(For more on why unneeded stents are likely to be a larger problem than the cases made public so far, read previous columns at baltimoresun.com/hancock)
Kelly Uebinger, the assistant U.S. attorney who got a Louisiana doctor sentenced to prison for implanting unneeded coronary-artery stents, is taking her show on the road.
Agents and prosecutors from across the country attend her lectures at criminal-law conventions. They want to know how cardiologist Dr. Mehmood Patel gave patients risky hardware they didn't need, how he billed insurers and how he was brought to justice.
"There's really an interest," says Stephanie Finley, Uebinger's boss and the U.S. attorney for western Louisiana. "They're honing in on this specific area. They want to understand the Patel case and what was involved with it."
There should be an interest.
The Patel scandal and similar allegations involving two Maryland cardiologists have revealed a shocking lack of accountability surrounding the doctors who install heart stents.
The absence of safeguards and the large profits made from stents make it likely that patients other than those in Louisiana and Maryland have received unneeded hardware.
Neither Uebinger nor Finley would confirm that stent investigations are under way in other parts of the country. But I doubt that assistant U.S. attorneys are learning about interventional cardiology for fun and recreation.
Policing unneeded stents is an important test for a nation wasting billions on excessive medical procedures. Stents do little if any good, even when arteries are blocked and guidelines say stents are appropriate, studies suggest. If officials don't thoroughly investigate and fix the more alarming risk of stents being placed in unblocked arteries, the system really is out of control.
It's far from clear whether the sensible question posed by Maryland Del. Peter A. Hammen in February — whether "patients at other hospitals receive unnecessary coronary stents" — will be satisfactorily answered for Maryland or the nation.
The Louisiana case was the first alarm. Then, starting late last year, St. Joseph Medical Center in Towson began telling nearly 600 patients of Dr. Mark Midei that they received what might have been unnecessary stents. This month a federal grand jury indicted Salisbury cardiologist Dr. John R. McLean, charging him with filing false reimbursement claims related to stent implants.
McLean and Midei have denied wrongdoing.
Maryland officials are lumbering into something that looks like action, having been prodded by Hammen, chairman of the House Health and Government Operations Committee.
Last week, John M. Colmers, secretary of Maryland's Department of Health and Mental Hygiene, urged hospitals to make sure procedures they perform are needed — a recommendation that tells you something about the state of existing controls.
For its part, the Maryland Hospital Association is bringing medical-fraud and patient-safety experts to brief hospital CEOs and trustees. Included are Aaron Beam, the former chief financial officer at HealthSouth Corp. who pleaded guilty to fraud as part of that company's massive book-cooking, and Stephen Klaidman, whose book, "Coronary," recounts unneeded heart-bypass operations at a California hospital.
"Whenever something like this happens, people sort of automatically take a look and figure out if there are similar holes in their operations," says MHA spokesman Jim Reiter.
The state's Health Services Cost Review Commission is running statistical screens to search for cardiologists installing unusually high numbers of stents as a portion of the patients they examine, a marker for possible overuse.
But there's no indication that anybody else is really digging into potential problems.
"We are not at this time pursuing any independent investigation of the stent matter as it relates to the appropriateness of the care rendered to CareFirst members," said Michael Sullivan, spokesman for CareFirst BlueCross BlueShield, the state's biggest health insurer.
What about Medicare, the huge government health program for seniors?
"We do not confirm or deny the existence of investigations," said Ellen Griffith, a spokeswoman for the Center for Medicare and Medicaid Services.
The Joint Commission, the private group the accredits hospitals, says it's not its job to prescribe specific steps to prevent stent fraud. "We would never tell an organization what issue or activity to measure," said John Herringer, associate director of the group's standards and interpretations unit.
A spokeswoman for the Senate Finance Committee declined to disclose details about its stent probe, opened earlier this year.
Even when investigators are on the trail, obstacles loom. Patient-privacy laws and confidential doctor-quality records hinder malpractice lawyers and government officials alike from investigating wrongdoing. Even evidence of stent abuse — enough to open a federal investigation — is no guarantee of a conviction.
Medical fraud is hard to prove. Prosecuting Patel took months of investigation, three weeks of trial and expert witnesses who cost the government more than $100,000, said Uebinger, the assistant U.S. attorney in Louisiana. Not every prosecutor wants to make that kind of bet.
So meetings on possible stent abuse are being held, memos written, concerns expressed. But if authorities are serious about comprehensively following up on what Patel's former partner, Dr. Christopher Mallavarapu, told me in January — "There are probably a lot of cases like this" — they have yet to demonstrate it.