The bipartisan proposal comes in response to a ProPublica story that showed how a personal trainer posed as a doctor to defraud prominent health insurers.
This article was first published on Friday, February 14, 2020 inProPublica.
Four United States senators have introduced a bipartisan bill to close a little-known, but gaping, loophole that allows scammers to plunder commercial insurers by posing as licensed medical providers.
The Medical License Verification Act, introduced Thursday, comes in response to a July ProPublica story that showed how absurdly easy it is to commit health care fraud, which experts say could be costing Americans hundreds of billions of dollars a year. ProPublica told the story of David Williams, a Texas personal trainer and convicted felon, who represented himself as a licensed physician when he applied for National Provider Identifiers, the unique numbers required by the federal government to bill insurance plans.
The Centers for Medicare and Medicaid Services administers the NPI program. But ProPublica found that it did not verify whether applicants had valid medical licenses, which could be done easily by checking with state licensing boards. That missing step allowed Williams to collect at least 20 different NPI numbers and bill some of the nation's most prominent health insurers, Aetna, Cigna and UnitedHealthcare, for millions of dollars in bogus medical services.
The insurance companies auto-paid the claims without checking to see if Williams had a license. Over more than four years, Williams filed more than $25 million in false claims with the companies, reaping more than $4 million. Some insurers actually sent him letters noting he wasn't a doctor and was filing false claims, but they continued to pay new claims anyway. In 2018, a jury convicted him of health care fraud and he's now in federal prison.
At his trial, investigators for the insurers said that their companies assume people are being honest when they file claims. The insurers told ProPublica it wasn't easy to stop the fraud because Williams billed them using different organization names and tax identification numbers.
The proposed Medical License Verification Act would require Medicare to verify that an NPI applicant's license is valid and in good standing before approving an NPI number. Sen. Rick Scott, R-Fla., called it a "commonsense step" in a statement released by the legislators. Consumers pay for fraud losses, Scott said, so the proposal will "prevent bad actors from defrauding families."
Cracking down on unlicensed providers will prevent fraud and lower health care costs across the board, Sen. Chris Van Hollen, D-Md., said in the statement. The bill was also signed by Sen. John Cornyn, R-Texas, and Sen. Catherine Cortez Masto, D-Nev. The bill's next step is to be assigned to a committee, where it will be considered, according to Scott's spokeswoman.
A Medicare official said the agency does not comment on proposed legislation. The trade group America's Health Insurance Plans, better known as AHIP, did not reply to a request for comment about the proposed legislation.
In the Williams case, the insurers and regulators were slow to stop the personal trainer's fraud even though his ex-wife and her father, Jim Pratte, had been reporting the criminal activity to them. Pratte said Thursday that he was pleased to hear about lawmakers' proposal to block scammers like Williams from easily getting NPI numbers. Politicians have talked for years about how to pay for the high cost of health care, Pratte said. "One major thing you can do without hurting anybody is cut out the fraud," he said.
The failure of insurers to take prompt action against Williams, and the ease of his fraud, led ProPublica to look at how aggressively such scams are pursued. Across the country, ProPublica foundthat insurance carriers not only made it easy for fraud to happen, they seldom pursued the fraudsters or referred them for prosecution.
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A government investigation found that the New Jersey hospital's transplant team was failing to learn from surgical errors.
This article was first published on Tuesday, January 21, 2020 in ProPublica.
Newark Beth Israel Medical Center's heart and lung transplant program was putting patients in "immediate jeopardy" before the hospital began to implement corrective measures, according to federal regulators.
In a pair of reports sent to the Newark, New Jersey, hospital on Dec. 12, the Centers for Medicare and Medicaid Services found that the transplant program repeatedly failed to fix mistakes. Spurred by ProPublica articles, the CMS investigation uncovered a series of incidents in which the hospital identified areas for improvement following botched surgeries but didn't carry out its own recommendations, allowing "subsequent adverse events to occur."
As a result, CMS determined that patients were in "immediate jeopardy," which is the regulator's most serious level of violation. It is invoked when "noncompliance has placed the health and safety" of patients "at risk for serious injury, serious harm, serious impairment or death."
Newark Beth Israel spokeswoman Linda Kamateh said in a statement that the hospital does not agree with all of CMS' findings, and that they did not warrant the "immediate jeopardy" designation. It will send a letter identifying "certain objections" to CMS, she said.
In particular, Kamateh criticized findings that attributed adverse events to "compliance failures in the transplant program." CMS' survey team, she said, lacks the "evidence, expertise and experience" to assess and diagnose patient outcomes. "Root cause analysis is a complicated exercise requiring much more extensive training, and much greater analysis than is reflected" in the CMS reports, she said.
On Dec. 15, three days after the hospital received the findings, it submitted a plan to remove the "immediate jeopardy" label by making certain policy changes, Kamateh said. The New Jersey Department of Health, which works in coordination with federal regulators, determined that those measures were enough to lift the designation, according to the hospital and CMS.
CMS also required the hospital to submit plans of correction, which are "under various stages of review and implementation," Kamateh said. As part of the plans, which the hospital sharedwith ProPublica, Newark Beth Israel has created a transplant steering committee to oversee the transplant program. Staff responsible for quality review in the transplant program will report directly to hospital management and not to the program's leaders.
Nevertheless, the hospital remains out of compliance with federal rules for quality assessment and performance improvement, surgical services, and patient rights, as well as special requirements for transplant centers, according to a CMS letter to the hospital on Jan. 12. In the letter, CMS warned Newark Beth Israel that, unless the issues are resolved by March 21, it will take steps to terminate the hospital from the Medicare program, which means the federal insurer would end reimbursements for Medicare patients. Medicare primarily insures people who are 65 or older.
CMS' December reports also cited violations of patient rights, including failures to obtain informed consent and to seek information from patients and family members on advance directives such as do not resuscitate orders. Although the reports do not identify patients or doctors by name, surgery dates and other specifics indicate that at least two of the cases were those brought to light by ProPublica articles last year.
CMS' findings may help to explain why the heart transplant program's one-year survival rate fell to 84.2% in 2018, well below the national average. The concern for statistics prompted the transplant team to keep Darryl Young, a patient in a vegetative state, alive without offering palliative options such as hospice care to the family, ProPublica reported last October.
Besides CMS and the New Jersey Department of Health, the FBI and New Jersey's Board of Medical Examiners are also investigating the hospital in the wake of ProPublica's reporting. Newark Beth Israel has placed Dr. Mark Zucker, the head of the transplant program, on administrative leave while it conducts an internal investigation.
Darryl Young suffered brain damage during a heart transplant at Newark Beth Israel and never woke up. But, hardly consulting his family, doctors kept him alive for a year to avoid federal scrutiny.
Legislators are seeking answers as well. On Jan. 14, citing ProPublica's "concerning reports," three members of New Jersey's congressional delegation asked CMS how it planned to hold Newark Beth Israel "and other programs that may engage in similar behavior" responsible and improve oversight "to ensure that this does not happen in New Jersey or any other state," according to aletter obtained by ProPublica.
"This lack of transparency, compassion, and communication" in the cases exposed by ProPublica "was cruel," wrote U.S. Sen. Robert Menendez, and U.S. Reps. Bill Pascrell Jr. and Donald M. Payne Jr., adding, "Both cases show a serious breach of the trust we place in health care providers and a clear violation of the Hippocratic Oath." CMS is working on a response, according to a spokeswoman.
The CMS reports focused mainly on Newark Beth Israel's heart and lung transplant programs, though one case involved patient safety in a psychiatric unit. Newark's heart program is one of the 20 largest in the country by volume, having transplanted more than 1,000 patients over the last three decades. Its lung transplant program is smaller.
Three patients suffered brain damage within a seven month span, apparently due to similar causes, according to the reports. In March 2018, a patient suffereda "neurological deficit" after a heart transplant operation. The hospital's own outcome report recommended a review of its blood pressure monitoring equipment, but CMS couldn't find evidence that any review took place. Less than a month later, another heart transplant patient suffered a "severe neurological deficit" during surgery. The outcome report gave the same recommendation. Again, CMS found no review occurred.
Then in September 2018, Darryl Young suffered brain damage during his heart transplant and never woke up again, ProPublica reported last year. CMS found that an unnamed patient — whose surgery date matches Young's — had a heart transplant resulting in "altered mental status." The hospital's outcome report recommended more frequent blood pressure monitoring, but CMS said it was unable to find evidence that staff were educated or that the change was implemented.
Before and after Young's surgery, in August and October 2018, a heart transplant patient and a lung transplant patient suffered complications during their operations that resulted in kidney failure. After the first incident, the hospital recommended increasing the frequency of blood pressure readings. In the second incident, the hospital report said the complication was "likely due to hypotension" — low blood pressure — in the operating room, and recommended monitoring for future occurrences. CMS said it could not find evidence that the recommendations were implemented.
Other improvement suggestions were also ignored. In January 2018, after a heart transplant patient died after surgery, the hospital's outcome report recommended having "a 2nd surgeon available for difficult and prolonged cases." The following May, after a complication occurred in another heart transplant operation, a similar note called for a "plan to encourage transplant physicians to ask and offer assistance for difficult and lengthy cases." However, CMS said it found no evidence that Newark Beth Israel educated its physicians to do so.
ECMO machines, which temporarily replace a patient's heart and lung function by pumping and oxygenating blood outside the body, malfunctioned during a lung transplant in December 2018, CMS found. The patient wasn't harmed, but the hospital noted it was a "near miss event" and recommendedusing what is known as a primed cardiopulmonary bypass machine in the event of problems with ECMO machines. "Perfusionists will be informed," the note said. However, CMS said it found no evidence that perfusionists — who operate bypass machines — were told. Then, the following February and April, ECMO equipment issues led to two other mishaps during lung transplant surgeries. The first patient ended up with a "neurological compromise," CMS found, and the second died in the operating room.
As part of its plans of correction, Newark Beth Israel said it has implemented a policy that makes sure backup equipment is available for any transplant procedure that involves an ECMO. It has has educated all perfusion and anesthesia staff, it said. It is also planning to review and monitor its blood pressure equipment, with the anesthesia department observing all transplant cases to make sure the equipment is properly placed "until 100% compliance has been achieved for three consecutive months."
In total, CMS detailed 10 "adverse events" from January 2018 to April 2019. As ProPublica reported last year, the heart transplant team became worried that its slipping survival rates — specifically, the proportion of patients who reached the one-year anniversary of their surgeries — would attract federal scrutiny. Zucker said at a staff meeting in May 2019 that Darryl Young "unfortunately became the seventh potential death in a very bad year, all right, and that puts us into a very difficult spot," according to an audio recording of the meeting obtained by ProPublica. Treating Young aggressively without offering other options to the family, Zucker said, "is a very, very unethical, immoral but unfortunately very practical solution, because the reality here is that you haven't saved anybody if your program gets shut down."
Young's sister and health proxy, Andrea Young, had told ProPublica that she felt doctors at Newark Beth Israel were "hiding something" from her, that her brother's prognosis wasn't fully explained to her and that she wasn't asked about her goals for his care until 10 months after his transplant surgery.
CMS' report corroborated this lack of candor. In the case of an unnamed patient, whose details, including transplant date and hospital admission date, matched Young's, the federal inspectors found that physicians wrote information including "prognosis is not great" in medical records in March and "overall prognosis is poor" in June. But CMS found no evidence that the patient's next of kin was given this information.
CMS located a social worker's note that Andrea Young had requested weekly updates on her brother's condition. The medical record "lacked documented evidence that the physicians contacted … next-of-kin on a regular basis, or a weekly basis as requested, regarding the progress of the patient," CMS said.
The hospital "is developing and will implement a standard for communications with patients and their authorized representatives," according to its plans of correction. Its spokeswoman, Kamateh, said medical records show that doctors and staff communicated repeatedly with Young's family and that family members "were contemporaneously informed of his status, his expected clinical trajectory, and his treatment options."
Told of CMS' findings in her brother's case, Andrea Young said in a statement: "It is my hope that NBI's Transplant Unit will implement the appropriate corrective measures to address the many existing deficiencies that plague their transplant program. Trust is especially paramount in the medical profession and restoration of that trust is essential to every patient and every family."
ProPublica reported in December on Andrey Jurtschenko, a heart transplant recipient at Newark Beth Israel who suffered brain damage during his operation. In earlier conversations, Jurtschenko had made clear to his children, Chris and Megan, that he didn't want to be a burden on them. The children told ProPublica that, when they sought a DNR order for their father after his surgery, they were initially rebuffed. The family continued to press the issue and secured a DNR more than a month after his surgery.
