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.
ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.
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.
ProPublica is a Pulitzer Prize-winning investigative newsroom. Sign up for The Big Story newsletter to receive stories like this one in your inbox.
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.
ProPublica is a nonprofit newsroom that investigates abuses of power. Sign up to receive our biggest stories as soon as they're published.
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.
Dignity Health said its employee, an ER nurse, failed to meet the deadline to add her premature newborn to its health plan, so she was responsible for the medical bills. It rejected her appeals for a year until ProPublica called.
This article was first published on Monday, November 4, 2019 in ProPublica.
Lauren Bard opened the hospital bill this month and her body went numb. In bold block letters it said, "AMOUNT DUE: $898,984.57."
Last fall, Bard's daughter, Sadie, had arrived about three months prematurely; and as a nurse herself, Bard knew the costs for Sadie's care would be high. But she'd assumed the bulk would be covered by the organization that owned the hospital where she worked: Dignity Health, whose marketing motto is "Hello humankindness."
She would be wrong.
Bard, 30, had been caught up in an unforgiving trend. As health care costs continue to rise, employers are shifting the expense to their workers — cutting back on what they'll cover or pumping up premiums and out-of-pocket costs. But a premature baby, delivered with gaspingly high medical claims, creates a sort of benefits bomb, the kind an employer — especially one funding its own benefits — might look for a way to dodge altogether.
Bard, distracted by her daughter's precarious health and her own hospitalization for serious pregnancy-related conditions, found this out the hard way. Her battle against her own employer is a cautionary tale for every expectant parent.
Bard's saga began, traumatically, when she gave birth to Sadie at just 26 weeks on Sept. 21, 2018, at the University of California, Irvine Medical Center in Southern California. Weighing less than a pound and a half, tiny enough to fit into Bard's cupped hands, Sadie was rushed to the neonatal intensive care unit. Three days after her birth, Bard called Anthem Blue Cross, which administers her health plan, to start coverage. Anthem and UC Irvine's billing department assured her that Sadie was covered, Bard said.
But Dignity's plan, like many, requires employees to enroll newborns within 31 days through its website, or they won't be covered — something Bard said she didn't know at the time.
Meanwhile, believing that everything with her health benefits was on track, Bard spent nine of those first 31 days recovering in her own hospital bed and then had to return to the emergency room because of a subsequent infection. She spent as much time as she could in the neonatal intensive care unit, where Sadie, in an incubator, attached to tubes and wires, battled a host of critical ailments related to extremely premature birth. At times, doctors gave her a 50-50 chance of survival.
"Right from birth she was a fighter," Bard said.
Then, eight days past the 31-day deadline, UC Irvine's billing department alerted Bard to a problem with Sadie's coverage. Anthem was saying it could not process the claims for the baby, who was still in the NICU.
Bard, an emergency room nurse at St. Bernardine Medical Center in San Bernardino, called Dignity's benefits department and made a sickening discovery. Sadie wasn't enrolled in its health plan. It was too late, she was told, she could no longer add her baby.
Dignity bills itself as the fifth-largest health system in the country, with services in 21 states. The massive nonprofit self-funds its benefits, meaning it bears the cost of bills like Sadie's. And it doesn't appear to be short on cash. In 2018, the organization reported $6.6 billion in net assets and paid its CEO $11.9 million in reportable compensation, according to tax filings. That same year, more than two dozen Dignity executives earned more than $1 million in compensation, records show.
Dignity is also a religious organization that says its mission is to further "the healing ministry of Jesus." Surely, Bard remembering thinking, they would show her compassion.
With the specter of the bills hanging over her, Bard said she literally begged Dignity to change its mind in multiple phone calls, working her way up to supervisors. She thought she'd enrolled Sadie by calling Anthem she told them. It was an innocent mistake.
The benefits representatives told her information about the 31-day rule was in the documents she received when she was hired. It didn't matter that it was six years earlier, long before she dreamed of having Sadie, she said. The representative also told her it wasn't just Dignity's decision, the Internal Revenue Service wouldn't allow them to add the baby to the plan.
Under Dignity's plan, Bard could have two written appeals. She got nowhere with either of them. "IRS regulations and plan provisions preclude us from making an enrollment exception," Dignity wrote in its Nov. 30, 2018, response to her first appeal.
IRS officials said they can't talk about specific cases because of privacy issues and could not comment in general in time to meet ProPublica's deadline.
Dignity rejected Bard's second written appeal in a July 8 letter, saying the deadline was included in a packet sent nine days before Sadie's birth. But at that time, Bard had already been admitted to the hospital because of complications. Dignity's letter said it "cannot make an exception to plan provisions."
But the federal regulator of Dignity's plan said such plans can, in fact, make exceptions. An official with the federal Labor Department, which regulates self-funded health benefits, told ProPublica that plans can make concessions as long as they apply them equally to participants. Plus, federal law allows plans to treat people with "adverse health factors" more favorably, the official said.
Bard scrambled, futilely, to see if any publicly funded insurance plan would be able to cover the costs. Meanwhile, the bills began arriving: $206 in November, $1,033 in January, $523 in February and $69,362 in April, with the biggest yet to come. Sadie had spent 105 days in the hospital and had several surgeries — and the bills would be Bard's alone.
