Progress, but not enough, against needless hospital procedures

Reports keep surfacing about doctors and hospitals running up medical bills by implanting allegedly unnecessary coronary artery stents.

Newly revealed cases are under investigation in Pennsylvania, Tennessee and Texas, according to news reports. Research published in the Journal of the American Medical Association this month showed that thousands of stents implanted at unidentified hospitals in 2009 and 2010 were "inappropriate."

Dr. John R. McLean is on trial in U.S. District Court in Baltimore for allegedly falsifying medical records to justify the installation of stents at a hospital on Maryland's Eastern Shore. Last week the Maryland Board of Physicians revoked the medical license of Dr. Mark Midei, finding that he, too, falsified patient records in connection with unnecessary stents. McLean and Midei have denied wrongdoing. Unlike McLean, Midei has not been charged criminally.

There's even a name for it: "overstenting." Under proper circumstances, stents prevent heart attacks by opening clogged arteries. But when they're installed in unblocked arteries they raise unnecessary risks for patients and cost the system dearly.

Just as important as identifying past abuses, however, is preventing future ones. Overstenting doctors and others milking the system with unnecessary procedures have exploited a big loophole in patient-safety procedures.

Led by Del. Dan Morhaim, a Baltimore County Democrat who is also a physician, Maryland is about to close the gap. But there is little evidence that other states are following Maryland's lead. And some people — notably the president of the Maryland chapter of the American College of Cardiology — don't believe Maryland law goes far enough.

Hospitals are good at reviewing obvious mistakes and complications. The doctor who amputates the wrong limb is instantly in trouble. But they're far less equipped to identify otherwise problem-free procedures that aren't performed based on medical need.

By several accounts, Midei was better than almost anyone at the delicate business of threading tiny stent screens into heart vessels. But St. Joseph Medical Center, where he practiced, wasn't doing much to make sure his patients really needed the hardware.

St. Joseph reviewed stent cases after the fact. But Midei, as chairman of the cardiology department, selected which ones to study, according to an investigation by the Senate Finance Committee. (Midei has denied manipulating this "peer review" process.)

The hospital, a defendant in hundreds of lawsuits from patients who say they received unnecessary stents, has since overhauled its quality control process. Among other changes, cases for review are now picked randomly by computer.

What has to happen next is for all hospitals to move in the same direction — and not just for stents. Unneeded MRI scans, back and neck surgery, knee replacements and many other kinds of unnecessary treatments cost the system billions of dollars — nearly a third of all care, according to some estimates.

Starting Oct. 1 in Maryland, maybe some of those will be stopped. A new law requires hospitals to randomly review all medical procedures for "appropriateness" — a first for the state.

"What it does is put into place really objective standards on this most important part of oversight of practitioners," says Morhaim, who sponsored the bill. "Patients have to know that when things are being done, they're being done for the right reasons."

Neither the American Hospital Association nor the National Conference of State Legislatures is aware of similar statutes passed in other states, spokespeople said. Too bad, because, as in so much else in health care reform, what's going on in the states is just as important as what's going on in Washington.

Dr. Samuel D. Goldberg, president of the Maryland chapter of the American College of Cardiology, doesn't believe Maryland law is stringent enough with regard to stopping the implantation of potentially unneeded stents. I was unable to speak with him, but in a letter to The Baltimore Sun he criticized the state for not requiring third-party accreditation of cardiac catheterization labs, where stents are implanted.

And he favors mandatory review of stent cases by professionals outside the hospital. Such scrutiny provides independent judgment. But under Maryland's new law, external review for procedures' appropriateness is left up to the discretion of the hospital.

That may not be good enough. Unnecessary care is so lucrative for hospitals and doctors that it may take outsiders without a stake in the review to crack down.

"Everything happens in steps," says Morhaim. The Maryland law that takes effect Oct. 1, he says, "is a giant step to get these institutions to do substantial oversight on a regular basis."

More steps are needed to stop unneeded procedures from endangering patients and costing us billions, both here and across the country. The only thing worse than scandal and trouble is not making sure they don't get repeated.