St. Joseph Medical Center in Towson is caring for fewer heart patients these days, and CEO Jeffrey K. Norman acknowledges that some are avoiding the hospital where a top physician has been accused of implanting unnecessary coronary stents.
After a monthslong internal review, the hospital disclosed in January that 369 patients of cardiologist Mark G. Midei do not appear to have needed the stents they received.
The allegation has been a blow to St. Joseph, ranked by research firm Thomson Reuters among the top 100 heart hospitals in the country. Cardiac care is a key plank of the hospital's business plan. And the drop in admissions in the hospital's specialty follows several years in which the number of admissions overall has been flat at St. Joseph, located in a region with some of the world's best medical facilities.
Norman arrived in the middle of the firestorm, taking over in November after an executive shake-up. The hospital brought in a crisis-management team and mobilized what it has characterized as a swift and comprehensive response.
After outside experts pored over files, Norman and administrators notified affected patients, talked publicly about the problem and tightened oversight of heart cases. Midei stopped practicing and lost his privileges at the hospital last summer and officially resigned in November.
"We want everybody to judge us by our actions," Norman said in an interview at the hospital, a nonprofit founded 146 years ago by Franciscan nuns. "We had a patient complaint, we took action, we did the right thing. ... We'll continue to do that."
Still, the aftereffects of the accusations about unneeded stents are likely to linger.
Last week, Sens. Max Baucus of Montana and Charles E. Grassley of Iowa, the Democratic chairman and senior Republican, respectively, on the Senate Finance Committee, demanded stent billing records and other documents from the hospital, saying that their panel was launching an inquiry as part of its role "to protect taxpayer dollars from waste, fraud and abuse." And lawsuits have been filed on behalf of patients.
St. Joseph also has been the focus of a separate, long-running federal health care fraud investigation into its relationship with MidAtlantic Cardiovascular Associates, the hospital's dominant cardiology practice. Norman said the hospital and federal government came to an "agreement in principle" last year and that he expects to "have that all settled and behind us" shortly. Court records indicate that the hospital will pay a fine expected to exceed $5 million.
But the crisis over cardiology care strikes at the core of what St. Joseph does. Cardiac surgery is St. Joseph's top inpatient service, with more than 3,900 cases in fiscal year 2009, according to Maryland's Health Services Cost Review Commission. Cardiology is No. 2. Doctors there have inserted more than 100,000 coronary stents since 1980.
But now the hospital is seeing a 10 percent drop in the number of people admitted for cardiac care, Norman said. Inpatient and outpatient cardiac procedures - a category that includes stent placement - have dropped 30 percent.
Norman attributes much of that decline to the departure last summer of Midei, the only person implicated by the St. Joseph review. Norman said he senses a "tentativeness" about St. Joseph care among heart patients and cardiologists since the hospital's announcement of its findings.
"Patients are taking a pause; maybe their physicians referring patients are taking a pause," Norman said. "I think we'll regain that trust and we'll regain that volume, but it'll take some time."
Midei was a star physician hired by St. Joseph in 2008 after he had performed surgeries there for years while on the MidAtlantic staff. In 2003, he told The Baltimore Sun that he was performing 1,000 stent procedures a year. Through a spokesman, he declined to comment for this article. He has said previously that he expects to be exonerated.
Stent implantation is a fairly routine procedure, often performed while patients are conscious. But stents - which open arteries blocked by plaque - come with risks of complications. They can't be taken out once put in. And they are expensive.
The patient complaint that prompted the internal review was made a year ago, according to Norman, about the same time that federal investigators delving into St. Joseph's relationship with MidAtlantic Cardiovascular asked the hospital to look into its peer-review process in cardiology.
Since then, the hospital has decided to randomly review all cardiology cases - a change recommended by outside cardiologists recruited to suggest improvements. Random reviews might also be extended to other specialties at the hospital, Norman said.
Broad checks and balances are important for regaining trust, said Mike Paul, a New York crisis-management consultant who is not part of the team brought in by the hospital. "This isn't just a cardiac crisis, this is a hospital crisis," he said. For patients, a problem in one unit can raise questions about all care.
"Hospitals compete," added Paul. "This is an opportunity for another hospital."
Organizations can move on after a crisis. They can even improve their reputation by the way they handle it, public relations professionals say. The oft-cited case is Johnson & Johnson, which took the then-unusual step of recalling Tylenol capsules across the country in 1982 after someone laced products in the Chicago area with cyanide, killing seven people. It quickly reintroduced Tylenol with "triple-sealed" tamper-proof packaging.