Sadie's total hospital tab was nearing $1 million and climbing when ProPublica first spoke to Bard. "I'll either work the rest of my life or file for bankruptcy," she said.
Bard said she and her fiancé — Sadie's father, Nathan Benton — considered delaying their wedding so he wouldn't be legally saddled with the bills as well.
The looming debt, and her employer's rejection, sent Bard reeling when she was already suffering from postpartum depression. She went back to her job while worrying that she might lose her home in Norco. She wept and beat herself up again and again about missing the deadline: How could she not think of something like that? She should've known. She should've been on top of it more.
Anthem declined to comment for this story. UC Irvine, where Bard said the care was excellent, said that cases like Bard's are unusual but may happen in 1% to 2% of births. The hospital tries to work with patients when they get stuck with the bills, a UC Irvine spokesman said.
With the appeals exhausted, the $898,000 bill landed. Bard could see right away that handling it the typical way, with a payment plan, was not going to work. If she chipped away at it at $100 a month, settling the obligation would take more than 748 years. "It would take so long I'd be dead," Bard said.
Bard could see no way out. On Oct. 7, she posted a photograph of the $898,000 bill on Facebook. "When Dignity Health (the company I work for) screws you out of your daughter's insurance…" she wrote.
A week later, ProPublica, which had been flagged to Bard's case while reporting about health insurance excesses, contacted a Dignity media representative.
The next day, Bard got a call from the senior vice president of operations for Dignity Southern California, who apologized and said she'd heard about the situation from the organization's media team and would help. Two days later, Dignity added Sadie to the plan, retroactive to her birth date. It would cover the bills.
Dignity officials told ProPublica that they'd learned about Bard through her Facebook post. Bard said she doubts Dignity would have reversed course without the questions from ProPublica.
Dignity said in a statement that it would review how it could better educate new parents about the enrollment requirement. But Bard still wants to know why her employer would make her suffer through such an ordeal. In a letter Bard received last week, the Dignity benefits department said it had received additional information that caused it to reverse course, but it appears to be the same information that Bard had been telling it all along.
"We based this new decision on certain extenuating and compelling circumstances, which, in all likelihood prohibited you from enrolling your newborn daughter within the Plan's required 31-day enrollment period," the letter said.
Bard recognizes a dark irony in her Christian employer's behavior, and it's made her skeptical. She urged the benefits department to change its process so other employees don't also have their benefits denied. Dignity needs to put its own ideals into practice, she told ProPublica. "You can't put on this facade," Bard said. "You have to live it. You have to walk the walk."
Bard said she and Benton still don't know the final total for Sadie's care. But they sometimes call the sassy and dimpled 1-year-old, who is healthy and reaching developmental milestones, their "million-dollar baby."
Has your employer wrongly denied your health benefits? Please share your story with reporter Marshall Allen at marshall.allen@propublica.org. Have you worked in health insurance or employer-sponsored health benefits? ProPublica is investigating the industry and wants to hear from you. Please complete our brief questionnaire.
New York state has laws governing what healthcare providers are obligated to provide to patients and families facing end-of-life decisions. It's hard to say how well they are being enforced.
This article was first published on Thursday, October 31, 2019 in ProPublica.
The case of the wrong person being taken off life support at St. Barnabas Hospital in the Bronx in 2018 is in many ways an aberration, a mix of bad luck, missed opportunities and unlikely coincidences.
It thus only touched in a limited way on the complex, emotional and legally fraught issues surrounding end-of-life care — what patients are entitled to, what doctors are obligated to do and who is responsible for making sure everything is done appropriately.
Until relatively recently, not much existed to protect the rights of the terminally ill in New York state. Doctors were trained to treat and treat and treat some more. Except in a very limited number of cases, families were not legally authorized to make decisions about end-of-life care for those patients who had lost the ability to decide for themselves. Across many years, needless suffering was common.
A decade ago, however, New York enacted a series of laws meant to improve how people died.
The legislation had two major components: First, health care providers treating the terminally ill are now required to offer to inform patients or those lawfully entitled to make decisions for them of the full range of options for navigating their final days, including the right to "comprehensive pain management" and the right to decline any or all care. Second, under the Family Health Care Decisions Act of 2010, families were empowered to make choices about care for an incapacitated loved one, including to end life-sustaining treatment if certan conditions are met. The legislation, dealing with people who did not have a designated health care proxy or a set of what are known as advanced directives, created a hierarchy of who got to make those decisions — a spouse or child or legal guardian, even what the law listed as a "good friend."
"A huge, huge victory," said David Hoffman, a lawyer, clinical ethicist and lecturer at Columbia University.
Ten years on, though, there are many who worry that the legislation has had less of an impact than hoped.
"We're certainly in a better place now with regard to the end of life and how people die than we were," said David Leven, executive director emeritus for End of Life Choices New York, an advocacy organization. "But we're not in a good place."
Leven, a lawyer who spent much of his early career representing the indigent, has been as involved as anyone in New York in the public policy debates surrounding end-of-life care. He has met and worked with lawmakers, families, doctors, scholars and lawyers. Today, he said, just about 30% of those who are eligible — people 18 or older and capable of making their own decisions — have designated a health care agent or completed legal documents making clear their wishes for end-of-life care. Too many health care providers remain uninformed, he said, and do not properly communicate with patients and families, and thus their wishes too often get ignored. Leven said he faults both the medical establishment and the state regulators meant to oversee the implementation and enforcement of the legislation.
