Hospitals Performed Needless Double CT Scans, Records Show

Performing two scans in succession is rarely necessary, radiologists say, yet some hospitals were doing that more than 80 percent of the time for their Medicare chest patients, according to Medicare outpatient claims from 2008, the most recent year available. The rate is typically less than 1 percent, or in some cases zero, at major university teaching hospitals.

Next month, the Center for Medicare and Medicaid Services is expected to release figures for 2009, but according to people who have seen the numbers, the practice of double scanning chest patients has continued.

“When I saw the 2009 numbers, they were the same essentially, and I was disquieted by that,” said Dr. Michael J. Pentecost, a radiologist and Medicare consultant who also reviews claims for commercial clients.

The overuse of scans has been the subject of growing concern in recent years, but a review of the federal data, focusing on a common procedure performed millions of times a year, offers a rare and detailed snapshot of the problem state by state, hospital by hospital.

In 2008, about 75,000 patients received double scans, one using iodine contrast to check blood flow, and one that did not. “If you do both, you bill for both,” Dr. Pentecost said.

Radiologists say one scan or the other is needed depending on the patient’s condition, but rarely both. Double scanning is also common among privately insured patients who tend to be younger.

Double scans expose patients to extra radiation while heaping millions of dollars in extra costs on an already overburdened Medicare program. A single CT scan of the chest is equal to about 350 standard chest X-rays, so two scans are twice that amount.

“The primary concern relates to radiation exposure,” said Dr. James A. Brink, chief of diagnostic radiology at Yale-New Haven Hospital, where double scans accounted for only a fraction of 1 percent of cases. He added: “It is incumbent upon all of us to limit it to the amount needed to make a diagnosis.”

Officials at hospitals with high scan rates said radiologists ordered the extra chest scan figuring that more information is better. In rare instances, the two scans might help a doctor distinguish between tangled blood vessels and a tumor, Dr. Pentecost said.

The Medicare agency distributed the data to hospitals last year to show how they performed relative to each other and to encourage more efficient, safer practices. The review of that data found more than 200 hospitals that administered double scans on more than 30 percent of their Medicare outpatients — a percentage that the federal agency and radiology experts considers far too high. The national average is 5.4 percent.

The figures show wide variation among states as well, from 1 percent in Massachusetts to 13 percent in Oklahoma. Overall, Medicare paid hospitals roughly $25 million for double scans in 2008.

Double scanning is more likely to occur at smaller, community hospitals such as Memorial Medical Center of West Michigan in Ludington. It gave two scans to 89 percent of its Medicare chest patients..

“We aren’t radiologists, but as we understand the practice, it was strictly a matter of physicians, independent practitioners who were doing their best to get to the bottom of what was ailing their patients,” said Bill Kerans, a spokesman for that hospital.

Since 2008, Memorial Medical Center lowered its rate to 42.4 percent in 2010 and to 3 percent in the first part of 2011. “We have made some dramatic changes in protocols and practices,” Mr. Kerans said.

A few large hospitals have had problems as well. St. John Health System in Tulsa double-scanned 80 percent — or 800 of its Medicare outpatients in 2008. “We recognized in late 2008 and early 2009 those numbers were higher than we needed to be,” said Charles Anderson, the hospital’s president and chief executive.

By changing protocols, the percentage of double scans is now “hovering around 5 percent,” Mr. Anderson said. “What that means for us is when a physician orders a scan from a radiology department, the radiologist begins to engage in a conversation with those physicians, talking about what might be a more reasonable and acceptable approach.”

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Jury Rejects Missouri Hospitals’ Case Against Tobacco Firms

About 40 Missouri hospitals sued the Philip Morris unit of the Altria Group, the R. J. Reynolds Tobacco Company, the Lorillard Tobacco Company and other cigarette makers in 1998, claiming they manipulated the nicotine content in cigarettes and misrepresented the health effects of smoking. The hospitals were seeking more than $455 million in damages, ranging from about $300,000 for some hospitals to $86.4 million for the Truman Medical Center in Kansas City, Mo.