Again, the CMS investigation bore out the family's concerns, though it focused on a later incident when Jurtschenko was readmitted to the hospital from a rehabilitation facility. Describing a patient whose details — including transplant surgery and other procedure dates, as well as quotes from medical records — matched Jurtschenko's, CMS found that Newark Beth Israel violated its own policy on advance directives. The hospital's policy states that "an inquiry will be made of each adult patient, at the time of admission … concerning the existence and location of an Advance Directive for Health Care. If the patient is incapable of responding to this inquiry, the medical center will ask the family or person with knowledge of the patient." Yet, when the hospital admitted Jurtschenko, it marked "NO" in his paperwork to the question of whether he had an advance directive, even though his children, who were his health proxies, would have requested a DNR order if it had consulted them.
Kamateh said that families "make these very personal decisions following a dialogue with the clinical team taking into consideration the best medical advice," adding, "Mr. Jurtschenko's medical record confirms that his family's decision to implement a DNR in June rather in April did not change his outcome."
CMS alsofound that Newark Beth Israel "failed to ensure a patient's right to have a family member notified of his/her admission to the hospital" because it had admitted Jurtschenko to the hospital from the rehabilitation facility without informing family members.
The hospital will train staff in obtaining information about advance directives, health care proxies, and surrogate decision-makers, according to the correction plans.
Andy Jurtschenko told his children that he didn't want to be a burden on them. But after he suffered brain damage during a heart transplant at a New Jersey hospital, his medical team deflected their request for a DNR.
In a reference to ProPublica's reporting, CMSfound that hospital staff members violated patients' rights by sharing patients' information with a journalist "for purposes other than treatment, payment and health care operation." It noted that Newark Beth Israel had an internal compliance hotline and ethics consultation team, which did not receive any complaints or reports of concerns regarding transplant patients.
Unrelated to the transplant program, CMS also found that a 14-year-old patient was left unsupervised in October 2019 in the presence of an adult patient "with a history of aggressive, violent and erratic behavior," accordingto the report. The minor, who wanted to use the bathroom, was brought there by a staff member and left there. Afterward, she told the staff that "a patient walked into the bathroom and kissed" her. The incident violated a patient's right to receive care in a safe setting, CMS said.
Immediately after the incident, Newark Beth Israel interviewed the patient and notified the parent, the Newark Police Department and the New Jersey Division of Mental Health Addiction Services, according to the hospital. According to its correction plans, the hospital has adopted a new policy to minimize contact between minor and adult patients in its psychiatric emergency screening services unit. "Policies around the monitoring of minor patients were immediately strengthened," Kamateh said.
Andy Jurtschenko told his children that he didn't want to be a burden on them. But after he suffered brain damage during a heart transplant at a New Jersey hospital, his medical team deflected their request for a DNR.
This article was first published on Tuesday, December 31, 2019 in MedPage Today.
Three weeks after his heart transplant, Andrey Jurtschenko still had not woken up.
A towering figure at 6 feet, 3 inches, with salt-and-pepper hair and matching mustache, Jurtschenko — known to one and all as Andy — delighted friends and family with his seemingly endless supply of wisecracks and goofball humor. On April 5, 2018, he went into surgery at Newark Beth Israel Medical Center in Newark, New Jersey, for a new heart and what he hoped would be renewed energy. He dreamed of returning to his carpet business and to enjoying New York Mets games on the weekends after years of exhaustion and strain caused by congestive heart failure.
Typically, patients begin reviving within 24 hours after transplant surgery. Andy didn't. As the days passed, his children, Chris and Megan Jurtschenko, became increasingly concerned. On April 26, a neurologist called Chris and explained what an MRI the day before had shown: Andy's brain had likely been deprived of oxygen during the procedure. The doctor said he "would basically be in a vegetative state," Chris recalled in an interview. Chris asked to meet with the medical team the next day.
The devastated family took some comfort in knowing what Andy would have wanted. In several conversations before the surgery, he had made clear that "he did not want to be a burden on us, he did not want to live in an incapacitated form," Andy's older sister, Anna DeMarinis, said.
Now that their father could not speak for himself, Chris and Megan, as Andy's next of kin, had to be his voice. On April 27, they went to the hospital for the meeting. Still hoping Andy might recover, they did not seek to withdraw his feeding tube or medications. But they asked for a do not resuscitate order. If he were to stop breathing or have no pulse, a DNR order would direct doctors not to compress his chest, use a machine to force air into his lungs or give electric shocks to restart his heart.
If his heart stopped, "we weren't going to force him to stay," Megan said.
Dr. Margarita Camacho, the surgeon who had performed the transplant, deflected their request, the siblings said. She told them that it was too early for a DNR, and that they shouldn't give up hope because their father might recover, his children said. At Camacho's urging, Megan and Chris said, they let it go. No DNR order was signed that day. The family would continue to press the issue and finally secure a DNR more than a month later.
Megan and Chris Jurtschenko waived their privacy rights to allow the hospital to discuss their father's case with ProPublica. Asked directly about the meeting with the surgeon and why the family's wishes were not followed at the time, Linda Kamateh, a spokeswoman for Newark Beth Israel and Camacho said in an email: "Physicians are obliged to give their best medical advice based on a patient's medical condition. However, ultimately the decision to have a DNR resides with the patient. The hospital believes that it adhered to those principles in its discussions with the Jurtschenko family."
Except for "a very specific set of dire medical circumstances, in which a patient may require resuscitation," a DNR "does not otherwise affect ongoing care and treatment," Kamateh wrote in a separate email. "... These decisions are often revisited and reassessed within the course of treatment."
Andy's medical record doesn't mention the children's request for a DNR. "The family was able to express their concerns and decided to continue to see how PT [patient] progresses over the next few weeks," a social worker wrote.
Bearing out Camacho's prognosis, Andy would awaken and recover some cognitive ability — but only enough to attain the incapacitated state he had dreaded, not to become again the man that his children knew and loved. They remained adamant that, if his heart stopped, he would have preferred to die than to be resuscitated for such an existence.
The American Medical Association's code of medical ethics states, "The ethical obligation to respect patient autonomy and self-determination requires that the physician respect decisions to refuse care." Yet Newark Beth Israel's transplant team was often reluctant to sign DNR orders, according to four former employees and an audio recording of a staff meeting. While the team wouldn't outright refuse, especially when patients or their family members repeatedly asked, it often delayed or discouraged DNRs, especially before key dates tied to performance metrics such as the one-year survival rate, or the proportion of people undergoing transplants who are still alive a year after their operations, three of the ex-employees said.
The team also lacked a process for discussing beforehand whether patients would want CPR if their pulse or breathing stopped after their operations, the former employees said. Typically, the staff addressed the issue only if a patient's condition became critical and family members were insisting on a DNR.
Newark Beth Israel's DNR policies are consistent with best practices, Kamateh said. "These policies guide our clinical teams in support of the treatment decisions of our patients and their families, from the most routine procedures to the most complex and stressful situations," she said. "We strive to explain care options and deliver sound medical advice in ways that are timely and clear, yet also respectful and sensitive."
At least indirectly, the concern about DNRs may have stemmed from Newark Beth Israel's aggressive approach to transplants. Newark Beth Israel's heart transplant program is one of the top 20 in the U.S. by volume, having grown under Dr. Mark Zucker, its director for three decades, and Camacho, the main surgeon. As of November, the hospital had performed 1,096 heart transplants.
The program is known for taking on sicker patients who might be rejected at other programs. From 2014 through 2017, compared with its counterparts in New Jersey and nearby states, Newark Beth Israel's transplant team operated on a higher percentage of patients who were older, more overweight or obese, and who had been in an intensive care unit while awaiting transplant, according to the Scientific Registry of Transplant Recipients. (The registry is funded by the U.S. Department of Health and Human Services to track and analyze transplant outcomes.) In those years, Newark Beth Israel also had a higher percentage of patients who had been on a pump or some other support before transplant, which increases the difficulty of surgery. This stance filled an important gap in care and helped the program grow both in size and revenue; hospitals typically bill insurers about$1.4 million for a heart transplant.
"While the Advanced Heart Failure Treatment and Transplant Program at NBI does not seek out cases that are more complex than those handled by other prestigious transplant programs, patients from other programs have been referred to our care and been successfully transplanted," Kamateh said. "Our clinical decisions are driven by the best interest of our patients, including their personal preferences, not by statistical results."
Scores of grateful patients say they owe their lives to Zucker and Camacho.
"Dr. Zucker has saved my life again and again," said Mark Reagan, a retired AIG executive in Bluffton, South Carolina. Reagan received his heart transplant at Newark Beth Israel in March 2003 after suffering from congestive heart failure for eight years. Reagan said his arteries were initially too narrow for a transplant, but Zucker opened his arteries with an experimental treatment so he could get onto the waitlist. After his surgery, Reagan became part of the "Hearty Hearts" volunteers at the hospital who advocate for organ donations and lift the spirits of other transplant recipients. Through "Hearty Hearts," he said, he has met several transplant candidates who were turned away by other hospitals but "walked out of Newark Beth Israel with a new heart, because of Mark."
Accepting more difficult cases, though, can raise the risk of adverse outcomes. According to former employees and audio recordings of staff meetings, Newark Beth Israel's transplant team worried about its one-year survival rate, which would drop below the national average in 2019. That anxiety, the employees said, appeared to underlie the team's unwillingness to sign DNR orders, since resuscitation might be needed to keep a patient alive.
Besides Andy Jurtschenko's children, two former NBI employees, including one with firsthand knowledge, said that the transplant team initially balked at a DNR order for him. By ruling out extreme measures to revive him, a DNR could conceivably have hastened Andy's death and lowered the program's one-year survival rate. Whether or how much metrics influenced Camacho's rebuff of the DNR request is unclear. While DNR orders are documented in the medical record, unapproved requests — and the reasons behind those decisions — generally aren't.
There can be few greater points of contention between physicians and families, few so infused with emotion and anguish on both sides, than whether to resuscitate someone on the verge of death. Hospitals have been suedand nursing homes finedfor resuscitating patients who had a DNR order on file. Or families may urge a medical team to initiate resuscitation that a physician believes is futile, or even torture, for a patient with a terminal diagnosis. The decision is inherently subjective, and ultimately, doctors are supposed to respect the wishes of patients — or, if they can't speak for themselves, their health care proxy.
A heart transplant itself is an act of resuscitation; there is a moment, after the old heart has been removed and the new organ not yet implanted, when the patient is only kept alive by a machine. If a surgery goes badly and a patient suffers serious complications, a request for a DNR can become a flashpoint, revealing the pressures that transplant teams are under to save patients, make sure that scarce donated organs don't go to waste and meet performance metrics.
More so than almost any other field of medicine, organ transplantation in the United States is tightly regulated. The U.S. Centers for Medicare and Medicaid Services can halt reimbursement if they find a program falling short of their standards. Transplant programs in the U.S. are constantly aware of the importance of keeping their survival rates at or above national medians, said a heart transplant surgeon at another hospital in the Northeast. "We are only judged on the numbers, on the results," said the surgeon, who requested anonymity to avoid jeopardizing future job opportunities. "My main job is to treat percentages, not patients."
In that context, medical staff can be reluctant to relinquish the option of resuscitation. "The 365-day problem is real, and if you gave truth serum to every transplant doctor in America, including me, and you asked if we didn't all keep an eye on it, and if we said we didn't, that would be a lie," said Dr. David Weill, a consultant to transplant programs and former director of the heart-lung transplant program at Stanford University Medical Center. As the one-year anniversary approaches, Weill added, he's seen doctors tell patients, "'It's too early [for a DNR], I've seen people recover, she has a strong will to live,' these kind of things."
Such attitudes extend beyond transplant wards to other types of cardiovascular surgery that judge success by survival metrics, though their key target is typically 30 days, not a year. An acute care nurse practitioner with more than two decades of experience in open-heart surgery care told ProPublica she's worked in several cardiac wards where families were discouraged from withdrawing life support or asking for a DNR before 30 days had elapsed.
"Families are lied to, they'll be told, 'It's too soon,' then after 30 days, doctors will say, 'Make them a DNR, go ahead,'" said the nurse, who requested anonymity because she feared retaliation from her employer. (She hasn't worked at Newark Beth Israel.) "Unless you have a medical directive and, if you're unable to speak for yourself, a relative with power of attorney, the hospital's driving the bus."
Metrics aren't the only reason that surgeons balk at DNR requests. They are trained to do everything they can to save lives. When a patient dies, while other doctors might blame a treatment protocol or the deceased's lifestyle, surgeons often feel personally responsible, according to Dr. Gretchen Schwarze, associate professor of vascular surgery at the University of Wisconsin School of Medicine and Public Health. In a 2010 study, Schwarze posed hypothetical scenarios to 10 surgeons, including a transplant specialist. One scenario described a patient who remained intubated and on a feeding tube a week after surgery. A family member then produces a previously undisclosed directive from the patient, asking not to be sustained by life support.
