A Bloomberg News article raises extremely troubling questions about policies and procedures that have made the Mt. Sinai hospital catheterization laboratory the busiest and most lucrative in New York City. It is unclear whether the specific allegations in the article will stand up to rigorous scrutiny but, say some experts, the ills identified in the article go far beyond Mt. Sinai and New York City and are actually endemic throughout the entire US healthcare system.
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The most explosive charge in the story by David Armstrong, Peter Waldman and Gary Putka is that hospital physicians scheduled emergency room appointments for patients lacking insurance and coached them to say they were having symptoms of an acute coronary syndrome. Because they were treated in the emergency room the patients could then receive a cardiac catheterization they couldn’t otherwise afford and the hospital could receive reimbursement from Medicaid, according to the Bloomberg story.
On a pair of representative Sundays in 2012, 10 patients told ER workers they’d been instructed to arrive there before their cath-lab appointments, according to internal hospital correspondence. Two of them said they’d been coached to say they were having acute symptoms of heart disease, according to the exchanges.
The rest of the article focuses on more routine but also dubious methods by which Mt. Sinai achieved its position as “the best and busiest” in the US. A large part of this success is due to the cath lab’s “thousands of patient referrals each year from a network of affiliated doctors in private practice,” many of whom have financial arrangements with the hospital.
In addition, physicians who are employed by the hospital also have incentives to pump up the volume:
Doctors working in Mount Sinai’s cath lab can have their target salary and bonus cut if they don’t reach a certain level of “relative value units,” which are assigned to procedures they perform based on their complexity….
“You essentially have physicians combing the streets of Staten Island, Queens, Brooklyn and Bronx looking for patients they can screen on a treadmill to feed into the cath lab, where the big reimbursement comes”…
The most dramatic example is Samin Sharma, Mt. Sinai’s well-known director of interventional cardiology. Sharma, who “performs more complex coronary interventions than any cardiologist in the country,” received $4.8 million from the hospital in 2012.
One leading cardiologist, Sanjay Kaul of Cedars-Sinai hospital in Los Angeles, told Bloomberg that Sharma and the other interventional cardiologists “are stellar proceduralists, with a track record of success worthy of emulating.”
But it would be a mistake to interpret Kaul’s comment as an endorsement of the situation. I asked Kaul for his thoughts about the charges directed at Mt. Sinai in the article. His response makes clear that these issues are by no means isolated to Mt. Sinai or New York City. Even if the specific allegations about Mt. Sinai turn out to be unfounded, there is a much broader systemic problems that needs to be considered. Here is what Kaul sent me:
What do you think are the main charges? And are any one of these charges unique to Mt. Sinai?
1. Having uninsured patients who ‘require’ a heart procedure come through the ED! This is more a blight on the US healthcare environment than any individual hospital.
2. Outreach programs in the community that refer patients for expensive (but often unnecessary) procedures that are reimbursed handsomely by the insurers.
3. Corporatization of medicine that rewards providing service and generating revenue for the hospital over creating value and goodwill among the patients it serves.
The RVU (relative value units) is indeed a misnomer; it should be ‘RRU” (relative revenue units). The hallowed halls of academia are ‘RRU’ hollow!
In my opinion, the article faithfully captures what ails our healthcare system. It targets one hospital to illustrate the issues, but let me assure you, this hospital is by no means unique in this regard.
(Mt. Sinai declined to provide a response to the Bloomberg article.)