"I think we can attribute the lack of compliance, if you will, to a lack of good continuing education of health care professionals — doctors, nurses, social workers, etc. — in hospitals, nursing homes and assisted living facility settings," Leven said.
Roughly a decade after the state adopted legislation, he said, "I know that there is widespread noncompliance with it throughout the health care community, in part because so many health care professionals still don't even know of its existence."
Thaddeus Pope, a law professor and the director of the Health Law Institute, has studied the kinds of failings still being made involving end-of-life legal requirements. In New York and other states, he said, those missteps fall into several consistent categories:
Doctors often turn to family members to make decisions when the patient actually still has the capacity to decide about care. The rules about who should make treatment decisions for the incapacitated are often not followed. Even if the rules are followed, nobody checks to see if the person is who they represent themselves to be. Sometimes, the family member who claims to be the health care proxy, he said, turns out to have forged the relevant documents.
Asked how prevalent the problems are, Pope said, "That's a great question."
Jonah Bruno, a spokesman for the New York State Department of Health, said the department does conduct regular checks on whether health care providers, such as hospitals and nursing homes, are abiding by the laws governing end-of-life care. He said the department provides "surveyors" with guides for conducting those checks — sample interview questions, lists of documents to review and observations they should make to determine whether the hospital is complying with regulations. He said the department was also obligated to investigate specific complaints made by patients or their families.
Bruno said the state had cited a variety of providers over the years for violating aspects of end-of-life care legislation. But the state has never cited a provider for violating the regulations involving end-of-life care for incapacitated patients without designated health care agents.
Half a dozen experts in the legal and medical issues surrounding end-of-life care said New York and other states, faced with making choices about how to spend their resources, had settled on what amounted to a complaint-driven model for oversight and enforcement of end-of-life regulations.
"We are willing to accept an error rate," Pope said.
Leven said New York was one of the relatively few states to have enacted laws governing palliative care. Pope said that almost all states have some form of statute dealing with how surrogates get identified and authorized for incapacitated patients.
Kathryn Tucker, a lawyer, said that in recent years families had become more willing to go to court to hold health care providers accountable for mistakes or misconduct involving end-of-life care. For many years, she said, courts had not looked kindly on what became known as "wrongful life" lawsuits — claims by families that extreme measures had been taken to keep a patient alive even when such measures were not what the patient or family wanted. That is changing, she said, and such lawsuits, should they result in major awards, might be the thing that provokes the health care establishment and its regulators to improve their performance.
This summer in the Bronx, a family sued Montefiore Hospital over allegations that it disregarded legally prepared documents and confused which family member was authorized to make additional health care decisions; as a result, the family claimed, an elderly and hopelessly ill father needlessly endured three weeks of pain and suffering.
Lawyers for Montefiore responded to the lawsuit by denying any wrongdoing and placing blame with the family.
"The cases you hear about," Tucker said, "are rare examples. There's a big iceberg below, but I don't know even how to quantify it."
There's no end of anecdotes, experts say. The former spouse permitted to end life support for their divorced husband or wife just because paperwork hadn't been updated. The patient who received unwanted life-sustaining care from a nurse or doctor because they did not want the added work created by a patient dying on their hospital shift.
"If you are a hospital administrator," said Hoffman, the bioethicist at Columbia, "you know that anything that can happen will happen."
Even when everything goes right at the hospital — the proper family member makes the end-of-life medical call and that wish is honored responsibly and respectfully — no one really knows if the decision to end an incapacitated patient's life is, in truth, what they would have wanted.
Pope said studies in which families are put through hypothetical end-of-life scenarios have consistently shown that the decisions surrogates make for loved ones are mistaken.
One of the more thorough reviews of such experiments, Pope said, was published in 2006 by the American Medical Association. Drawing from a wide variety of work, the authors concluded that people asked to play the role of designated health care surrogate incorrectly predicted the wishes of a loved more than a third of the time.
"Neither patient designation of surrogates nor prior discussion of patients' treatment preferences improved surrogates' predictive accuracy," they wrote.
On the last Tuesday of July, Tres Biggs stepped into the courthouse in Coffeyville, Kansas, for medical debt collection day, a monthly ritual in this quiet city of 9,000, just over the Oklahoma border. He was one of 90 people who had been summoned, sued by the local hospital, or doctors, or an ambulance service over unpaid bills.
Some wore eye patches and bandages; others limped to their seats by the wood-paneled walls. Biggs, who is 41, had to take a day off from work to be there. He knew from experience that if he didn't show up, he could be put in jail.
Before the morning's hearing, he listened as defendants traded stories. One woman recalled how, at four months pregnant, she had reported a money order scam to her local sheriff's office only to discover that she had a warrant; she was arrested on the spot. A radiologist had sued her over a $230 bill, and she'd missed one hearing too many. Another woman said she watched, a decade ago, as a deputy came to the door for her diabetic aunt and took her to jail in her final years of life. Now here she was, dealing with her own debt, trying to head off the same fate.