The surgeons "expressed significant emotional reaction," including "betrayal, unhappiness, disappointment," Schwarze reported. They felt that there was an implicit contract that patients entered into when signing up for surgery. One surgeon put it this way: "There is a commitment made by both the patient and the surgeon to get through the operation, as well as all of the post-operative issues that come up." While acknowledging that they were being "paternalistic" and contradicting the patient's directives, several of the surgeons in the study said they would refuse to withdraw life support in Schwarze's scenario.
One reason for conflicts over DNRs is that most patients aren't asked ahead of time about their desires for post-operative care. A 2010 study of admissions at two U.S. hospitals found that only one-third of seriously ill patients were asked what code status they wanted if they went into cardiac or respiratory arrest, and those conversations on average lasted one minute.
"We tend to wait too long to have a meaningful conversation. We wait until someone's been in the ICU for a while, until the point that the patient cannot participate in the conversation," said Luke Adams, a critical care nurse in Pennsylvania who founded a company called Advanced Care Solutions, which helps people write advance directives and navigate end-of-life decisions.
During a heart transplant operation, a patient cannot have a DNR order in place. The new heart may need to be shocked or stimulated with chest compressions to help it function properly. These actions would be considered "resuscitation."
After surgery, however, a patient should be able to ask for a DNR order at any time, and in the case of patients who can't speak for themselves, the request can come from a surrogate, usually the closest relative. A DNR order must be signed by a physician and put in the medical record. In New Jersey, DNR orders are typically entered as part of a form called a POLST, short for Practitioner Orders for Life-Sustaining Treatment, which also includes sections for other medical directives, including whether to use artificial nutrition and antibiotics.
Resuscitation is no assurance of either immediate or long-term improvement. A 2003 study of in-hospital resuscitation tracked 14,720 cardiac arrests and found that 44% of patients regained circulation, but only 17% recovered enough to be discharged from the hospital.
Darryl Young suffered brain damage during a heart transplant at Newark Beth Israel and never woke up. But, hardly consulting his family, doctors kept him alive for a year to avoid federal scrutiny.
Sometimes a DNR order is the obvious choice, said Dr. Perla Macip-Rodriguez, assistant professor of internal medicine at the Boston University School of Medicine, who specializes in palliative care and geriatrics. She gave the example of a patient with late-stage cancer that is no longer treatable. If the patient's heart stopped, CPR would not affect the terminal diagnosis. "It's just going to prolong their dying process."
Other cases are murkier. Andy Jurtschenko's brain was severely damaged. If his heart stopped and he was resuscitated, nobody could know what the outcome would be.
When the prognosis is uncertain, the medical team should focus on the patient's individual goals, said Dr. Jessica Zitter, an internist at Highland Hospital in Oakland, California, who practices both critical care and palliative care. "We should never, ever force treatment on a patient or their surrogate," she said. "There's no way you can ever insist on someone remaining on a machine or being resuscitated so long as the family has the patient's best interest in mind. That's called autonomy."
Megan Jurtschenko's fondest childhood memories involve visiting her father's carpet store, climbing on the stacks of samples and running her fingers over soft rugs while listening to him bantering and laughing with his clients.
The U.S.-born son of Eastern European immigrants, Andy Jurtschenko worked his way up through local furniture chains until he was able to open his own store, Route 46 Carpet, in West Paterson, New Jersey. His gift for patter made him a natural salesman. Divorced, he stayed close to his children. On his Facebook page, he described himself as "a caring American."
But in 2012, Andy began to feel tired and short of breath. Doctors diagnosed him with congestive heart failure. By 2014, as his heart became weaker, Andy had to stop working and go on disability. He was 57 years old. It frustrated him to rely on the government for financial support.
"All he ever wanted was to care for himself and his family. Losing that was not easy for him," Megan said.
Megan and Chris knew Andy would not want to be kept alive by extraordinary means. Just surviving wasn't his goal. His children wanted his caregivers to understand this as well.
On May 21, Andy was transferred from Newark Beth Israel to a rehab facility, JFK Johnson Rehabilitation Institute. Within a few days, a staff member of the facility called, asking for medical directives.
"They described him as very high risk for code, and they wanted to establish what we wanted," Megan recalled. If his heart were to stop, she instructed them, "they would not do any chest compressions, no electric shock. And if his lungs stopped functioning they would not put in a breathing tube. We wanted no artificial care."
Chris noted the difference between the rehab facility and the hospital. JFK "came to us and said we need to put this in place, where Newark kind of avoided it," he said.
Hackensack Meridian Health, a New Jersey network that includes JFK Johnson, "has comprehensive DNR policies that we consider an essential part of providing high-quality patient care," spokeswoman Mary Jo Layton said in an email. "Our teams work collaboratively with patients, their families and loved ones to ensure our patients' wishes are honored."
In September 2018, five months after Andy's surgery, another Newark Beth Israel patient, Darryl Young, suffered brain damage during a heart transplant. As ProPublica has reported, Zucker instructed his staff to keep Young alive and not to discuss palliative care options, such as hospice, with his family until the one-year anniversary of his surgery.
If Young were to die, the hospital's annual one-year survival rate, already at its lowest in a decade, would drop even further. In a previously unreported audio recording obtained by ProPublica, Zucker told his staff at a meeting in April 2019, "You can send him back to a rehab facility, but if you make him DNR at the rehab facility — they will make him DNR — it'll be a problem for us."
Zucker continued, "So, I don't really know what to do except to tell you that I recognize what I'm asking, I said myself I'm not sure that this is ethical, moral or right, but for the global good of the future transplant recipients, the others who come along, this program can't be put into an SIA."
SIA stands for systems improvement agreement, a process through which CMS can force a transplant program to get back into compliance. It typically costs a hospital at least $2 million. After the April meeting, Zucker's team never released Young to a rehab center, and he remains at the hospital. Young's sister, Andrea, did not request a DNR, and the team only discussed the option with her after ProPublica's article was published, she said.
The Centers for Medicare and Medicaid Services, the FBI, the New Jersey Department of Health and the State Board of Medical Examiners are investigating the hospital's treatment of Young. The hospital has placed Zucker on leave pending the results of its own review.
Newark Beth Israel and Zucker did not respond to questions about his comments regarding a DNR for Young.
On June 1, 2018, Megan Jurtschenko went to visit her father at the rehab facility, but his room was empty. After being transported to Newark Beth Israel the previous day for a checkup, he hadn't returned to JFK Johnson.
Panicked, Megan grabbed an Uber to the hospital. There, she raced to the fourth floor, sneakers pounding against the floor as she beelined for the cardiology unit. By that point, Andy had regained consciousness and could sometimes nod yes or no, but he easily became agitated, according to his children. Andy's medical record from that day described him as "non-verbal."
Megan went to her father's room first "to let him know that he wasn't alone" and then to the nurse's station, where two physicians met her. She said they told her that her father had a fever when he arrived for his checkup, so they kept him overnight and started a course of antibiotics. The hospital suspected pneumonia, according to his medical record.
Nobody at the hospital had called Megan, Chris or anyone else in the family to let them know that Andy was being admitted or treated, his children said. A few days later, a handwritten note in Andy's medical record said that the family was "upset" that they weren't informed.
Megan said she turned to a nurse to ask, "What's his code status?"
"Oh don't worry, he is at full code," the nurse responded, meaning that if Andy stopped breathing or his heart stopped, they would do everything possible to resuscitate him.
Her words riveted Megan to the floor.
"I said, 'Oh, no, that is the complete opposite of what we want.'"
Newark Beth Israel didn't respond to questions about this incident.
Andy needed to stay in the hospital until his infection cleared. That Friday, Megan refused to leave the hospital until she got a DNR order, so a cardiologist signed one. "Extensive discussion with daughter — Patient is DNR," a note in the medical record states. The family scheduled a formal meeting to discuss the order on the following Monday with a palliative care nurse practitioner and Zucker, the transplant program's director.
Chris was out of town, so Megan and her aunt, Anna DeMarinis, attended the meeting. Megan reminded Zucker that her father's goals for the transplant had been to resume his normal life, she said. She reiterated that the family wasn't asking to withdraw his feeding tube or medications. They just didn't want Andy to endure what they saw as extraordinary measures.
As Camacho had, Zucker urged caution. "He looked at me and said: 'You know, this is a very serious document. It's very extreme. Are you sure you want to do this?'" Megan recalled.
She wondered if Zucker was appealing to her emotions. "I got the impression he thought I was going to be the one who was going to say, 'No, I don't want to lose my Dad, let's keep trying!'"
Megan wasn't swayed. "I could see what was actually happening, which is — he was suffering and that's the only thing I saw." The palliative care nurse at the meeting revised and signed Andy's POLST form, indicating that Andy would continue full medical treatment unless he stopped breathing or had no pulse. In the CPR section, she checked the box for "Do not attempt resuscitation."
Even then, Zucker wouldn't let it go. After returning from his trip, Chris was sitting by his father's bedside when Zucker came by. Unprompted, Zucker brought up the DNR.
"He said, 'So, you're giving up on him.'" Chris recalled.
Chris didn't respond. "I was shocked, for a doctor to throw that in my face," he said.
Newark Beth Israel and Zucker did not respond to questions about the meeting with Megan or Zucker's conversation with Chris. "Mr. Jurtschenko's medical record confirms that his family's decision to implement a DNR in June rather than in April did not change his outcome," Kamateh said.
Andy Jurtschenko eventually returned to JFK Johnson. Over the next few months, during which he was moved to a different long-term care facility, Andy's condition improved modestly, until he was able to track people with his eyes and have short conversations.
But his gains soon plateaued. He was never able to stand, sit or eat on his own. He started hallucinating, seeing people who weren't there. Over time, his hands began to atrophy and curl in on themselves, despite attempts at physical therapy.
Andy's family members took turns visiting, making sure he had company nearly every day. Sitting by his side, they tried to engage him by flipping through photo albums, playing music from his favorite band, AC/DC, and watching sports on TV. They ached to see his misery. The spark in her younger brother's eyes was gone, DeMarinis said. Holding back tears, she said, "When he did become cogent, he just kept reiterating what we already knew — he was suffering. He was suffering terribly."
On the morning of Oct. 31, 2018, the rehab facility phoned Chris. Andy had died at sunrise. When his heart stopped, and his breathing faded, there was no attempt to resuscitate him.
CMS terminated an agreement and federal funding for Chicago Lakeshore Hospital, and the Illinois Department of Public Health is moving forward with plans to revoke the facility's license.
The article was first published on Friday, December 27, 2019 in ProPublica.
After more than a year of lawsuits and government extensions, federal authorities this week ended their Medicare agreement with a Chicago psychiatric hospital plagued by allegations of abuse and safety violations. The Illinois Department of Public Health said Thursday it is moving forward with plans to revoke the hospital's license.
The Centers for Medicare and Medicaid Services terminated the agreement and accompanying federal funding for Chicago Lakeshore Hospital on Monday after seven inspections since July 2018 found deficiencies that threatened the health and safety of the patients, federal records show.
The federal government will continue payment for up to 30 days for patients admitted to the hospital in Chicago's Uptown neighborhood before midnight Monday, a federal spokesman said. Hospital officials said Monday that Lakeshore, formerly known as Aurora Chicago Lakeshore Hospital, will remain open as they work with authorities and examine their options.
Meanwhile, IDPH has taken steps with the Illinois Hospital Licensing Board to begin an administrative proceeding to "revoke Chicago Lakeshore's state license imminently," department spokesman Cris Martinez said Thursday.
"Chicago Lakeshore Hospital has demonstrated a continued failure to comply with regulations," Martinez said.
Gov. J.B. Pritzker's office said Thursday that IDPH worked with the hospital to take corrective action, but that the facility has not only failed to comply with regulations but also "jeopardized patient health and safety," Pritzker press secretary Jordan Abudayyeh said. The governor's office is working with state agencies to "ensure patients can receive the care they need without interruptions," she said.
Payments from Medicaid, a joint state and federal program, also were terminated. Lakeshore officials have previously said the hospital will be forced to close if its Medicare and Medicaid payments were ended. Last year, more than 80% of its patients were insured through one of the two programs, court records show. Those patients and hospital employees would suffer, Lakeshore officials have argued, as the facility is one of the largest behavioral health providers in the state, serving about 5,000 patients annually.
In anticipation of the termination of payments, officials began to halt Medicaid admissions to Lakeshore earlier this month. There are currently about 40 Medicaid patients there, who will be discharged or transferred, according to a spokesman for the Illinois Department of Human Services.
Last month, IDPH inspectors, acting on behalf of federal authorities, found that Lakeshore had failed to implement proper safety precautions after a suicidal patient notified a nurse she wanted to hurt herself, according to records. The patient was later found unresponsive with a sheet wrapped around her neck. The nursing staff was able to revive her, records show, and she was transferred to another hospital. Inspectors also cited the hospital for failing to monitor a patient who was known to sexually act out and who allegedly abused another patient.
