed as a provider in insurance plans. However, insurance plans are unlikely to deny a physician membership in its health plans unless there have been multiple malpractice suits or other indications of problems.

Finally, there is a developing fourth point of impact, and that’s the way Dr. Fata was taken down: Being busted by the feds for Medicare fraud. However, that can only happen if there is actual evidence that a doctor is committing Medicare fraud, something that might or might not be related to substandard patient care. Often the two go together, but not necessarily. It is possible to provide adequate care and still defraud the government.

So what to do? Clearly, at the very least, state medical boards, particularly those that are substandard, need to be empowered and funded to do their jobs. That, at least, is a start. There also needs to be a shift in the culture of medicine in which physicians and other health care professionals who observe behavior like Dr. Fata’s report such doctors to the state medical board. Surely, lots of oncologists saw Dr. Fata’s patients as second opinions and were disturbed by what they saw him doing. Did any of them report their concerns to the state medical board? To me, it doesn’t matter if it’s an alternative medicine quack, a fraudster treating patients inappropriately with chemotherapy in order to bilk Medicare and Medicaid, or a doctor administering unapproved drugs or potentially toxic unvalidated cocktails of chemotherapy and targeted agents to patients. We as a medical profession need to protect patients from them all.