Biggs, who is tall and broad-shouldered, with sun-scorched skin and bright hazel eyes, looked up as defendants talked, but he was embarrassed to say much. His court dates had begun after his son developed lymphoma, and they'd picked up when his wife started having seizures. He, too, had been arrested because of medical debt. It had happened more than once.
Judge David Casement entered the courtroom, a black robe swaying over his cowboy boots and silversmithed belt buckle. He is a cattle rancher who was appointed a magistrate judge, though he'd never taken a course in law. Judges don't need a law degree in Kansas, or many other states, to preside over cases like these. Casement asked the defendants to take an oath and confirmed that the newcomers confessed to their debt. A key purpose of the hearing, though, was for patients to face debt collectors. "They want to talk to you about trying to set up a payment plan, and after you talk with them, you are free to go," he told the debtors. Then, he left the room.
The first collector of the day was also the most notorious: Michael Hassenplug, a private attorney representing doctors and ambulance services. Every three months, Hassenplug called the same nonpaying defendants to court to list what they earned and what they owned — to testify, quite often, to their poverty. It gave him a sense of his options: to set up a payment plan, to garnish wages or bank accounts, to put a lien on a property. It was called a "debtor's exam."
If a debtor missed an exam, the judge typically issued a citation of contempt, a charge for disobeying an order of the court, which in this case was to appear. If the debtor missed a hearing on contempt, Hassenplug would ask the judge for a bench warrant. As long as the defendant had been properly served, the judge's answer was always yes. In practice, this system has made Hassenplug and other collectors the real arbiters of who gets arrested and who is shown mercy. If debtors can post bail, the judge almost always applies the money to the debt. Hassenplug, like any collector working on commission, gets a cut of the cash he brings in.
Across the country, thousands of people are jailed each year for failing to appear in court for unpaid bills, in arrangements set up much like this one. The practice spread in the wake of the recession as collectors found judges willing to use their broad powers of contempt to wield the threat of arrest. Judges have issued warrants for people who owe money to landlords and payday lenders, who never paid off furniture, or day care fees, or federal student loans. Some debtors who have been arrested owed as little as $28.
More than half of the debt in collections stems from medical care, which, unlike most other debt, is often taken on without a choice or an understanding of the costs. Since the Affordable Care Act of 2010, prices for medical services have ballooned; insurers have nearly tripled deductibles — the amount a person pays before their coverage kicks in — and raised premiums and copays, as well. As a result, tens of millions of people without adequate coverage are expected to pay larger portions of their rising bills.
The sickest patients are often the most indebted, and they're not exempt from arrest. In Indiana, a cancer patient was hauled away from home in her pajamas in front of her three children; too weak to climb the stairs to the women's area of the jail, she spent the night in a men's mental health unit where an inmate smeared feces on the wall. In Utah, a man who had ignored orders to appear over an unpaid ambulance bill told friends he would rather die than go to jail; the day he was arrested, he snuck poison into the cell and ended his life.
In jurisdictions with lax laws and willing judges, jail is the logical endpoint of a system that has automated the steps from high bills to debt to court, and that has given collectors power that is often unchecked. I spent several weeks this summer in Coffeyville, reviewing court files, talking to dozens of patients and interviewing those who had sued them. Though the district does not track how many of these cases end in arrest, I found more than 30 warrants issued against medical debt defendants. At least 11 people were jailed in the past year alone.
With hardly any oversight, even by the presiding judge, collection attorneys have turned this courtroom into a government-sanctioned shakedown of the uninsured and underinsured, where the leverage is the debtors' liberty.
Seated at the front of the courtroom, Hassenplug zipped open his leather binder and uncapped his fountain pen. He is stout, with a pinkish nose and a helmet of salt and pepper hair. His opening case this Tuesday involved 28-year-old Kenneth Maggard, who owed more than $2,000, including interest and court fees, for a 40-mile ambulance ride last year. Maggard had downed most of a bottle of Purple Power Industrial Strength Cleaner, along with some 3M Super Duty Rubbing Compound, "to end it all." His sister had called 911.
Maggard took his seat. He had cropped red hair, pouchy cheeks and mud-caked sneakers. "The welfare patients are the most demanding, difficult patients on God's earth," Hassenplug told me, with Maggard listening, before launching into his interrogation: Are you working? No. Are you on disability? He was diagnosed with schizoaffective disorder, bipolar type, and anxiety. Do you have a car? No. Anyone owe you money you can collect? I wish.
They had been here before, and they both knew Maggard's disability checks were protected from collections. Hassenplug set down his pen. "Between you and me," he asked, "you're never going to pay this bill, are you?"
"No, never," Maggard said. "If I had the money, I'd pay it."
Hassenplug replied, "Well, this will end when one of us dies."
Though debt collection filings are soaring in parts of America, Hassenplug speaks with pride about how he discovered their full potential in Coffeyville long before. A transplant from Kansas City, he was a self-dubbed "four-star fuck-up" who worked his way through law school. He moved to Coffeyville to practice in 1980 and soon earned a reputation as a hard ass. He saw that his firm, Becker, Hildreth, Eastman & Gossard, hadn't capitalized on its collections cases. The lawyers didn't demand sufficient payments, and they rarely followed up on litigation, he said. Where other attorneys saw petty work, Hassenplug saw opportunity.