Lakeshore officials said in their statement Monday that the hospital has a decadeslong history of providing critical mental health services to patients, especially those with "nowhere else to go."
"Quality patient care has always been a top priority for our dedicated staff," the statement read. "In light of all that has been taken out of context, distorted, or exaggerated, it has been difficult over the last year to give justice to the great care Chicago Lakeshore Hospital provides every day, every work shift to a population of patients who have been forgotten by so many before landing at our door."
Hospital officials said they will continue to provide services for their patients and work with state and federal authorities over the next month to safely transition all Medicare and Medicaid patients out of the facility.
A new lawsuit calls Chicago Lakeshore a "hospital of horrors," where children as young as 7 were allegedly sexually abused and others were injected with sedatives and physically attacked — all while officials covered it up.
ProPublica Illinois and the Chicago Tribune last year separately reported troubling conditions at the hospital, including allegations of sexual and physical abuse against children in the state's child welfare system. At the time, the Illinois Department of Children and Family Services relied heavily on the psychiatric hospital but, following the news reports and subsequent pressure from lawmakers and the American Civil Liberties Union of Illinois, the agency late last year stopped sending children in its care there.
Over the past 15 months, Lakeshore has filed multiple lawsuits and administrative appeals in an attempt to halt the Medicare termination initially set to take effect August 2018. U.S. District Judge Sharon Johnson Coleman last December approved the hospital's request to keep federal officials from immediately pulling funding, but Coleman vacated that order last week. She also denied the hospital's latest effort to avert the termination.
In her Dec. 19 ruling, Coleman wrote that federal officials have offered Lakeshore numerous opportunities to correct the deficiencies. Officials were not required to to give the hospital yet another opportunity, she wrote, "especially in light of (the hospital's) inability to provide a safer environment for its young patients."
Also last week, the Cook County public guardian filed a lawsuit that called Lakeshore a "hospital of horrors" where children as young as 7 had been abused.
In response to the Medicare termination, a spokeswoman for Blue Cross and Blue Shield of Illinois said the insurer had removed the hospital from its networks on Tuesday. In recent court filings, Lakeshore said Blue Cross was the hospital's third-largest source of revenue in 2018, at around 9%, after Medicaid and Medicare.
Lakeshore can file an administrative appeal with federal authorities, but the termination will remain in place during that time. Federal regulations also allow the hospital to reapply for its Medicare certification, but it must provide "reasonable assurance" that the cause for the termination no longer exists and will not recur.
Drug companies have paid doctors billions of dollars for consulting, promotional talks, meals and more. A new ProPublica analysis finds doctors who received payments linked to specific drugs prescribed more of those drugs.
This article first appeared on Friday, December 20, 2019 in ProPublica.
Doctors who receive money from drugmakers related to a specific drug prescribe that drug more heavily than doctors without such financial ties, a new ProPublica analysis found. The pattern is consistent for almost all of the most widely prescribed brand-name drugs in Medicare, including drugs that treat diabetes, asthma and more.
The financial interactions include payments for delivering promotional talks, consulting and receiving sponsored meals and travel.
The 50 drugs in our analysis include many popular and expensive ones. Thirty-eight of the drugs have yearly costs exceeding $1,000 per patient, and many topped the list that are most costly for the Medicare Part D drug program.
Take Linzess, a drug to treat irritable bowel syndrome and severe constipation. From 2014 to 2018, the drug's makers, Allergan and Ironwood, spent nearly $29 million on payments to doctors related to Linzess, mostly for meals and promotional speaking fees.
ProPublica's analysis found that doctors who received payments related to Linzess in 2016 wrote 45% more prescriptions for the drug, on average, than doctors who received no payments.
Those findings were repeated for drug after drug. In 2016, doctors who received payments related to Myrbetriq, which treats overactive bladder, wrote 64% more prescriptions for the drug than those who did not. For Restasis, used to treat chronic dry eye, doctors who received payments wrote 141% more prescriptions. The pattern holds true for 46 of the 50 drugs.
On average, across all drugs, providers who received payments specifically tied to a drug prescribed it 58% more than providers who did not receive payments.
Other research, including our own, has found a correlation between payments and overall prescribing. This new analysis expands upon past work by looking individually at a variety of popular drugs. "What clearly jumps out is how consistent the association is across drugs," said Aaron Mitchell, a medical oncologist at Memorial Sloan Kettering Cancer Center who has studied pharmaceutical payments for oncology drugs.
Our analysis looked at the relationship in two ways: whether those who received payments prescribed more of a drug, as well as whether those who prescribed a drug received higher payments than those who did not. We found that, on average, physicians who prescribed a drug received higher payments related to the drug that same year than those who didn't prescribe it. For Linzess, the value of payments was more than four times higher for providers who prescribed the drug than among those who did not. For Myrbetriq, it was three times higher, and for Restasis, it was twice as much. (Read our methodology for more about the analysis.)
Holly Campbell, a spokeswoman for the Pharmaceutical Research and Manufacturers of America, an industry trade group, said it stands to reason that doctors who have interactions with a company about a drug may prescribe more of it "because they have more information about the appropriate uses for the products."
Through spokespeople, Allergan (maker of Linzess as well as Alphagan P, Bystolic, Combigan, Lumigan, Namenda and Restasis), Janssen (maker of Invega, Invokana, Xarelto and Zytiga) and Novo Nordisk (maker of Levemir, Novolog and Victoza) described their interactions with physicians as important for sharing medical information.
Novo Nordisk added that prescribing data is not used to target physicians for speaking or other promotional interactions. Eli Lilly said in a statement that meals can take place in many contexts, including in doctors' offices, at speaker events and at conferences, but didn't answer other questions. GlaxoSmithKline, Ironwood, Astellas and Purdue declined to comment.
For some drugs that are household names, it was more common for prescribers to receive a payment than not to. More than half of doctors who prescribed Breo, an expensive asthma drug, to Medicare patients received payments involving the drug in 2016. This was also true for Invokana and Victoza, both of which are diabetes medications. For Linzess, nearly half of doctors who prescribed the drug had interactions with its maker.
More than one in five doctors who prescribed OxyContin under Medicare in 2016 had a promotional interaction with the drug's manufacturer, Purdue Pharma. The company did not respond to a request for comment.
"If there are physicians out there that deny that there is a relationship, they are starting to look more and more like climate deniers in the face of the growing evidence," said Aaron Kesselheim, a professor of medicine at Harvard Medical School and an expert in pharmaceutical costs and regulation. "The association is consistent across the different types of payments. It's also consistent across numerous drug specialties and drug types, across multiple different fields of medicine. And for small and large payments. It's a remarkably durable effect. No specialty is immune from this phenomenon."
Huey Nguyen, a gastroenterologist in southern Indiana, increased his prescribing of Linzess in recent years. From 2013 to 2015, Nguyen's Medicare patients had fewer than 60 claims per year for Linzess. In 2016 and 2017, that jumped to over 110 claims per year.
Over that time, Nguyen was a promotional speaker for Linzess. Allergan paid him $1,000 in 2013, over $4,000 in both 2016 and 2017, and $2,000 in 2018 to speak about the drug.
Though Linzess has been on the market since 2012, Ironwood and Allergan made a big push to promote the drug in 2016 and 2017. Spending on doctors reached $10 million in 2016 and nearly $8 million the following year, up from under $4 million in both 2014 and 2015.
In total, Nguyen has earned $25,000 from 2014 to 2018 related to six drugs from four pharmaceutical companies, excluding meals. In 2018, he was paid by two companies to promote competing drugs that treat irritable bowel syndrome.
ProPublica's analysis did not set out to examine, nor did it resolve, whether industry payments change doctors' behavior, or if patients receive inferior care from doctors who receive payments. Many factors can influence doctors' prescribing choices. Some patients, for instance, have conditions for which only brand-name treatments are available or for which other drugs have failed.
Nguyen said promotional speaking educates doctors about how a drug works, whether insurance covers it and when not to prescribe it.
"It's a way for the primary care physicians to have access to a gastroenterologist where they can ask one-on-one questions," Nguyen said. "I'm more educated towards the drug, because I have to be trained to speak on it, so I'm more comfortable prescribing it."
Experts are skeptical that interactions between companies and doctors benefit patients. "If there really were innovations and real benefits that were accruing to patients for a new treatment, it shouldn't take so much spending by the company to get the word out," said Stacie B. Dusetzina, associate professor of health policy at Vanderbilt University Medical Center, who advised ProPublica on the design of its analysis. "I wonder if promotion is really to try to push products that have a much less substantial benefit because they're not gaining the market share naturally."
Nguyen said he takes many things into account when prescribing a drug, including its approved uses, cost and side effects. "In my day-to-day practice, my patients still come first," Nguyen said. He said the speaking engagements do not influence his prescribing, "at least not consciously. Unconsciously, I don't know." He sees the public disclosure of industry payments to doctors as a way to help patients be active participants in their care.
Nguyen said he works with companies for the extra compensation but acknowledged that "it's perfectly reasonable for people to question my motives."
ProPublica's analysis matched doctors' prescribing in Medicare's prescription drug program to the industry payments doctors received. Drug and medical device companies are required to report these payments annually through the federal Open Payments program, and they are made public on a government website. More than 600,000 doctors receive payments annually. (Companies also report research payments and ownership interests, but these were excluded from our analysis.)
Some providers were paid thousands of dollars, often for promotional speaking. But the typical doctor took in much less. Most only received meals, typically worth less than $100 per year.
In 2016, ProPublica found a relationship between the total dollar value of a doctor's interactions with drug and device companies and the overall percentage of brand-name drugs he or she prescribed.
Brand-name drugs are more expensive than generic options, both for patients and for Medicare. A recent report from the Department of Health and Human Services found that Medicare Part D and its beneficiaries could have saved almost $3 billion by switching from brand-name drugs to generics.
Linzess is an expensive drug, costing Medicare and patients an average of about $1,500 annually. A common alternative is the laxative Miralax, available over the counter as generic polyethylene glycol, which costs less than $200 annually if taken every day. Nguyen said he recommends Miralax to many patients, but that wouldn't show up in Medicare's data because Medicare doesn't cover over-the-counter drugs. He said he often prescribes Linzess to patients who have tried Miralax and not seen the symptom relief they hoped for.
For brand-name drugs that have good generic alternatives, "every time a doctor prescribes one of these brand-name medications, it's extra money transferred from the Medicare program to the manufacturer," said Michael Barnett, assistant professor of health policy at Harvard T. H. Chan School of Public Health. "Medicare spending is out of control. And drug costs are one of the major reasons."
Drug cost can have major consequences, not just for Medicare balance sheets but also for patients' well-being. "The newest, latest drug is often not any better than the old drugs" that treat the same condition, Mitchell said. "But the new drugs are always more expensive. That really hurts patients' pocketbooks. You've got physicians prescribing more expensive drugs and patients who aren't taking them as a result. A generic medicine that's cheaper that a patient does take is a whole lot more effective than an on-brand, expensive medicine that they don't take.
Last year, the federal government promised to improve vetting of doctors who administer immigration medical exams. But ProPublica found doctors with records of unprofessional behavior, including sexual misconduct, drug abuse and fraud, still have the federal government's approval.
This article first appeared on Thursday, December 12, 2019 in ProPublica.
Last year, government investigators found that the federal program for vetting the health of green card applicants included scores of doctors with histories of professional misconduct. Physicians who had been disciplined by state medical boards for abusing patients, and in some cases had faced criminal charges, had the government's blessing to conduct screenings that can decide the fate of an immigrant's petition for permanent residency.
The investigators found one doctor who had been convicted of hiring a hitman to kill a disgruntled patient, and in the same sample, found more than a hundred other physicians with serious disciplinary histories. The review concluded that U.S. Citizenship and Immigration Services, the agency that maintains the list of more than 5,000 doctors, inadequately vets the physicians, and that it often fails to follow its own standards. "As a result of these deficiencies, USCIS may be placing foreign nationals at risk of abuse by physicians performing medical examinations," investigators concluded.
Fifteen months after the audit was released, the list still includes scores of doctors with histories of professional misconduct similar to those flagged in the audit. In the directory of so-called civil surgeons, ProPublica found at least 150 doctors accused of patient abuse and negligence as of early December, and we determined that many of them are still offering the exam.Bottom of Form
One is James Richard Luu, of San Jose, California, who allowed his sister, an acupuncturist, to use his prescription pad and to treat patients with hemorrhoids in his office, misdiagnosing them and causing pain. Luu, 53, came to the United States as a refugee from Vietnam, and he and his sister placed ads in Vietnamese-language media to recruit patients from the immigrant population in San Jose. In 2011, Luu was charged with aiding and abetting the unlicensed practice of medicine in relation to his sister. He pleaded guilty, was sentenced to one day in jail and one year of probation. In 2014, the medical board put him on professional probation for three years.