The hospitals argued that the industry’s actions had raised spending for unreimbursed and uncompensated tobacco-related health care. The tobacco companies denied any responsibility for patient care costs at the hospitals or any financial losses by the hospitals. The jury, in Missouri Circuit Court in St. Louis, rejected the hospitals’ claims on a 9-3 vote Friday in the seventh day of deliberations.

“The jury correctly rejected the entirety of the hospital’s claims,” Murray Garnick, associate general counsel for Altria Client Services, said in a statement. The jury agreed with Philip Morris “that ordinary cigarettes are not negligently designed or defective,” he said.

The hospitals haven’t decided whether to appeal, their lawyer, Kenneth Brostron, said.

The case is the third such health care cost-recovery claim to reach trial, according to regulatory filings by Altria. The tobacco industry won the first, in Ohio, in 1999. The second initially resulted in a $17.8 million award for a health insurer by a New York jury in 2001. That was reversed on appeal in 2004.

The Missouri suit, which did not include patients as plaintiffs, went to trial in January.

The hospitals, which provide care to indigent patients and others who do not pay, represent the majority of licensed, adult acute care hospital beds in Missouri, according to the complaint. The hospitals said medical ethics required them to serve people in need regardless of their ability to pay.

Tobacco companies should reimburse the hospitals for care provided to patients who were unable to pay and were suffering from tobacco-related illness, the plaintiffs said. Hospitals also should “recover the increased costs incurred to providing all health care services” as a result of tobacco use and exposure to tobacco smoke, according to the complaint.

 

The Texas Tribune: Children’s Hospitals See Peril in Proposed Budgets

Despite some efforts to ease the blow to pediatric health care providers, Texas’ proposed budget cuts will most likely have a disproportionate effect on children’s hospitals. The financial implications will not mean halting operations, or necessarily curbing care, advocates for the hospitals say. Instead, said Ben Melson, chief financial officer at Texas Children’s Hospital in Houston, the result will be cutting back on expansions needed to serve a growing population and on efforts to recruit and retain the best specialists and faculty.

The reason for the heavier impact hinges on Medicaid, the joint state-federal health care program that covers nearly three million needy children in Texas. State lawmakers, facing a huge budget shortfall, cannot find the multibillion-dollar savings they need without cutting already skimpy rates for Medicaid providers.

Children’s hospitals generally have much higher Medicaid populations than the average hospital — meaning rate reductions hit them harder. Their advocates estimate that the House’s budget would cost the hospitals a combined $275 million over two years; they say the version under consideration in the Senate would cost them roughly half that amount.

For Driscoll Children’s, where about 70 percent of patients are on Medicaid, the concern is not about preserving his bottom line, it is about just trying to break even. Both budget proposals “would essentially leave me a negative cash flow of about $10 million a year,” Mr. Woerner said.

Both the House and Senate versions of the budget lower Medicaid outpatient rates for children’s hospitals by 10 percent and reduce payments for nonurgent emergency room care. The House version goes even further, cutting inpatient children’s hospital rates, as well as all doctor and dentist reimbursement rates, by 10 percent.

While the Senate’s budget sharply reduces financing used to draw down a hefty federal match for children’s hospitals, the House’s zeroes it out altogether — at a loss of roughly $60 million, including the federal match, over the next biennium.

Bryan Sperry, president of the Children’s Hospital Association of Texas, said that on average, nearly 60 percent of the patients at the seven nonprofit children’s hospitals he represents are on Medicaid. In South Texas, Mr. Sperry said, that figure can reach 80 percent.

He estimates that for most Texas hospitals a 10 percent cut in the Medicaid rate would represent a loss of 1 percent of net patient revenue — but that for children’s hospitals, it would be up to 5 percent or 6 percent.