Hassenplug started collecting for doctors, dentists and veterinarians, but also banks and lumber yards and cities. He recognized that medical providers weren't being compensated for their services, and he was maddened by a "welfare mentality," as he called it, that allowed patients to dodge bills. "Their attitude a lot of times is, 'I'm a single mom and … I'm disabled and,' and the 'and' means 'the rules don't apply to me.' I think the rules apply to everybody," he told me.
He logged his cases in a computer to track them. First with the firm and later in his own practice, he took debtors to court, and he won nearly every time; in about 90% of cases nationally, collectors automatically win when defendants don't appear or contest the case. Hassenplug didn't need to accept $10 monthly payments; he could ask for more, or, in some cases, even garnish a quarter of a debtor's wages. His fee was, and often still is, one-third of what he collects. He asked the court to summon defendants, over and over again. It was the judge's contempt authority that backed him, he said. "It's the only way you can get them into court."
The power of contempt was originally the power of kings. Under early English rule, monarchs were considered vicars of God, and disobeying them was equivalent to committing a sin. Over time, that contempt authority spread to English courts, and ultimately to American courts, which use it to encourage compliance with the judicial system. There is no law requiring that a court use civil contempt when an order isn't followed, but judges in the U.S. can choose to, whether it's to force a defendant to pay child support, for example, or show up at a hearing. A person jailed for defying a court order is generally released when they comply.
When Casement took the bench in 1987, after passing a self-study exam, he didn't know much legalese — he had never been in a courtroom. But attorneys taught him early on that the power of contempt was available to him to punish people who ignored his orders. At first, Casement could see himself in the defendants. "I was a much more pro-debtor aligned judge, much more sympathetic, much less inclined to do anything that I thought would burden them," he told me. "And over the years, I've gradually moved to the other side of the fulcrum. I still consider myself very much in the middle, and I don't know if I am or not."
Once a bustling industrial hub, Coffeyville has a poverty rate that is double the national average, and its county ranks among the least healthy in Kansas. Its red-bricked downtown is lined with empty storefronts — former department stores, restaurants and shops. Its signature hotel is now used for low-income housing. "The two growth industries in Coffeyville," Hassenplug likes to say, "are health care and funerals."
Coffeyville Regional Medical Center is the only hospital within a 40-mile radius, and it reported $1.5 million in uncollectible patient debt in 2017. A nonprofit run in a city-owned building, the hospital accounts for the vast majority of medical debt lawsuits in the county — about 2,000 in the past five years. It also accounts for the majority of related warrants. Account Recovery Specialists Inc. handles its collections, and it does so for hospitals in most Kansas counties. Though the hospitals can direct ARSI and its contracted attorneys to tell judges not to issue warrants, hardly any have. The Coffeyville hospital's attorney, Doug Bell, said that its only motivation is to continue to serve the area, and that Kansas' decision to not expand Medicaid under the Affordable Care Act has had a "dramatic effect on the economic liability of small rural hospitals."
Three nearby hospitals in this rural region have closed in the past several years, meaning ambulances make more trips. A half-hour from Coffeyville, Independence runs its ambulance service at about a $300,000 annual loss. Its bills were at the root of four arrests this year alone. Derek Dustman, who is 36 and works odd jobs, had been driving a four-wheeler when he was hit by a car and rushed to the hospital. Though he was sued for not paying his $818 ambulance bill, he didn't have a license to drive to the courthouse. This spring, he spent two nights in jail. "I never in a million years thought that this would end with jail time," he told me.
For years, Hassenplug has requested that the judge issue warrants on the ambulance service's behalf. When I asked Lacey Lies, the city's director of finance, if she ever considered telling him not to resort to bench warrants, she was puzzled. "You're saying an attorney with no teeth?"
The first time Tres Biggs was arrested, in 2008, he was dove hunting in a grove outside Coffeyville. It had been just a year since his 6-year-old son Lane was diagnosed with lymphoma, and Biggs watched him breathe in the fresh air, seated on a haybale under an orange sky. When a game warden came through to check hunting permits, Biggs' friends scattered and hid. He wasn't the running type, and he took Lane by the hand. The warden ran Biggs' license. There was a warrant out for his arrest. Biggs asked a friend to take Lane home and crouched into the warden's truck, scouring his memory for some misstep.
The last few years had been a blur. His wife, Heather, had quit her job as a babysitter to care for their son. Then, she got sick. Some days, she passed out or felt so dizzy she couldn't leave her bed. Her doctors didn't know if the attacks were linked to her heart condition, in which blood flowed backward through a valve. To provide for his wife, son and two other kids, Biggs worked two jobs, at a lumber yard and on construction sites. He didn't know when he would have had time to commit a crime. He'd never been to jail. As he stared out the window at the rolling hills, his face began to sweat. He felt his skin tighten around him and wondered if he would be sick.
The warrant, he learned at the jailhouse, was for failure to appear in court for an unpaid hospital bill. Coffeyville Regional Medical Center had sued him in 2006 for $2,146, after one of Heather's emergency visits; neither of his jobs offered health insurance. In the shuffle of 70-hour workweeks and Lane's radiation, he had missed two consecutive court dates. He was fingerprinted, photographed, made to strip and told to brace himself for a tub of delousing liquid. His bail was set at $500 cash; he had about $50 to his name.