Robert Mathias, managing director for the Washington office of Ogilvy Public Relations, said that while he doesn't know all the details about the situation at St. Joseph, it "sounds like it's a manageable crisis." But new revelations of other patient-care problems could escalate it, he said.
"You stand up and say, 'It's just this one guy and our peer review, and we've fixed that," Mathias said. "[But] if other problems start to show themselves, then, boom, lack of credibility and lack of trust."
That's the Toyota dilemma - new recalls keep cropping up, he said. It was a floor-mat issue. Then a gas-pedal issue. Then brakes.
"In today's world, trust is something that's earned, and it's hard-given," he said.
The Johns Hopkins Institutions faced outrage from black leaders after news reports in 2008 that Hopkins and Kennedy Krieger researchers, in an effort to reduce incidences of lead poisoning - "a major problem among children in the city's older housing - put sludge containing human and industrial waste on some low-income Baltimore residents' yards. Civil rights leaders were incensed; Maryland lawmakers called for a federal inquiry.
At first, Hopkins did not move forcefully to defend itself. The controversy died down only after Hopkins leaders said publicly that what researchers used was Orgro - a commercially available compost used on lawns. Such fertilizer is made in part from treated sludge but is not considered dangerous.
Whatever the crisis, clamming up is the wrong strategy, crisis-management consultants say.
"The conversation's still happening, and this is particularly true today with social media," Mathias said. "The only thing you're deciding is, do you want to be a part of it?"
St. Joseph, founded by the Sisters of St. Francis of Philadelphia, got its start in three Caroline Street rowhouses in Baltimore. It moved to Towson in 1965, and Greater Baltimore Medical Center opened nearly across the street.
St. Joseph looks new, after an expansion completed little more than a year ago. Inside, it is all arcs and curves, a design intended to reduce stress. Outside, there's a Japanese meditation garden. Just beyond the lobby is the three-level Heart Institute.
A two-year-old building next to the main hospital houses the Cancer Institute, where patients eat, read and tap on laptops in a window-filled atrium while undergoing chemotherapy. In rented space on the top floor is the cardiology practice of MidAtlantic Cardiovascular Associates.
That practice and its relationship with St. Joseph is the focus of the federal health care fraud investigation. The hospital has not provided details, other than to say that it is not directly related to the stent cases.
Norman defines his role as moving the hospital forward - a goal broader than getting it past the cardiology crisis. While the number of inpatient admissions at Maryland hospitals grew modestly during the past three years, admissions at St. Joseph have remained around 25,500.
"With a population that's growing a little bit, but also a population that's aging, you would expect to see more needs in the population we need to serve," Norman said.
The longtime hospital administrator, who moved from Arizona, said he wouldn't have taken the job at St. Joseph if he didn't see "great potential" there.
While cardiology will continue to be a key specialty, he said, St. Joseph has increasingly focused on cancer care and is the only hospital in Maryland with a National Cancer Institute community cancer center program, which gives patients access to clinical trials. As cardiology cases were declining, outpatient cancer cases increased nearly 10 percent from July through December 2009 over the same period in 2008.
Emergency services are another St. Joseph priority. By applying auto industry efficiency techniques to the emergency room a year and a half ago, staff decreased how long patients stay there by about 25 percent, said Dr. Gail P. Cunningham, head of the emergency department. Cardiac patients in particular are being evaluated much quicker, she said.
Cunningham, also president-elect of the hospital's medical staff, said employees were shocked by the stent allegation and concerned "about the decrease in [patient] volumes." But she said she can see from the patients who pass through the emergency department that it hasn't shaken their faith in St. Joseph.
"People are still coming in with their chest pain and heart problems and will voluntarily say, 'I know this is the best place to be,' " she said. "That's ... gratifying and makes me continue to be proud to work here despite the problems we're facing."
Alfred L. Brennan Sr., 81, a retired Baltimore County circuit judge and cancer patient at St. Joseph, said he is aware of the hospital's cardiac troubles. But as he sat in the sunny atrium, getting a chemo treatment while finishing lunch, he declared it "one fantastic hospital."
The spot on his liver is gone, he said, and the golf ball-size lump in his esophagus has shrunk. When he's in for treatments, he reads books, makes crafts or listens to a retired nurse who comes in to play the harp.
"You would think you died and went to heaven," he said.
Gerard Anderson, director of the Center for Hospital Finance and Management at the Johns Hopkins Bloomberg School of Public Health, said personal experiences are really the key for hospitals. People tend not to make decisions about care based on breaking news, he said, but on the care they or people they know received there. That's why he believes St. Joseph will recover from the stent crisis.
"If they clean up the situation with this doctor, the hospital will return to normal," Anderson predicted. "These are very resilient organizations."