“We’re more dependent on Medicaid than any group of hospitals,” Mr. Sperry said. “Anything that happens to it has a big effect on us.”

Mr. Melson, of Texas Children’s Hospital, said his hospital stands to lose $4 million to $6 million a year through the proposed Medicaid cuts.

“We’re a high-acuity provider; we see a lot of critically ill children in our hospital,” he said. As the number of children in Texas continues to rise — it is expected to spike by another one million over the next decade — “we want to make sure we can continue to grow,” Mr. Melson said.

Mr. Sperry said children’s hospitals, which receive roughly one million outpatient visits and 500,000 emergency room visits a year, can “make it through the next two years” with the current Senate budget proposal, which could come up for a vote in the upper chamber as early as next week. The House version would be much tougher.

Regardless, Mr. Sperry said, lawmakers need to consider the long-term implications of clipping the wings of the hospitals that teach 70 percent of Texas’ pediatricians-in-training, especially as the country faces a growing shortage of physicians and specialists.

 

Jury Rejects Missouri Hospitals’ Case Against Tobacco Firms

About 40 Missouri hospitals sued the Philip Morris unit of the Altria Group, the R. J. Reynolds Tobacco Company, the Lorillard Tobacco Company and other cigarette makers in 1998, claiming they manipulated the nicotine content in cigarettes and misrepresented the health effects of smoking. The hospitals were seeking more than $455 million in damages, ranging from about $300,000 for some hospitals to $86.4 million for the Truman Medical Center in Kansas City, Mo.

The hospitals argued that the industry’s actions had raised spending for unreimbursed and uncompensated tobacco-related health care. The tobacco companies denied any responsibility for patient care costs at the hospitals or any financial losses by the hospitals. The jury, in Missouri Circuit Court in St. Louis, rejected the hospitals’ claims on a 9-3 vote Friday in the seventh day of deliberations.

“The jury correctly rejected the entirety of the hospital’s claims,” Murray Garnick, associate general counsel for Altria Client Services, said in a statement. The jury agreed with Philip Morris “that ordinary cigarettes are not negligently designed or defective,” he said.

The hospitals haven’t decided whether to appeal, their lawyer, Kenneth Brostron, said.

The case is the third such health care cost-recovery claim to reach trial, according to regulatory filings by Altria. The tobacco industry won the first, in Ohio, in 1999. The second initially resulted in a $17.8 million award for a health insurer by a New York jury in 2001. That was reversed on appeal in 2004.

The Missouri suit, which did not include patients as plaintiffs, went to trial in January.

The hospitals, which provide care to indigent patients and others who do not pay, represent the majority of licensed, adult acute care hospital beds in Missouri, according to the complaint. The hospitals said medical ethics required them to serve people in need regardless of their ability to pay.

Tobacco companies should reimburse the hospitals for care provided to patients who were unable to pay and were suffering from tobacco-related illness, the plaintiffs said. Hospitals also should “recover the increased costs incurred to providing all health care services” as a result of tobacco use and exposure to tobacco smoke, according to the complaint.

 

Medical Experts Dispute a Hospital’s Claims on Heart Device Data

This month, University Medical Center of Southern Nevada said in a statement, “results to date show significantly improved outcomes for our cardiac patients” who got heart implants made by a little-known company, Biotronik. The statement was attributed to Kathleen Silver, the chief executive of the hospital.

Ms. Silver issued that statement after an article in The New York Times reported that cardiologists there switched in 2008 to using Biotronik devices after that company started paying them thousands of dollars in consulting fees.

A hospital spokeswoman later said in response to a reporter’s question that Ms. Silver’s comments were based on data drawn from a national registry of heart patients who received an implanted defibrillator. University Medical Center also provided The Times with limited data from that registry that it said backed its contention.

But several experts knowledgeable about that defibrillator database said in separate interviews that it did not track how device recipients fared after they left a hospital. As a result, it cannot and does not provide data to hospitals or manufacturers about the long-term performance of any company’s device. It also does not produce data that can be used to compare the performance of competing implants made by different companies.