His friend bailed him out the next morning, but at the bond hearing, the judge granted the $500, minus court fees, to the hospital. Biggs compensated his friend with a motorboat that a client had given him in exchange for a hunting dog. But it wasn't long before the family received a new summons. In 2009, a radiologist represented by Hassenplug sued them for $380.
Some court hearings fell on days when Lane had treatment, at a hospital in Tulsa, an hour south. Heather refused to postpone his care. Lane's condition was improving — in a year, he would be cancer-free — and his dirty blond hair was sprouting again. Her health, though, had taken a turn. She began having weekly seizures, waking up on the floor, confused about where their Christmas tree had gone or why a red Catahoula puppy was skidding around their ranch house. Her doctors concluded she had Lyme disease, which was affecting her nervous system and wiping her short-term memory. Each time she woke up, she repeated: "Don't take me to the hospital."
Biggs was still on the hook for the bill that had landed him in jail; bail had covered only part of it, and the rest was growing with 12% annual interest. The hospital had garnished his wages, and the radiologist had garnished his bank account, seizing contributions that his family had raised for Lane's care. Living on $25,000 a year, Biggs couldn't afford to buy insurance. His family was on food stamps but didn't qualify for Medicaid, a federal insurance program for people in poverty. Other states were about to expand it to cover the working poor, but not Kansas, which limited it, for families of his size, to those who earned under $12,000. Like millions of others across America, he and Heather fell into a coverage gap.
By 2012, the Biggs family had accrued more than $70,000 in medical debt, which it owed to Coffeyville Regional Medical Center and other hospitals, pediatricians and neurologists. Some forgave it; others set up lenient payment plans. Coffeyville's was the only hospital that sued. The doctors who took them to court were represented by Hassenplug.
Biggs began to panic around police, haunted by the fear that at any moment, he might be locked up. That spring, outside the Woodshed gas station, he spotted a sheriff's deputy who was also an old friend. To shake off his dread, he asked the friend to run his license. The deputy found another warrant, signed by Casement, involving the $380 radiologist's bill. "You're not really going to take me in, right?" Biggs remembers asking. The deputy said he had no choice. Bail, as usual, was set at $500.
The family filed for bankruptcy, a short-term fix that erased their debt but burdened them with legal fees. They lost their home and started renting. Biggs ultimately got a job that offered insurance, as a rancher, covered by Blue Cross Blue Shield. But it required Biggs to pay the first $5,000 before it covered medical expenses. When chest pain hit him as he worked cattle in the heat, and he began vomiting, the only nearby hospital was Coffeyville's. In 2017, the hospital sued again. It was the family's sixth lawsuit for medical debt.
Sitting in Casement's courtroom this July, Biggs calculated that he was losing about $120 by taking time off from work to attend this hearing. "I haven't received a bill," he told me, slouched over his turquoise shorts. "The only thing I received was this summons." Around noon, he finally sat down with an ARSI representative, who explained that the underlying bill had been garnished from his wages, but he still owed $328 in interest and court fees. He had another couple thousand dollars in collections for separate bills he hadn't paid, for which he hadn't yet been sued. He said the most he could afford to pay, every two weeks, was $12.50.
Before the end of the Tuesday docket, Casement returned to the courtroom to read off the names of the hospital's defendants. Five had failed to show up for contempt citations, to give their reasons for missing their debtor's exams. Casement saw that two of the no-shows hadn't been properly notified of the hearing, so attorneys would need to try to reach them again. The judge read the names of the other three defendants and told the hospital's collections lawyer, "That would be a bench warrant if you want it."
The following morning, I was reading court files in the clerks' office when Christa Strickland arrived at 10:20 in flip-flops and black leggings, her caramel hair wrapped in a bun atop her head. She ran her finger down a docket on the bulletin board and asked why her case wasn't listed. When the clerk pulled up her file, she told Strickland that her contempt hearing had been on Tuesday and she was one day late. "You need to call the law office of Amber Brehm," the clerk insisted, referring to ARSI's contracted lawyer, who represents the hospital. She handed over the phone number.
Strickland sat on a hard bench and took out her cellphone. She had saved the hearing in the wrong day on her calendar, but she had taken the day off from work and wanted to clear up the misunderstanding. "I had a court date," she said when a man answered at the law office. "I thought it was today but apparently it was yesterday. I'm just needing to see if I can set something up?"
"By not appearing at that, the court would be in the process of issuing a bench warrant," he said.
"What does that mean?" Strickland asked, shaking her head.
"You don't know what a bench warrant means?" he asked. "That means you will be arrested and taken to jail and ordered to post bond."
"Oh my God." Strickland squeezed her eyes shut, wetness smudging her mascara. She poked at her cheek with her index finger. Her father was a preacher. She'd never been in trouble with the law. She had made a mistake, she tried to explain. She wanted to make an arrangement to pay.
The man on the phone told her that it might take a couple weeks before the court processed her warrant paperwork, which the law office had not yet submitted. Once the judge issued the warrant, she could turn herself in. Strickland wanted to scream, I'll pay the bill, don't make me go to jail! but she didn't have the money. Instead, she looked at the ceiling and asked: "Turn myself into the court? The police station?"
"The Sheriff's Department," he responded.