He is currently offering immigration exams, and he said he has had no issues since he was put on probation in 2014. "Everything has been cleared."
Another doctor who was in the good graces of USCIS for years is Alvaro Genao, of New York City, who forged another physician's name to prescribe medications, including a potentially addictive sleep aid, to himself and others. After an investigation, the state medical board suspended his license in 2014, for professional misconduct and fraudulent practice. In 2017, the medical board withdrew the suspension, putting him on probation for 10 years.
Genao, 49, was still listed on the USCIS website until last week when he was removed after ProPublica contacted the agency. He did not respond to emails or text messages and hung up when a ProPublica reporter called him.
After the audit last year, USCIS promised to clean up the list and take actions to prevent green card applicants from being exposed to potential harm. But USCIS does not require any consideration of doctors' disciplinary histories when they apply for the program. The agency requires only that applicants have an active medical license, and almost all of the doctors on the list who have serious records do.
The audit noted that doctors who have had issues with misconduct in the past could still present a risk to patients. "Although some disciplinary conduct may have occurred years ago, the nature of the offense may continue to render these physicians a risk to those applying for immigration benefits," the report said.
It recommended that USCIS, which is part of the Department of Homeland Security, develop stricter standards, like those used by the Department of Health and Human Services, under which many of the physicians on the agency's directory could be disqualified. But the agency has already missed several self-imposed deadlines to make fixes. The audit also suggested using the National Practitioner Data Bank, a federal database, to bolster the vetting of doctors.
The doctor who was convicted of hiring the hitman was removed from the USCIS website this summer, along with about two dozen others. But our analysis found that as of early last week, more than a hundred doctors with records of unprofessional and sometimes dangerous behavior are still listed online.
After ProPublica contacted USCIS on Dec. 4 — and before it provided any response to our inquiry — the agency removed 16 more doctors with a history of misconduct from the website. In an email, the USCIS press office said, "Due to a computer glitch, civil surgeon revocations made in the past few weeks were not reflected online. USCIS has corrected the issue." But many of the doctors who were removed last week, including Genao, were disciplined several years ago.
Look Up Doctor Disciplinary Records
The list of doctors changes week to week, as it has in the course of our reporting.
One of the doctors with the USCIS stamp of approval admitted to a state medical board that in the early 1990s he had "sexual relations" with at least 16 of his patients. He is still listed online. Another doctor, who investigators found provided substandard care to green card seekers in a makeshift office without an exam table, was specifically barred from doing work related to USCIS. He was removed from the directory last week after ProPublica's inquiry.
To assess the state of the USCIS list, ProPublica analyzed the disciplinary records of doctors in the top five states for green card applications. In 2017, 57% of green card applications filed within the U.S. were sent from California, Florida, Texas, New York and New Jersey. We entered every ZIP code from those five states into the USCIS Find a Doctor website, and we looked up the medical board disciplinary record of each doctor who appeared in the search results.
We considered doctors to have a history of unprofessional or dangerous behavior if they had been disciplined for sexual misconduct, drug abuse, negligent patient care, inappropriate prescribing of controlled substances or deceptive practices. We did not include doctors who were disciplined for administrative errors like failing to submit a death certificate or not updating a practice's address with the medical board.
We found dozens of doctors who improperly prescribed controlled substances to themselves, friends or family members; some who violated patient privacy by revealing medical records to unauthorized people; some who failed to supervise assistants and technicians; and others who improperly diagnosed and documented medical conditions.
"It is horrible to know that there are doctors out there that have been disciplined for this type of action, and that they're responsible as gatekeepers to these immigrants," said Mario Urizar, an immigration lawyer in Miami whose firm handles more than 100 cases of green card applications annually.
The audit, issued in September 2018, was conducted by the inspector general for the Department of Homeland Security. It listed eight recommendations, including stricter requirements for doctors and improved training for the USCIS staff reviewing doctors' applications. USCIS agreed and set projected completion dates. Two of those dates have passed and two more are at the end of this year.
In an email, USCIS's press office wrote that the agency has "begun implementing the recommendations."
"USCIS concurred with last year's Inspector General report and continues toward implementation of recommendations, including drafting updated policy to develop stricter eligibility requirements for civil surgeons and strengthening the health-related inadmissibility training program," a spokeswoman, Marilu Cabrera, said in a statement.
While the Trump administration's focus on illegal immigration has captured the nation's attention, the federal government has also made the pathways to legal immigration more challenging. Immigration lawyers told ProPublica that recent changes in USCIS policies have made it difficult to correct mistakes in green card applications, raising the stakes for the immigrants, doctors and attorneys who fill out the forms.
The case of Fernando Romero illustrates how a single mistake by a USCIS-designated doctor — even one without a disciplinary record — can upend a petition for permanent residency. Romero, 41, traveled to Miami from Argentina almost two decades ago, when Argentine tourists could enter the U.S. with a visa waiver. He overstayed his visa waiver and was undocumented for several years. In 2016, he applied for a green card through his wife, also an Argentine immigrant, who had become a U.S. citizen years earlier. Last July, the petition was denied. In a letter, USCIS said it had turned down Romero's application because the doctor who examined him didn't include her contact information in the medical form. (The doctor who examined Romero is not on ProPublica's list of doctors with serious disciplinary records and declined to comment for this story.)
The letter from USCIS instructed Romero to make arrangements to leave the United States "as soon as possible." If he didn't, he could be barred from entering the country or receiving any immigration benefits, the letter said.
"When we got the letter, we panicked. My wife and I started wondering, what are we going to do? Are we going to have to return to Argentina?" said Romero, who installs wood flooring for a living. "I feared that the feds were going to knock on my door any day."
Under a past policy, implemented during the Obama administration, the USCIS officer working on Romero's case would have been likely to notify Romero about the missing contact information. But last September, the agency changed its policy. Now, officers aren't required to send a notification, although they can. The agency has said that it made the change to cut down on "frivolous" green card applications, and that it was not intended to penalize applicants for "innocent mistakes" or misunderstandings.
In October 2018, USCIS also changed the appointment system for many of its field offices, limiting in-person meetings between applicants or their attorneys and the agency's officers. In a press release, USCIS said the change was part of an effort to move more services online and reduce case processing times.
But attorneys say that these changes leave immigrants like Romero with few options to address issues with their applications.
In its letter denying Romero's green card petition, USCIS advised him that his only other option was to file a "motion to reopen or a motion to reconsider" his case, which carries a $675 filing fee. Even if that succeeded, it would have likely meant starting the costly and lengthy green card process all over again. In the meantime, neither his driver's license nor his work permit would be valid.
"The whole time while they do that, I essentially would have gone back to zero… as if I was here illegally again," said Romero, who had already spent more than $4,000 on the application and legal fees.
Romero said he called the agency dozens of times, hoping to correct the doctor's mistake by submitting a new medical form, instead of restarting the application process. But he said everyone he reached at USCIS referred him to the letter. He said that he and his wife talked to nearly 20 attorneys, but all of them offered only to file the motion. Eventually he reached Urizar, the lawyer in Miami, who suggested Romero sue USCIS. The lawsuit, filed in August, claimed that the USCIS was arbitrarily punishing Romero for a mistake by a doctor who was working on behalf of the agency. Two weeks later, the USCIS agreed to allow Romero to submit the corrected form and approved his green card.
The immigration medical forms are only valid for two years. If the process takes longer, an applicant would have to see a USCIS-designated doctor again and pay another exam charge. The medical exam, which is not covered by insurance, has no fixed price. In phone calls to doctors' offices, ProPublica was given prices ranging from $100 to $1,000.
Immigrants "are completely vulnerable because the doctor gives them the report in a sealed envelope to provide immigration with," Urizar said. "So not only are they not privy to their documents unless they ask for a copy, they have no say as to what immigration will decide on it."
According to USCIS, the purpose of the immigration medical exam is to protect public health. A green card applicant may be deemed inadmissible on medical grounds, a power established in the Immigration Act of 1891, which stated that entry could be denied to all "idiots, insane persons, paupers or persons likely to become a public charge," as well as "persons afflicted with tuberculosis or with a loathsome or dangerous contagious disease."
Although the conditions that could render a person inadmissible today are no longer described as loathsome, the same principles apply to current immigration exams. Tuberculosis remains a part of the screening, along with communicable diseases such as syphilis, gonorrhea and leprosy. Drug addiction, considered a disorder "associated with harmful behavior," is also listed as grounds for denying an immigrant entry.
Last year, just over 2,700 immigrant visa applications were rejected for medical reasons, according to data from the State Department. Nearly 1,000 of these applications cited communicable disease as the cause for ineligibility. The data does not show how many of these immigrant visas are connected to green card applications.
The list of conditions that could make an immigrant inadmissible has been the subject of controversy. The Centers for Disease Control and Prevention removed HIV from the list in 2010, stating that including HIV was "at odds with human rights considerations," after Congress repealed a travel ban on tourists and immigrants who were HIV-positive. Until 1973, when homosexuality was removed from the official list of mental illnesses in the U.S., the medical exam could be used to bar LGBTQ applicants.
The term civil surgeon is a holdover from the days of Ellis Island. The original screeners were officers of the U.S. Public Health Service, led by the surgeon general. Civil surgeons today do not have to be civil servants or surgeons. Most are private doctors, and the process to become certified is simple: Any physician who is authorized to work in the United States, has four years of professional experience and is licensed without restriction in the state where they work can apply by filling out a form and paying a $785 filing fee. State and local health department physicians and military physicians are automatically eligible.
Francisco Velazquez, an internist in the Houston area, said he became a USCIS-designated doctor to serve the immigrant community. Velazquez said he was motivated to join the program after hearing about clinics that were charging a lot and prescribing unnecessary vaccines.
"It's just a numbers game," Velazquez said. "It adds up, and if you're very greedy and you charge a little bit more here and there, the demand is there."
Velazquez, who became a civil surgeon last October, sees 30 to 40 patients a month for the immigration exam. He said that most of the immigrants who come to his office are working-class people who are referred by immigration attorneys. Others have found his office while calling different doctors looking for a price they can afford. He charges $265 per exam, plus the cost of any vaccinations the applicants need. To avoid mistakes, he says he types the information in the form, instead of writing by hand, and gives a copy to the patient to review.
Physicians in the program are required to follow the CDC's instructions for administering and evaluating the exams. The CDC also runs conferences and workshops for the doctors on how to administer the exams properly, but attendance is voluntary.
USCIS has a history of significant lags in updating and maintaining its list of approved doctors. In May 2017, the inspector general sent a list of 48 doctors to USCIS whose licenses were restricted or expired. It took several months for the agency to act, and in the end 11 of them were never removed.
Physicians are required to notify USCIS within 15 days if they stop practicing or stop administering immigration exams. The agency's press office said that when USCIS revokes a civil surgeon's designation, it removes that doctor from the directory. But ProPublica found at least a dozen physicians whose offices said they were no longer giving green card exams in mid November, even though they were still listed as doing so online.
According to the inspector general's report, USCIS relies on a contractor specializing in health care compliance to review the list of doctors twice a year and identify those with inactive or restricted licenses. Then, a USCIS employee manually reviews the results.
Last year, the inspector general's audit recommended that USCIS stop using the contractor, Evercheck. The audit called the agency's process inefficient and suggested that USCIS use the National Practitioner Data Bank, which is run by Health and Human Services.
USCIS's press office said in an email that the agency is still using Evercheck to confirm that physicians are licensed and to identify any restrictions on the licenses. The agency said it has increased license reviews to four times a year. The office also wrote that the agency is still "determining how best to utilize the National Practitioners Data Bank (NPDB) in a manner that is feasible, cost effective, and appropriate for the agency's needs."
In an email, Brian Solano, the CEO of Evercheck, said that the company has had the same contract with USCIS for several years, and that the terms have not changed. He said that he was not aware of the audit.
Solano wrote that Evercheck provides monthly reports of doctors' license statuses, including disciplinary actions taken against them. But it's up to USCIS to decide what to do with those reports.
"We're just alerting them of any changes on the license," Solano said. "And then they can make the business decision of what to do about it."
Of the audit's eight recommendations, all but one — creating a training program and quality control for the designation of physicians — remain open, according to Tanya Alridge, a spokeswoman for the inspector general. The inspector general's office said that agency liaisons check in on the status of open recommendations every 90 days, and that progress is reported to Congress twice a year.