“To saying that we are doing better is a bridge too far for the data they have,” said Dr. Jeptha Curtis, an assistant professor of medicine at Yale, who has worked on research studies involving registry data.

Told of the experts’ assessments, Danita Cohen, the spokeswoman for the Las Vegas hospital, responded in writing by stating, “By way of clarification, U.M.C. did not intend to say that our better outcomes can be attributed to a particular device.”

She added that the hospital’s remarks about “improving patient outcomes” were intended to mean that its use of the defibrillator database was helping it monitor its performance.

The hospital’s disputed claims may intensify scrutiny of the ties between the Las Vegas physicians, Biotronik and a company called Western Medical that acts as the company’s sales representative in Nevada and several other states. Those ties are currently under review by state officials in Nevada. The Justice Department started a separate investigation last year into Biotronik’s sales and marketing practices.

The Times article focused on relationships between a device industry sales official named Caesar Fonte and cardiologists at a Las Vegas practice, Nevada Heart and Vascular. Before 2008, when Mr. Fonte worked at Boston Scientific, a defibrillator producer, the same cardiologists were paid consultants to that company and almost exclusively used its devices, hospital data shows.

Then in 2008, Mr. Fonte quit Boston Scientific and started Western Medical, the Biotronik distributor. The implant specialists at Nevada Heart and Vascular then became paid consultants to Biotronik and switched to using its devices in nearly all patients.

Both Biotronik, the physicians and Mr. Fonte have rejected any suggestion that the consulting fees were inducements to get them to use the company’s devices.

The defibrillator database is part of the National Cardiovascular Data Registry, a project run by the American College of Cardiology Foundation, in conjunction with a professional medical group, the Heart Rhythm Society. It is often referred to as the ICD registry, which is short for implantable cardioverter-defibrillator, the device’s formal name.

In 2004, Medicare mandated the creation of a national ICD registry as a condition for approving payments for defibrillators for a new class of patients, for whom evidence of a benefit was equivocal. Implant makers, who have realized vastly added sales from the Medicare ruling, supported the registry for one year then cut back financing. Its is now underwritten by hospitals, but limited financing has restricted the data it can collect.

Essentially, during a procedure to implant a defibrillator, information is collected about areas like a patient’s heart function and other medical conditions. If an existing defibrillator is being replaced by a new one, a hospital can also indicate one of several reasons why such a replacement is being performed.

The information from the national ICD registry provided by University Medical Center to The Times reflected data from two of those device replacement fields. It showed that for a four-year period between 2007 and 2010, no device had been replaced at University Medical Center because it had been recalled or because it had malfunctioned.

Earlier, when providing the data, Ms. Cohen, the hospital spokeswoman, said that its results were “highly significant” when compared with the national average for such replacement reasons. The hospital added that Biotronik has not issued any recent device recalls.

Experts like Dr. Curtis said, however, that the hospital’s data was effectively meaningless because there was no way of knowing from it whether a device being replaced at U.M.C. had been initially implanted there, or whether devices implanted at U.M.C. were later replaced elsewhere.

“If they are thinking that no news is good news from the registry, then they are misunderstanding what function the registry is performing,” said another registry expert at Yale, Dr. Harlan Krumholz.

The national ICD registry does report back to hospitals about in-hospital complication rates related to device implantation procedures so they can compare it with the national average. Asked for its complication rate, U.M.C. declined to release it.

 

Medical Experts Dispute a Hospital’s Claims on Heart Device Data

This month, University Medical Center of Southern Nevada said in a statement, “results to date show significantly improved outcomes for our cardiac patients” who got heart implants made by a little-known company, Biotronik. The statement was attributed to Kathleen Silver, the chief executive of the hospital.

Ms. Silver issued that statement after an article in The New York Times reported that cardiologists there switched in 2008 to using Biotronik devices after that company started paying them thousands of dollars in consulting fees.