"They're here in the same building," she said. "I won't leave here until I get this figured out. Thank you!"
She hung up. Prick, she muttered to herself. You're going to talk to me like I'm a freaking idiot? That's not okay. Educate me. The court has to process it? Her mind kept moving in circles. She herself worked in debt collection, for an auto title lending company. She understood that everyone was doing their job. Still, she couldn't grasp how this bill had gotten this far.
Before she had taken this position, during her second pregnancy, her right breast had developed a chronic infection. In 2008, she was uninsured, needed surgery to remove the swollen abscess and ran up a $2,514 bill. More than a decade later, she was still chipping away at a balance that, because of interest and court fees, had more than doubled to $5,736. She had fallen behind on her monthly payment plan and now worried that her booking photo would be on Mugshot Monday, a Facebook album run by the Police Department. She imagined what she would tell her boss: I went to jail … because I missed a court date … for medical bills. It sounded absurd.
She spotted a sheriff's deputy in a bulletproof vest with a name tag that said Bishop and a pistol on his hip. "Hey!" she called out, explaining her phone call and how the man said something about a warrant and turning herself in. Bishop radioed into dispatch and smiled with an update: "There's no warrant in the system yet," he told her.
"Yet!" Strickland replied, deflating his look of reassurance. "That's what I'm worrying about."
"You better give Amber a call back," Bishop said.
When I asked ARSI about how attorneys decide to request warrants, Joshua Shea, who is general counsel, told me that they don't. The judge can choose to issue one if court orders are not followed, he said. But Casement said the opposite, telling me that he gave the choice to the attorneys. "I'm not ordering a bench warrant. My decision is to give them that option," Casement told me. "Whether they exercise it is up to them, but they have my blessing if that's what they want to do."
Shea sent me an eight-page email to make clear, in large part, that ARSI, as a collection agency, has no involvement in the courts, and that Brehm is a lawyer whom the agency contractually employs and who represents the hospital directly. Her email address, though, has an ARSI domain, and her resume lists her as ARSI's director of legal. Brehm said that court hearings aren't the only option for debtors, who can call her instead and answer questions under oath. Shea said nobody — not the hospital, ARSI, Brehm or the court — uses the threat of jail to "extract payment."
Strickland reached Brehm after several days, and the attorney agreed to a new hearing. On Aug. 13, when they met in court, Brehm sat at the front of the room.
"We're giving you a second chance on that citation; just to try to take care of this without there having to be any sort of bench warrant," the lawyer said. "I want to make sure that we're all on the same page about the consequences of not coming into court when the order has been issued."
Strickland nodded.
"Again, if you set a payment plan and keep it," Brehm said, "we won't have to worry about that."
In some courthouses, like Coffeyville's, collection attorneys are not only invited to decide when warrants are issued, but they can also shape how law is applied. Recently, Hassenplug came to believe that debtors were only attending every other hearing in a scheme to avoid jail, and he raised his concern with the judge. He suggested that the judge could fix this by charging extra legal fees; Casement wrote a new policy explaining that anyone who missed two debtor's exam hearings without a good reason would be ordered to pay an extra $50 to cover the plaintiff's attorney fees. If they didn't pay, they would be given a two-day jail sentence; for each additional hearing that they missed, they would be charged a higher attorney fee and get a longer sentence.
Most states don't allow contempt charges to be used for nonpayment, and some, like Indiana and Florida, have concluded that it is unconstitutional. Michael Crowell, a retired law professor at the University of North Carolina and an expert in judicial authority, reviewed Casement's policy. "You can't lock people up for contempt for failing to pay unless you have gone to the trouble to determine that they really have the ability to pay," he said. Casement told me he hadn't made findings on ability to pay before ordering defendants to foot attorney's fees, "but I know that's something the court should consider," he said. He also made plain why he wrote the policy: "Mr. Hassenplug and Brehm's outfit have asked me to." (Brehm denied she requested this.)
Casement has not done everything the debt collection lawyers have suggested. At first, he agreed to their requests to set bail at the amount of the debt, but he eventually settled on $500. "Most people can come up with $500," he said. "It may not be their money, but they know someone who will pay." He made sure no one was arrested unless they'd been reached by personal service or certified mail.
Kansas law allows courts to order debtors in "from time to time," leaving discretion to judges. Casement limited the frequency of Hassenplug's debtor's exams to once every three months. He came to the decision by his own logic around what seemed like a reasonable burden for defendants, and it remains his personal policy today. The law also states that anyone found to be disabled and unable to pay can only be ordered to appear once a year. Without an attorney, debtors like Kenneth Maggard don't know to assert this right.
Allowing bail money to count toward collections raises some of the most critical legal questions. Hassenplug told me that he thinks it's great that cash bail is applied to the debt. "A lot of times, that's the only time we get paid, is if they go to jail," he said. Peter Holland, the former director of the Consumer Protection Clinic at the University of Maryland Law School, explained that this practice reveals that the jailing is not about contempt, but about collection. "Most judges will tell you, 'I'm working for the rule of law, and if you don't show up and you were summoned, there have to be consequences,'" he explained. "But the proof is in the pudding: If the judge is upholding the rule of law, he would give the bail money back to you when you appear in court. Instead, he is using his power to take money from you and hand it to the debt collector. It raises constitutional questions."