How We Reported This Story
To assess the doctors authorized to perform immigration exams, ProPublica analyzed the disciplinary records of more than 4,000 doctors who are designated as civil surgeons. We scraped USCIS'Find a Doctor website, which is the public list of civil surgeons, according to USCIS's policy manual. We entered every ZIP code from the top five states for green card applications (California, Florida, Texas, New York and New Jersey) and scraped and saved those search results. For each doctor that showed up in the search results, we looked up their disciplinary record from the state medical board website, which is public information. We matched the doctors on their first and last name (and middle name, if one was listed), and the state in which they were listed as practicing on USCIS' website. If multiple doctors had the same name in the same state, we cross-checked the name of their practice and ZIP code.
We read through the medical board findings on each doctor's misconduct. We considered doctors to have a record of unprofessional behavior if they had been disciplined for sexual misconduct, drug abuse, negligent patient care, inappropriate prescribing of controlled substances or deceptive practices. For example, we included doctors that prescribed controlled substances to their friends and family members, posted false advertisements about their treatments, administered watered down or expired vaccines and medications, sexually assaulted and harassed patients, and allowed staff members who were not medically trained to treat patients. We did not include doctors that were disciplined for administrative errors, such as failing to submit a death certificate or neglecting to update information such as their address or phone number with the medical board.
Lexi Churchill, Nate Schweber and John Surico contributed reporting.
The chairman of the U.S. Senate Finance Committee has called on the largest health care system in Memphis, Tennessee, to explain its debt collection, charity care and billing practices after an investigation by MLK50 and ProPublica found that it was aggressively suing poor patients, including its own employees.
In a letter sent last week, Sen. Charles Grassley, R-Iowa, who has been a leading critic of nonprofit hospitals that misuse their tax-exempt status, asked Methodist Le Bonheur Healthcare how it intended to carry out promised reforms of its financial assistance system.
Tax-exempt hospitals are required by the IRS to provide charity care to patients who cannot afford their hospital bills and to avoid what's called "extraordinary collection actions," such as suing a patient or seeking to garnish a patient's wages.
"Unfortunately, I have seen a variety of news reports lately discussing what appear to be relentless debt-collection efforts by various tax-exempt hospitals, including Methodist Le Bonheur Healthcare," Grassley wrote in the Dec. 3 letter.
"These efforts raise questions about how Methodist Le Bonheur Healthcare, and other tax-exempt hospitals, are complying" with requirements by the IRS to fulfill charitable obligations.
In June, MLK50 and ProPublica reported that Methodist, a religious nonprofit, sued more than 8,300 patients in five years, many of whom are low-income and could not afford their doctors bills. After winning a judgment, Methodist would then seek to seize part of the defendant's paycheck, even when the defendant made very little money and even when the defendant was one of its employees.
A Methodist spokesperson said the hospital had received the letter and "will work with Sen. Charles Grassley to address his concerns."
In response to the MLK50-ProPublica articles, Methodist dropped hundreds of lawsuits against patients and has not filed additional lawsuits for unpaid hospital bills. It reduced the bills for about 2,200 patients and erased the balance owed for more than 5,100 patients who had judgments against them.
In addition, Methodist expanded the threshold for financial assistance to uninsured patients whose household incomes fall below 250% of the federal poverty guidelines, up from 125% previously. The new threshold equates to just over $64,300 for a family of four. The hospital also will not pursue legal action against any patient in households that earn less than 250% of the federal poverty guidelines, regardless of their insurance status.
Grassley acknowledged the change in his letter, but asked questions about how it would be implemented.
"How will Methodist Le Bonheur Healthcare's new financial assistance policy better serve low-income patients compared to its old policy beyond including more people in it?"
Grassley's letter at one point mischaracterized the findings of the MLK50-ProPublica stories as saying Methodist "does not offer free or highly discounted care." Methodist does offer discounts for uninsured patients, but not for insured ones. (A spokesman for Grassley did not have an immediate comment on that point.)
Grassley's nine-page letter to Methodist is similar to a 2015 letter he sent to Heartland Regional Medical Center, a nonprofit hospital in Missouri that was the subject of a 2014 ProPublica-NPR investigation into its debt collection practices.
"The practices appear to be extremely punitive and unfair to both low income patients and taxpayers who subsidize charitable hospitals' tax breaks," he wrote to Heartland, which had been rebranded as Mosaic. Afterward, Mosaic implemented a three-month debt forgiveness program during which more than 5,000 applications for financial assistance were approved and more than $16 million in debt, legal fees and interest was forgiven.
The MLH Associate Advancement Program is intended to help its employees "create greater economic security for themselves and their families so more Memphians can truly escape the cycle of poverty," the hospital said in a press release.
Methodist will cover the costs for employees to enroll in a specialized course at the University of Memphis to become a certified nursing assistant or surgical technologist. The median annual pay for certified nursing assistants is around $27,000 and for surgical technologists is $47,300.
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The medical center's transplant director instructed staff to keep a vegetative patient alive, and not to discuss options such as hospice care with his family, until the one-year anniversary of his surgery.
This story was first published by ProPublica on November 29, 2019.
The FBI is investigating the organ transplant program at Newark Beth Israel Medical Center, according to people contacted by the bureau.
The bureau is looking into whether the program, which kept a vegetative patient on life support for the sake of boosting its survival rate, attempted to defraud federal insurers Medicare and Medicaid, said one person familiar with the situation, who spoke on the condition of anonymity. FBI spokeswoman Patty Hartman said that the agency could neither confirm nor deny the existence of an investigation.
Andrea Young, the sister of the Newark Beth Israel patient at the center of the case, said that the bureau is seeking to interview her. ProPublica reported in October that Newark Beth Israel's transplant director, Dr. Mark Zucker, instructed his staff to keep Darryl Young alive, and not to discuss options such as hospice care with his family, until the one-year anniversary of his surgery. Federal regulators relied on the one-year survival rate to evaluate—and sometimes penalize—transplant programs.
Young, who is covered by Medicare and Medicaid, suffered brain damage during heart transplant surgery in September 2018 and never woke up. He remains hospitalized at Newark Beth Israel. The bureau launched its investigation within days after the article was published.
Besides the FBI, the New Jersey State Board of Medical Examiners has also started an investigation. The board, which oversees physician licensing, declined to comment on which doctors it is looking at. Andrea Young said that a board investigator interviewed her. Also investigating are the U.S. Centers for Medicare and Medicaid Services and the New Jersey Department of Health.
Linda Kamateh, a spokeswoman for the hospital, did not respond to questions about the FBI or state board probes. "Newark Beth Israel Medical Center is fully cooperating with all regulatory agencies and investigative bodies," she said in an email. The hospital "bills the Centers for Medicare and Medicaid Services in accordance with approved billing guidelines," she added. Newark Beth Israel has hired a private law firm and a consultant to conduct an internal review of its transplant program, and it has placed Zucker on leave.
Newark Beth Israel's heart transplant program is one of the top 20 in the country by volume, and it has performed 1,096 heart transplants over the past three decades, according to the hospital. It also has a lung transplant program.
The hospital typically only bills insurers when the patient is released. Young was discharged twice and moved to long-term care facilities, but he returned to the hospital in early 2019 after developing infections. Even if Newark Beth Israel hasn't yet billed the government insurance programs for Young's care, the FBI could be considering a number of potential criminal charges related to defrauding Medicare and Medicaid, said Michael Elliott, a defense lawyer in Dallas who was previously the lead attorney for the federal government's Medicare Fraud Strike Force in North Texas.
ProPublica reported that the transplant team appeared to tailor medical decisions for at least three other patients because of concerns about its survival rate. The FBI is likely looking for other instances similar to the Young scenario in which federal insurance was already billed, Elliott said, adding that the investigation could take months or even years.
"If medical records were being falsified to keep him on a service, each false statement is a criminal charge," Elliott said. Audio recordings published by ProPublica, in which doctors discussed the need to keep Young alive for the sake of survival statistics, could be evidence of "some kind of conspiracy to commit health care fraud, because they would be charging Medicare for his care, and there appears to be some agreement among the people who are taped," he said.
ProPublica's investigation found that Newark Beth Israel's transplant team was worried about the possibility of being disciplined by CMS, after six out of 38 patients who received heart transplants in 2018 died before their one-year anniversary. That translated into an 84.2% one-year survival rate, considerably worse than the 91.5% national probability of surviving a year for heart transplant patients, according to the Scientific Registry of Transplant Recipients, which tracks and analyzes outcomes for the government.
The transplant program has touted a higher success rate. In a July 29 letter to New Jersey cardiologists, Zucker and Dr. Margarita Camacho, a heart surgeon, wrote, "Outcomes remain excellent at 98% survival rate for the past 48 transplants."
In an email, Kamateh said the rate was based on transplants from May 2018 to May 2019. She did not respond to questions about how the 98% rate was calculated and how long patients had to live after their operation to qualify as survivors. The rate does not match up with any official statistics.
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The Trump administration redesigned the online Medicare Cost Finder for seniors to compare complex health insurance options. But consumer advocates have identified instances when the tool has malfunctioned and given inaccurate plan and price data.
This article was first published on Monday, November 25, 2019 in ProPublica.
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The federal government recently redesigned a digital tool that helps seniors navigate complicated Medicare choices, but consumer advocates say it's malfunctioning with alarming frequency, offering inaccurate cost estimates and creating chaos in some states during the open enrollment period.
Diane Omdahl, a Medicare consultant in Wisconsin, said she used the tool Friday to research three prescription drug plans for a client. The comparison page, which summarizes total costs, showed all but one of her client's medications would be covered. When Omdahl clicked on "plan details" to find out which medicine was left out, the plan finder then said all of them were covered.
So she started checking the plans' websites, and it turns out there are two versions of the same high blood pressure medication. One is covered. The other is not. The difference in price: $2,700 a month.
In Nebraska, miscalculations offered through the new Medicare Plan Finder were so worrisome that the state in late October temporarily shut down a network of about 350 volunteer Medicare advisers for a day because without the tool, narrowing the numerous choices — more than 4,000 Medicare plans are available nationwide — down to three top selections would be nearly impossible.
Days later, EnvisionRxPlus, a prescription drug plan, sent an email to independent insurance brokers nationwide recommending they not use the Medicare Plan Finder because of incorrect estimates on drug prices and patient deductibles. (It's a warning they had yet to retract some two weeks later.)
Minnesota's Association of Area Agencies on Aging said in a news release on Nov. 14 that the Medicare Plan Finder "continues to produce flawed results," including inaccurate premium estimates, incorrect prescription drug costs and inaccurate costs with extra help subsidies.
More than 60 million people use Medicare, which covers those over 65 and the disabled. Users have to pick their plans annually. The current open enrollment period ends Dec. 7. Medicare advisers — as well as advocates for seniors — worry that the full weight of the tool's inaccuracies will not be felt until the 2020 coverage year begins and seniors head to pharmacies to fill prescriptions or show up for medical appointments. For many Medicare participants, selections made during open enrollment are irreversible.
"Millions of people are going to be absolutely affected," said Ann Kayrish, senior program manager for Medicare at the National Council on Aging. "And you hate to think about millions of people having the wrong plan. That's kind of crazy."
"It's not like there's one consistent problem that you can fix and then be addressed," said David Lipschutz, associate director of the Center for Medicare Advocacy. "It's really like a game of whack-a-mole."
The Centers for Medicare and Medicaid Services, the government agency that administers federal health programs, acknowledged in a statement that some problems have been reported but said development of the redesigned tool, which cost about $11 million, was an "iterative" process. The statement said CMS did "extensive consumer testing … to ensure that the information that is displayed is complete, streamlined, understandable, and is in plain language."
CMS said it previewed the new plan finder in June and began "road-testing" it in July, saying "stakeholder feedback led to enhancements" that were implemented before a public launch on Aug. 27. Updates have continued as users report issues, according to the statement.
CMS said this is the first time since the Medicare Plan Finder was developed in 2005 that the tool has been redesigned. The complete rebuild was necessary, it said, because legacy technology and "proprietary software" couldn't keep pace with "the needs of today's digital audience" and because the explosion in options available to seniors under various plans.
Millions of Medicare beneficiaries use the plan finder to reevaluate their insurance choices during open enrollment. The tool drives traffic to Medicare.gov, where users may filter, sort and compare choices. A recent Kaiser Family Foundation analysis found that beneficiaries will have an average of 28 Medicare Advantage plans and 28 prescription drug plans to choose from in 2020. As of Friday, there was no alert on the federal website warning of possible inaccuracies because of the redesign.
Choosing from myriad options can be so befuddling to the typical Medicare participant that states offer help through the federally supported Senior Health Insurance Program, which offers free one-on-one counseling to those eligible for Medicare, their families and caregivers. In Nebraska, for example, seniors choose from 30 Medicare Advantage and 29 Part D prescription drug plans, and the plan finder tool offers a way to quickly sort through dense information.