A hospital spokeswoman later said in response to a reporter’s question that Ms. Silver’s comments were based on data drawn from a national registry of heart patients who received an implanted defibrillator. University Medical Center also provided The Times with limited data from that registry that it said backed its contention.

But several experts knowledgeable about that defibrillator database said in separate interviews that it did not track how device recipients fared after they left a hospital. As a result, it cannot and does not provide data to hospitals or manufacturers about the long-term performance of any company’s device. It also does not produce data that can be used to compare the performance of competing implants made by different companies.

“To saying that we are doing better is a bridge too far for the data they have,” said Dr. Jeptha Curtis, an assistant professor of medicine at Yale, who has worked on research studies involving registry data.

Told of the experts’ assessments, Danita Cohen, the spokeswoman for the Las Vegas hospital, responded in writing by stating, “By way of clarification, U.M.C. did not intend to say that our better outcomes can be attributed to a particular device.”

She added that the hospital’s remarks about “improving patient outcomes” were intended to mean that its use of the defibrillator database was helping it monitor its performance.

The hospital’s disputed claims may intensify scrutiny of the ties between the Las Vegas physicians, Biotronik and a company called Western Medical that acts as the company’s sales representative in Nevada and several other states. Those ties are currently under review by state officials in Nevada. The Justice Department started a separate investigation last year into Biotronik’s sales and marketing practices.

The Times article focused on relationships between a device industry sales official named Caesar Fonte and cardiologists at a Las Vegas practice, Nevada Heart and Vascular. Before 2008, when Mr. Fonte worked at Boston Scientific, a defibrillator producer, the same cardiologists were paid consultants to that company and almost exclusively used its devices, hospital data shows.

Then in 2008, Mr. Fonte quit Boston Scientific and started Western Medical, the Biotronik distributor. The implant specialists at Nevada Heart and Vascular then became paid consultants to Biotronik and switched to using its devices in nearly all patients.

Both Biotronik, the physicians and Mr. Fonte have rejected any suggestion that the consulting fees were inducements to get them to use the company’s devices.

The defibrillator database is part of the National Cardiovascular Data Registry, a project run by the American College of Cardiology Foundation, in conjunction with a professional medical group, the Heart Rhythm Society. It is often referred to as the ICD registry, which is short for implantable cardioverter-defibrillator, the device’s formal name.

In 2004, Medicare mandated the creation of a national ICD registry as a condition for approving payments for defibrillators for a new class of patients, for whom evidence of a benefit was equivocal. Implant makers, who have realized vastly added sales from the Medicare ruling, supported the registry for one year then cut back financing. Its is now underwritten by hospitals, but limited financing has restricted the data it can collect.

Essentially, during a procedure to implant a defibrillator, information is collected about areas like a patient’s heart function and other medical conditions. If an existing defibrillator is being replaced by a new one, a hospital can also indicate one of several reasons why such a replacement is being performed.

The information from the national ICD registry provided by University Medical Center to The Times reflected data from two of those device replacement fields. It showed that for a four-year period between 2007 and 2010, no device had been replaced at University Medical Center because it had been recalled or because it had malfunctioned.

Earlier, when providing the data, Ms. Cohen, the hospital spokeswoman, said that its results were “highly significant” when compared with the national average for such replacement reasons. The hospital added that Biotronik has not issued any recent device recalls.

Experts like Dr. Curtis said, however, that the hospital’s data was effectively meaningless because there was no way of knowing from it whether a device being replaced at U.M.C. had been initially implanted there, or whether devices implanted at U.M.C. were later replaced elsewhere.

“If they are thinking that no news is good news from the registry, then they are misunderstanding what function the registry is performing,” said another registry expert at Yale, Dr. Harlan Krumholz.

The national ICD registry does report back to hospitals about in-hospital complication rates related to device implantation procedures so they can compare it with the national average. Asked for its complication rate, U.M.C. declined to release it.