Congress has not acted on advocates' calls to amend the Fair Debt Collection Practices Act to prohibit collectors from requesting warrants. There are also no current efforts to bar nonprofit hospitals or medical providers that receive funds through Medicare or Medicaid from seeking warrants. Some states have reformed their laws, to make sure defendants are properly served or to prohibit wage garnishments for debt. But legal experts on collections say that more remains to be done, like taking jail out of the equation and instead requiring debtors to sign a financial affidavit or a promise to appear.
Shea, from ARSI, said that using the legal process is time-consuming and costly — a last resort; arrests are "the least desirable stage for any case to reach for all involved." Even after lawsuits are filed, they try to connect eligible debtors with the Coffeyville hospital to apply for financial assistance, he said. Last year, the hospital wrote off $1.7 million in charity care, said Bell, the hospital lawyer. "That is evidence of a hospital that cares."
Casement said he did not consider the legality of his policies a problem. He placed some blame on the health care system. "What we have isn't working," he said. "As a lifelong Republican, I would probably be hung, but I think we need health care for everybody with some limits on what it's going to cost us."
The way he saw it, he had wide latitude to enforce compliance with a court orders, though he acknowledged that creditors used bail money to their advantage. "I don't know whether the Legislature intended it to be used that way or not," he told me. "I have not had enough pushback from the defendants' side to give me the impression that I'm really abusing this badly."
Before I left Coffeyville, I sat down with Hassenplug in the low-ceilinged courtroom. I asked him whether he thought that the system in Coffeyville was effectively imprisonment for debt, in a country that has outlawed debtors' prisons. "The only thing they're in jail for is not appearing," he replied. "I do my job, I follow the law. You just have to show up in court."
Debt collection is an $11 billion industry, involving nearly 8,000 firms across the country. Medical debt makes up almost half of what's collected each year. Today, millions of debt collection suits are overwhelming state courts. The practice is considered a "race of the diligent," where every creditor is rushing to the courthouse, hustling to get the first judgment, in order to be the first to collect on a debtor's assets. In Hassenplug's view, though, this work is not the rich taking from the poor. He laughed at how locals spread rumors, saying that he seized wheelchairs or Christmas trees. Once, he confessed, he took a man's Rolex, only to find out it was a fake. Some months, he said, even his law office could not make ends meet.
After a couple of hours, a clerk poked her head into the courtroom and told us it was time to leave. Hassenplug and I began to walk out, and on the terrazzo steps, he asked if I wanted to see his buildings. He owned five of them on a shuttered stretch of town. He wondered out loud if he was making a mistake by inviting me, but he was pleased when I accepted. "There ain't any place on earth quieter than downtown Coffeyville," he said, leading me into the silent streets.
He walked me through the alleys under a cloudless sky, and when he arrived at one of his buildings, he tapped a code to his garage. The door lifted, and inside, five perfectly maintained motorcycles, Yamahas and Suzukis, were propped in a line. To their left, nine pristine, candy-colored cars were arranged – a Camaro SS with orange stripes, a Pontiac Trans Am, a vintage Silverado pickup with velvet seats. He toured me around the show cars, peering into their windows, and mused about what his hard work had gotten him.
Lizzie Presser covers health and healthcare policy at ProPublica. She previously worked as a contributing writer for The California Sunday Magazine, where she wrote about labor, immigration, and how social policy is experienced.
The U.S. Centers for Medicare and Medicaid Services "takes allegations of abuse and mistreatment seriously," spokeswoman Maria LoPiccolo said in an email on Monday. "CMS is actively monitoring the situation and is in close communication with" New Jersey's Department of Health, she added. The department said Friday that it was reviewing the allegations.
CMS works with state health departments to review transplant programs and determine if they are eligible for Medicare reimbursement.
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 to an 84.2% 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 team appeared to tailor medical decisions for at least four patients because of these concerns. In the case of Darryl Young, a heart transplant recipient, members of the medical staff didn't offer options like hospice care to his family because they wanted to make sure Young lived at least a year after his surgery, according to current and former employees familiar with his care.
In an audio recording obtained by ProPublica, Dr. Mark Zucker, the director of the heart and lung transplant programs, told the team at an April meeting, "I'm not sure that this is ethical, moral or right," but it's "for the global good of the future transplant recipients."In response to the concerns raised by the article, Newark Beth Israel said that it would conduct an "evaluation and review of the program, its processes and its leadership." It later added that it had hired an outside consultant to perform the review.
Dr. Herb Conaway, a New Jersey assemblyman and chair of the Legislature's Health and Senior Services Committee, called for the transplant team's actions to be reviewed. "The implicated doctors must face consequences if the allegations are indeed accurate," he said in a statement on Friday. "Their actions are a stain on the entire medical community, and they must be held accountable for what they have done to both this patient and his family."
The editorial board of The Star-Ledger in Newark, which co-published the ProPublica investigation, urged prompt scrutiny of the hospital. "This is astoundingly unethical, and if true, should prompt firings of those involved and a federal and state review," the board wrote. "The Attorney General's Office should look into it, too, in case there's something criminal here."
The Attorney General's Office and the New Jersey Board of Medical Examiners would not confirm or deny the existence of investigations, a spokeswoman said.