"You put in the drugs and you put in the pharmacies they want to go to, and it prices them all out," said Alicia Jones, administrator of the Senior Health Insurance Information Program in the Nebraska Department of Insurance and chair of the national SHIP Steering Committee. Without the plan finder, she said, "the only way to do that is go to 29 different websites and do them individually."
Jones said she has flagged about 100 errors with the new tool since Oct. 1, some small but others more significant. She noticed it wasn't importing the correct quantity of drugs, specifically with tubes of medication. It was, she said, giving people way more medicine than needed, "so if you didn't look at it close, it would give very high prices."
One day, she said, the numbers for someone she was helping enroll in a prescription drug plan were off by $2,000. The inconsistencies grew so worrisome that Jones said they "just completely stopped" on Oct. 28 to better assess the situation.
Omdahl, the Medicare consultant in Wisconsin, said it recently took her 32 clicks — she counted — to return to the main page after trying to figure out what limits apply for a specific Medicare Advantage plan's referral and prior authorization requirements.
Every day, each of the 21 Senior LinkAge Line specialists working with Metropolitan Area Agency on Aging, serving the Minneapolis-St. Paul area, have come across at least one error, said Hannah Fox, a Senior LinkAge Line specialist.
"The inaccuracies we're seeing and are concerned about have to do with the medication copays," Fox said. "The plan finder is telling us that a medication is on a plan formulary — or not on the plan formulary — and, again, we're contacting the plan and getting the reverse."
Julie Roles, spokeswoman for the Minnesota agency, said "specialists know what to be looking for, so they can ID something that might be wrong. But an ordinary person who is just looking by themselves really won't be alerted to an issue."
The agency advised beneficiaries who have already enrolled in a plan to verify pricing and other details with the plan provider. It's also asking CMS "to immediately remedy this situation and to extend the open enrollment period for at least three months once the Plan Finder tool is fixed."
In New York, Judith Esterquest said she had previously grown so frustrated using the tool to reevaluate her Medicare options that she gave up. This year, she tried again, finding a prescription drug plan that would save her money. Then she decided to double-check with a friend who also happens to be a SHIP adviser, asking, "Am I reading this right?"
"I'm an educated person. I have a PhD. I should be able to figure it out," she said, adding that she spent "an enormous amount of time" on the National Institutes of Health's website looking at research protocols when her husband was diagnosed with a rare form of leukemia. "I am comfortable with technology, and I had trouble with the Medicare website."
According to federal documents used during a national Medicare education meeting, more than 20 million users visited Medicare.gov to use the plan finder in 2017, accounting for about a third of all traffic to the site.
"Plan Finder users often find the process daunting," the documents said. "Research has shown that users want Plan Finder to provide the following: Simpler results - only information they really need to make a good decision; Personalized information - based on their individual situation. Clarity on out-of-pocket costs."
The U.S. Government Accountability Office laid out a number of issues with the old plan finder in a July report, including "cumbersome" navigation, confusing instructions, difficult filter and sort functions, and incomplete cost estimates for traditional Medicare that makes it difficult to compare with Medicare Advantage.
"So many of these systems are held together by baling wire and chewing gum," said Lisa Bari, an independent consultant who previously worked on health IT, interoperability and artificial intelligence at CMS' innovation center.
The contract for completely redesigning the Medicare Plan Finder was awarded to the software design and engineering company Ad Hoc, which describes itself as being born from "the successful effort to rescue HealthCare.gov after its disastrous initial launch." The federal online insurance marketplace, a major component of the Affordable Care Act, crashed within hours of launching in 2013, and additional technical problems kept it from functioning properly for weeks.
In a July 2018 blog post, Greg Gershman, Ad Hoc's chief executive officer and co-founder, announced that his company had won the contract for developing a replacement plan finder as part of the Medicare Coverage Tools initiative. He said "Ad Hoc proposed a product development process that centers around understanding beneficiaries desires when trying to make care decisions, tests our understanding early and often via a minimum viable product, and adds value to the experience with iterative product enhancements."
Gershman did not respond to requests for comment.
Bari, who did not work on the project, said the issues described to her suggest logic, calculation and coding errors that stem from poor user acceptance testing. That kind of testing, typically the final phase before new software is released, ensures the software can handle real-world tasks and perform up to development specifications. It can be difficult, she said, to find enough people with the necessary skills to do appropriate testing with something as complex as drug coverage.
With a large-scale project that will be used by millions, such as the Medicare Plan Finder, there should be about a month of testing to identify problems, fix them and get everything signed off on, Bari said. Each cohort of features, she added, should go through this process.
"It sounds like they're just patching stuff now," she said, "trying to catch the holes that weren't caught or specified."
OxyContin's makers delayed the reckoning for their role in the opioid crisis by funding think tanks, placing friendly experts on leading outlets, and deterring or challenging negative coverage.
This article was first published on Tuesday, November 19, 2019 in ProPublica.
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up for ProPublica's Big Story newsletter to receive stories like this one in your inbox as soon as they are published.
This story is a collaboration between ProPublica and STAT.
In 2004, Purdue Pharma was facing a threat to sales of its blockbuster opioid painkiller OxyContin, which were approaching $2 billion a year. With abuse of the drug on the rise, prosecutors were bringing criminal charges against some doctors for prescribing massive amounts of OxyContin.
That October, an essay ran across the top of The New York Times' health section under the headline "Doctors Behind Bars: Treating Pain is Now Risky Business." Its author, Sally Satel, a psychiatrist, argued that law enforcement was overzealous, and that some patients needed large doses of opioids to relieve pain. She described an unnamed colleague who had run a pain service at a university medical center and had a patient who could only get out of bed by taking "staggering" levels of oxycodone, the active ingredient in OxyContin. She also cited a study published in a medical journal showing that OxyContin is rarely the only drug found in autopsies of oxycodone-related deaths.
"When you scratch the surface of someone who is addicted to painkillers, you usually find a seasoned drug abuser with a previous habit involving pills, alcohol, heroin or cocaine," Satel wrote. "Contrary to media portrayals, the typical OxyContin addict does not start out as a pain patient who fell unwittingly into a drug habit."
The Times identified Satel as "a resident scholar at the American Enterprise Institute and an unpaid advisory board member for the Substance Abuse and Mental Health Services Administration." But readers weren't told about her involvement, and the American Enterprise Institute's, with Purdue.
Among the connections revealed by emails and documents obtained by ProPublica: Purdue donated $50,000 annually to the institute, which is commonly known as AEI, from 2003 through this year, plus contributions for special events, for a total of more than $800,000. The unnamed doctor in Satel's article was an employee of Purdue, according to an unpublished draft of the story. The study Satel cited was funded by Purdue and written by Purdue employees and consultants. And, a month before the piece was published, Satel sent a draft to Burt Rosen, Purdue's Washington lobbyist and vice president of federal policy and legislative affairs, asking him if it "seems imbalanced."
On the day of publication, Jason Bertsch, AEI's vice president of development, alerted Rosen to "Sally's very good piece."
"Great piece," Rosen responded.
Purdue's hidden relationships with Satel and AEI illustrate how the company and its public relations consultants aggressively countered criticism that its prized painkiller helped cause the opioid epidemic. Since 1999, more than 200,000 people have died from overdoses related to prescription opioids. For almost two decades, and continuing as recently as a piece published last year in Slate, Satel has pushed back against restrictions on opioid prescribing in more than a dozen articles and radio and television appearances, without disclosing any connections to Purdue, according to a ProPublica review. Over the same period, Purdue was represented by Dezenhall Resources, a PR firm known for its pugnacious defense of beleaguered corporations. Purdue was paying Dezenhall this summer, and still owes it money, according to bankruptcy filings.
Purdue funded think tanks tapped by the media for expert commentary, facilitated publication of sympathetic articles in leading outlets where its role wasn't disclosed, and deterred or challenged negative coverage, according to the documents and emails. Its efforts to influence public perception of the opioid crisis provide an inside look at how corporations blunt criticism of alleged wrongdoing. Purdue's tactics are reminiscent of the oil and gas industry, which has been accused of promoting misleading science that downplays its impact on climate change, and of big tobacco, which sought to undermine evidence that nicotine is addictive and secondhand smoke is dangerous.
Media spinning was just one prong of Purdue's strategy to fend off limits on opioid prescribing. It contested hundreds of lawsuits, winning dismissals or settling the cases with a provision that documents remain secret. The company paid leading doctors in the pain field to assure patients that OxyContin was safe. It also funded groups, like the American Pain Foundation, that described themselves as advocates for pain patients. Several of those groups minimized the risk of addiction and fought against efforts to curb opioid use for chronic pain patients.
Purdue's campaign may have helped thwart more vigorous regulation of opioid prescribing, especially in the decade after the first widespread reports of OxyContin abuse and addiction began appearing in 2001. It may also have succeeded in delaying the eventual reckoning for Purdue and the billionaire Sackler family that owns the company. Although Purdue pleaded guilty in 2007 to a federal charge of understating the risk of addiction, and agreed to pay $600 million in fines and penalties, the Sacklers' role in the opioid epidemic didn't receive widespread coverage for another decade. As backlash against the family swelled, the company filed for Chapter 11 bankruptcy in September.
"Efforts to reverse the epidemic have had to counter widespread narratives that opioids are generally safe and that it is people who abuse them that are the problem," said Caleb Alexander, co-director of the Center for Drug Safety and Effectiveness at the Johns Hopkins Bloomberg School of Public Health, who has served as a paid expert witness in litigation alleging that Purdue's marketing of OxyContin misled doctors and the public. "These are very important narratives, and they have become the lens through which people view and understand the epidemic. They have proven to be potent means of hampering interventions to reduce the continued oversupply of opioids."
Satel, in an email to ProPublica, said that she reached her conclusions independently. "I do not accept payment from industry for my work (articles, presentations, etc)," she wrote. "And I am open to meeting with anyone if they have a potentially interesting topic to tell me about. If I decide I am intrigued, I do my own research."
As for Purdue's funding of AEI, Satel said in an interview that she "had no idea" that the company was paying her employer and that she walls herself off from information regarding institute funders. "I never want to know," she said. She didn't disclose that the study she referred to was also funded by Purdue, she said, because "I cite peer-reviewed papers by title as they appear in the journal of publication."
The sharing of drafts before publication with subjects of stories or other interested parties is prohibited or discouraged by many media outlets. Satel said she didn't remember sharing the draft with Rosen and it was not her usual practice. "That's very atypical," she said. However, Satel shared a draft of another story with Purdue officials in 2016, according to emails she sent. In that case, Satel said, she was checking facts.
Satel said she didn't remember why the doctor with a patient on high doses of painkillers wasn't named in the Times story. The draft she sent to Purdue identified him as Sidney Schnoll, then the company's executive medical director, who defended OxyContin at public meetings and in media stories. In an interview, Schnoll described Satel as an old friend and said her description of his patient was accurate. He left Purdue in 2005 and now works for a consulting company that has Purdue as a client, he said.
Purdue, in a statement, said it has held memberships in several Washington think tanks over the years. "These dues-paying memberships help the company better understand key issues affecting its business in a complex policy and regulatory environment," it said. "Purdue has been contacted over the years by policy experts at a variety of think tanks who are seeking additional context on industry issues for their work. Our engagement has always been appropriate and aimed at providing a science-based perspective that the company felt was often overlooked in the larger policy conversation." The company declined to discuss specific questions about internal documents and emails reviewed by ProPublica.
A spokeswoman for the Times, Danielle Rhoades Ha, said in an email that the company doesn't know the details of how the Satel story was handled because the editors who worked on it are no longer employed there. She noted that the Times labeled the article as an "Essay" and cited Satel's connection to AEI. Currently, she said, Times editors "generally advise reporters not to share full drafts of stories with sources in the course of fact-checking," but there is no formal rule.
Purdue launched OxyContin in 1996, and it soon became one of the most widely prescribed opioid painkillers. By 2001, it was generating both enormous profits as well as growing concern about overdoses and addiction. That August, a column in the New York Post opinion section criticized media reports that OxyContin was being abused. The piece — headlined "Heroic Dopeheads?" — mocked a "new species of 'victim,' the 'hillbilly heroin' addict." The real victims, the article contended, were pain patients who may lose access to a "prescription wonder drug."
At 5:17 a.m. on the day the article was published, Eric Dezenhall, the founder of Washington, D.C., crisis management firm Dezenhall Resources, sent an email to Purdue executives, according to documents filed by the Oklahoma attorney general in a lawsuit against opioid makers.
"See today's New York Post on OxyContin," he wrote. "The anti-story begins."
Purdue had hired Dezenhall Resources that summer. Dezenhall's hard-nosed reputation fit the blame-the-victim strategy advocated by Purdue's then-president, Richard Sackler. "We have to hammer on the abusers in every way possible," Sackler wrote in a 2001 email quoted in a complaint by the state of Massachusetts against the company. "They are the culprits and the problem. They are reckless criminals."
