Dollars and stents

It's been a busy November already for Baltimore's federal prosecutors, who have been cracking down on drug dealers, child porn producers, gang leaders and … St. Joseph Medical Center.

No disrespect to those accomplished dealers of drugs or porn, but they probably could learn something about how to ruthlessly corner their respective markets from St. Joe's. Something along the lines of creating demand and providing supply. Or maybe what the MBAs call supply chain management.

As The Sun's Tricia Bishop reported last week, the Towson hospital agreed to pay $22 million to settle allegations that they'd been running quite the cozy and lucrative kickback scheme for 10 years. St. Joe's, the feds said, had been paying a group of doctors to refer patients for expensive cardiac surgery and procedures.

This is where fairness, not to mention the legal profession, requires that I note St. Joe's has admitted to no wrongdoing. Whatever. These are some pretty damning allegations of how medicine was not so much practiced as transacted — and, whether or not you were one of those patients who apparently was bought and paid for over the years, this should have you clutching your heart. Or maybe your wallet.

Because while the St. Joe's case might be a particularly egregious example, it speaks to a larger problem with the health care system — how the U.S. manages to spend the most in the world on medical care and yet lags behind other countries on any number of measures of health, such as life expectancy and infant mortality rates. In other words, we're not getting what we're paying for.

I had thought, silly me, that when we embarked on the whole health care reform thing, these were the types of issues that would be debated — how to rein in the runaway costs of modern medicine and improve the quality of care that was being delivered.

Instead, of course, the debate got hijacked into fear-mongering over imaginary death panels and the supposed government takeover of health care — never mind that: a) the public option was tossed out early on; and b) uh, Medicare, anyone?

But back to St. Joe's. The settlement announced Tuesday is the latest development in the saga surrounding Dr. Mark Midei, the cardiologist who co-founded the doctors' group accused of taking the kickbacks before joining the staff of St. Joe's. There, he's been accused of implanting artery-opening stents on hundreds of patients that were medically unnecessary.

And that, in microcosm, is why medical costs have skyrocketed in the U.S. — more so than any other country, experts say, doctors tend to over-prescribe tests, procedures, scans, surgeries and all the various -ectomies and -oscopies that they have at their disposal. Now, you can argue over why they do this — from protecting against potential malpractice suits to our propensity to do something rather than nothing — but undeniably, it contributes to the high cost of health care.

Any number of analysts have described this phenomenon — most convincingly, in my mind, Atul Gawande, a surgeon and writer for New Yorker magazine. Last year, in a widely admired article, he described a visit to a city that, despite being in the county with the lowest household income in the country, spends just about the most for health care — tiny McAllen, Texas. There, Medicare spent nearly $15,000 per enrollee, almost twice the average for the country, yet by an accepted set of metrics, patients were not receiving dazzlingly wonderful care. In fact, researchers have found an inverse relationship between the amount spent on health care and the quality of that care, Gawande wrote.

What he found in McAllen was a community in which, compared with a demographically similar Texas town, doctors were many more times likely to prescribe tests and specialist visits and rely on devices like, yes, coronary artery stents. And, he found a culture in which doctors' decisions might be tinged by financial considerations, given that they might just happen to own an imaging center, for example. And, as Gawande anonymously quotes one hospital executive, there are even expectations of kickbacks: "I've had doctors here come up to me and say, 'You want me to admit patients to your hospital, you're going to have to pay me.' "

Sound familiar?

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