Purdue later followed this approach to fend off a New Jersey mother who was urging federal regulators to investigate the marketing of OxyContin. Her daughter had died while taking the drug for back pain. "We think she abused drugs," a Purdue spokesman said without offering evidence. Purdue later apologized for the comment.
However, pain patients with legitimate prescriptions for OxyContin and similar painkillers can and do become addicted to the drugs. The Centers for Disease Control and Prevention warnsthat "anyone who takes prescription opioids can become addicted to them," and that "as many as one in four patients receiving long-term opioid therapy in a primary care setting struggles with opioid addiction." A review article in The New England Journal of Medicine reported rates of "carefully diagnosed addiction" in pain patients averaged just under 8% in studies, while misuse, abuse and addiction-related aberrant behaviors ranged from 15% to 26% of pain patients.
Although Dezenhall Resources was working for Purdue until recently, it rarely has been linked publicly to the company. Purdue paid Dezenhall a total of $309,272 in July and August of this year and owes it an additional $186,575, according to bankruptcy court filings. The total amount paid to Dezenhall since 2001 was not disclosed in records reviewed by ProPublica.
Dezenhall Resources has also defended Exxon Mobil against criticisms from environmental groups and former Enron CEO Jeffrey Skilling as he fought against fraud charges, according to a 2006 BusinessWeek profile of Eric Dezenhall that called him "The Pitbull of Public Relations." (Skilling was later convicted.) It reported that Dezenhall arranged a pro-Exxon demonstration on Capitol Hill to distract attention from a nearby environmental protest, and that the company discussed a plan to pay newspaper op-ed writers to question the motives of an Enron whistleblower. "We believe a winning outcome can only be achieved by directly stopping your attackers," Dezenhall Resources states on its website.
ProPublica reviewed emails to Purdue officials in which Dezenhall and his employees took credit for dissuading a national television news program from pursuing a story about OxyContin; helping to quash a documentary project on OxyContin abuse at a major cable network; forcing multiple outlets to issue corrections related to OxyContin coverage; and gaining coverage of sympathetic pain patients on a television news program and in newspaper columns.
"Dezenhall has been instrumental in helping with the placement of pain patient advocacy stories over the last several years," Dezenhall Executive Vice President Sheila Hershow wrote in a 2006 email.
Eric Dezenhall told ProPublica that he does not confirm or deny the identity of clients. While declining to answer questions about Purdue, or comment on the BusinessWeek article about him, he said that his company acts appropriately and seeks fair and truthful coverage.
"We regularly work with experts and journalists, including Pro Publica, to ensure accuracy in reporting and persuade and dissuade them regarding various storylines with facts and research," he wrote. "Ultimately, these journalists and experts decide how to use the information provided."
One of Dezenhall Resources' first moves, after being hired by Purdue, was to cultivate Satel. In July 2001, Hershow reported to Purdue officials that she and Eric Dezenhall had lunch with Satel and the doctor was "eager to get started." Hershow said Satel had read a "debunking package" and was "interested in doing an opinion piece on the medical needs of patients being sacrificed to protect drug abusers."
Satel said that the meeting with Dezenhall was not unusual, and that "I often talk to people who have interesting stories."
Satel was raised in Queens and has an Ivy League pedigree. She attended Cornell University as an undergraduate before going to medical school at Brown University. She was a psychiatry professor at Yale University for several years and then moved to Washington. For a little over a decade beginning in 1997, she was a staff psychiatrist at a methadone clinic in the city.
She has become an influential voice on opioids, addiction and pain treatment. Her writings have been published in The Wall Street Journal, USA Today, The Atlantic, Slate, Health Affairs, Forbes, Politico and elsewhere. She frequently appears on panels, television shows and in newspaper articles as an expert on the opioid crisis and pain prescribing guidelines. "We've entered a new era of opiophobia," she recently told The Washington Post.
Satel has been a resident scholar at the American Enterprise Institute since 2000. Among the notable figures who have spent time at AEI are the late Supreme Court Justice Antonin Scalia and former Trump national security adviser John Bolton. Current fellow Scott Gottlieb returned to AEI this year after serving as commissioner of the U.S. Food and Drug Administration, which approves and regulates prescription drugs like OxyContin.
Purdue said its annual payments of $50,000 to AEI were part of the institute's corporate program. That program offers corporations the opportunity to "gain access to the leading scholars in the most important policy areas for executive briefings and knowledge sharing," according to the institute's website. Corporations can choose between three levels of donations: At $50,000 a year, Purdue was in the middle level, the "Executive Circle." Besides the annual payments, Purdue has also paid a total of $24,000 to attend two special events hosted by the institute, according to a company spokesman.
Internal emails show the main Purdue contact with AEI was Rosen, the drugmaker's in-house lobbyist based in Washington. In one email, Rosen described the leaders of the think tank as "very good friends" and also noted that former FDA Commissioner Mark McClellan ascended to that job after a stint at AEI as a scholar. Rosen also organized a group of pain reliever manufacturers and industry funded groups into an organization called the Pain Care Forum. It met to share information on government efforts to restrict opioid prescribing, according to records produced in litigation against Purdue.
Veronique Rodman, a spokeswoman for AEI, said the institute does not publicly discuss donors. She said that the institute does not accept research contracts, and that its researchers come to their own conclusions. "It makes sense" that Satel would be unaware of AEI funders, she said.
Dezenhall's courting of Satel soon paid off. A month after the lunch with Dezenhall and Hershow, Satel defended Purdue's flagship drug in an article for the opinion page of The Boston Globe.
"Something must be done to keep OxyContin out of the wrong hands, but the true public health tragedy will be depriving patients who need it to survive in relative comfort day to day," she wrote.
In February 2002, AEI held a panel discussion at its headquarters to answer the question, "Who is responsible for the abuse of OxyContin?" The panel of experts included Satel, a Purdue executive and a Purdue lawyer. Covering the event, Reuters Health reported that the panel "mostly agreed that Purdue Pharma should not be viewed as the culprit in the problem of the abuse of its long-acting painkiller OxyContin."
Two months later, Purdue approved spending $2,000 to pay for Satel to speak to the staff of a New Orleans hospital about addiction, according to internal company records. Satel said she had "absolutely no memory of speaking at a hospital in New Orleans." The physician who organized the planned event said he doesn't recall if it took place, and the hospital no longer has records of medical staff talks from that period.
In 2003, a Dezenhall staffer recommended Satel as a guest to a producer for "The Diane Rehm Show" on NPR. The firm and Purdue executives, including Vice President David Haddox, helped prep Satel for the appearance. Haddox passed along what he called "interesting intel for Sally" that Rehm's mother suffered from chronic headaches. "Thanks for helping us get her up to speed for the show," Hershow replied.
A spokeswoman for WAMU, the NPR station in Washington that produced the Rehm show, said there was no policy to ask guests about funding of their organizations, or if there was a financial connection to the show's topic. "For most segments, the producers would try to bring as many perspectives to the table as possible so that listeners would be better able to make their own informed judgment of the topic at hand," wrote the spokeswoman, Julia Slattery.
ProPublica was unable to reach Haddox for comment.
Also that year, when conservative radio commentator Rush Limbaugh revealed that he was addicted to prescription painkillers, Purdue declined a request from CNN for a company representative to discuss the news on the air. Instead, Purdue recommended Satel, who assured viewers that OxyContin was a "very effective and actually safe drug, if taken as prescribed." Dezenhall's Hershow told Purdue executives in an email that she was "very glad Sally went on." Hershow, a former investigative producer at ABC News, declined comment for this article.
In September 2004, Forbes magazine published a Satel article under the headline, "OxyContin doesn't cause addiction. Its abusers are already addicts."
"I am happy this morning!" Purdue's then general counsel, Howard Udell, emailed other company executives and Eric Dezenhall with the subject line "RE: Forbes Article." Three years later, Udell and two other Purdue executives would plead guilty in federal court to a misdemeanor criminal charge related to misleading patients and doctors about the addictive nature of OxyContin.
As part of that 2007 settlement, Purdue admitted to acting "with the intent to defraud or mislead" when it promoted OxyContin as less addictive and less subject to abuse than other painkillers. In an article for The Wall Street Journal headlined "Oxy Morons," Satel defended the company. "The real public-health damage here comes from the pitched campaign conducted by zealous prosecutors and public-interest advocates to demonize the drug itself," she wrote.
After Purdue and Dezenhall launched their "anti-story," media reports of OxyContin addiction and abuse declined for several years. In 2001, there were 1,204 stories that included the words "OxyContin," "abuse" and "Purdue" published in media outlets archived on the Nexis database. The number plummeted to 361 in 2002 and to 150 in 2006.
Purdue's counterattack against an ambitious investigative series about OxyContin abuse may have contributed to that drop. An October 2003 series in the Orlando Sentinel, "OxyContin Under Fire," found that Purdue's aggressive marketing combined with weak regulation had contributed to "a wave of death and destruction."
The series, however, was marred by several errors that were detailed in a front-page correction nearly four months later. The reporter resigned, and two editors on the series were reassigned. While acknowledging the mistakes, the newspaper did not retract the series, and its review upheld the conclusion that oxycodone was involved in a large number of the overdoses in Florida.
Dezenhall Resources, in an email, took credit for forcing the newspaper to issue the corrections. "Dezenhall's efforts resulted in a complete front-page retraction of the erroneous 5-day, 19-part, front-page Orlando Sentinel series," Hershow wrote in a 2006 email summarizing Dezenhall's work for Purdue under the subject line "Success in Fighting Negative Coverage."
Purdue officials and the company's public relations agencies came up with a 13-point plan to generate media coverage of the errors. It included getting a doctor to talk about how the series "frightened and mislead (sic) the people of Florida" and having a pain patient write a newspaper opinion column on the subject. The Sentinel series, one Purdue official wrote to other company executives and Dezenhall's Hershow, was an opportunity to let the country know about "all of the sensational reporting on OxyContin abuse over the past 4 years. The conclusion: this is the most overblown health story in the last decade!"
In the six years after Purdue challenged the Sentinel's findings, the death rate from prescription drugs increased 84.2% in Florida. The biggest rise, 264.6%, came from deaths involving oxycodone. The state became a hotbed for inappropriate opioid prescribing as unscrupulous pain clinics attracted out of state drug seekers. The route traveled by many from small towns in Appalachia to the Florida clinics was nicknamed the "Oxycontin Express."
In 2017, 14 years after the Sentinel series was published, the Columbia Journalism Review described it as "right too soon" and said it "eerily prefigured today's opioid epidemic."
Purdue couldn't hold off restrictions on opioid prescribing forever. Since 2011, a growing number of states, insurers and federal health agencies have adopted policies that have led to annual declines in prescribing. Advocates for pain treatment have complained that this turnabout has gone too far, and the CDC recently advised doctors against suddenly discontinuing opioids. Still, the U.S. remains far and away the world leader in per capita opioid prescriptions.
Under increasing pressure, Purdue enlisted other public relations firms known for aggressively helping corporations in crisis. Burson-Marsteller, which after a merger last year is now known as BCW, signed an agreement in 2011 to provide Purdue "strategic counsel." Burson-Marsteller represented Johnson & Johnson as it responded to the Tylenol poisoning case and Union Carbide after the deadly Bhopal explosion in India.
According to documents, it helped Purdue identify and counter "potential threats," such as congressional investigators and the group Physicians for Responsible Opioid Prescribing. A 2013 proposed work plan between the companies called on Burson to perform as much as $2.7 million of work for Purdue. BCW did not respond to requests for comment.
Purdue also employed the services of Purple Strategies, a Washington-area firm that reportedly represented BP after the Deepwater Horizon disaster. Purdue paid $621,653 to Purple Strategies in the 90 days prior to the drugmaker's Sept. 15 bankruptcy filing and owes it an additional $207,625, according to court filings. Purple Strategies did not respond to requests for comment.
Purdue also added Stu Loeser to its stable. The head of an eponymous media strategy company, Loeser was press secretary for Michael Bloomberg when he was mayor of New York City, and he is now a spokesman for Bloomberg's possible presidential bid.
Soon after Loeser began representing Purdue, Satel wrote in a 2018 piece for Politico headlined, "The Myth of What's Driving the Opioid Crisis," about "a false narrative" that the opioid epidemic "is driven by patients becoming addicted to doctor-prescribed opioids."
Loeser told Purdue executives in an email that "we are going to work with AEI to 'promote' this so it comes across as what it is: their thoughtful response to other writing." His team was working to target the Satel story "to land in social media feeds of people who have searched for opioid issues and potentially even people who have read specific stories online," he added.
Loeser said in an interview that he didn't end up working with AEI to promote the story. He said Purdue is no longer a client.