In one case, a patient claims a surgeon sewed a major vein closed, causing blood to back up in his head. In the other, a patient alleges that the same surgeon sewed through his colon, filling his abdomen with feces. The lawsuits follow a yearlong investigation by ProPublica and the Houston Chronicle.
This article first appeared January 17, 2019, on ProPublica.
Two new lawsuits have been filed against Baylor St. Luke's Medical Center by patients who say they suffered serious injuries as a result of surgical errors during heart transplants at the troubled Houston hospital.
The suits, both filed Friday in Harris County District Court, bring to five the number of malpractice complaints involving heart transplants that have been leveled against St. Luke's or its doctors since a Houston Chronicle and ProPublica investigation last yeardocumented deaths and unexpected complications in the once-renowned program.
In one of the lawsuits filed last week, Lazerick Eskridge alleges that Dr. Jeffrey Morgan sewed a major vein closed during his heart transplant in February 2017, causing blood to back up into his head and requiring an emergency repair in the operating room. That led to several serious complications and resulted in a three-month hospital stay, according to the lawsuit.
In the other case, Ronald Coleman alleges that Morgan sutured his colon to his diaphragm during his heart transplant in October 2016, damaging the digestive organ and causing Coleman's abdomen to fill with feces. That caused serious infections, the lawsuit says, leading to several follow-up surgeries and "nearly costing Mr. Coleman his life."
Eskridge's story was detailed in a Chronicle and ProPublica report last year. Coleman's case has not been made public before now.
Both patients survived their ordeals but continue to suffer debilitating complications, according to their lawsuits.
St. Luke's and Morgan each declined to comment on the lawsuits, as did Baylor College of Medicine, which is named as a defendant in both cases as Morgan's employer. In previous interviews, all three have defended the quality of care provided to heart recipients at St. Luke's.
Hospital leaders also defended Morgan in past statements and interviews, calling him a skilled surgeon who they said had successfully turned the heart program around after a string of deaths in 2015. The hospital's heart transplant survival rates improved in 2016 and 2017, meeting national benchmarks.
In October, however, after losing Medicare funding, hospital leaders announced they had hired two new heart surgeons, effectively replacing Morgan as leader of the program.
The latest lawsuits come as the federal Centers for Medicare and Medicaid Services conducts a comprehensive investigation into care provided at St. Luke's after the recent death of an emergency room patient who received a transfusion of the wrong blood type. Following that mishap and numerous other care lapses reported by the Chronicle and ProPublica over the past year, the hospital announced Monday that it was replacing its president, its chief nursing officer and a top physician.
Even as the hospital seeks to move forward under new leadership, it continues to deal with fallout from the problems in its heart transplant program. Three otherlawsuitshave already been filed in Harris County on behalf of St. Luke's patients who died or suffered serious complications after receiving new hearts. The hospital has declined to comment on pending litigation and has filed motions denying wrongdoing in two of the earlier cases; the third doesn't name the hospital as a defendant.
The two most recent lawsuits accuse Morgan of making technical mistakes with sutures during surgeries.A similar problem occured in one of his first transplant operations after taking over as the top heart transplant surgeon at St. Luke's in 2016, according to six medical professionals familiar with the case.
In that case, doctors and hospital staffers told reporters that Morgan sewed shut another major vein that carries blood back to the heart, and the patient died a few weeks later. The patient's family has not filed suit and Morgan has not commented on the situation, citing patient privacy.
In the case of Eskridge, Morgan said in a statement last year that his vein tissue was "severely abnormal" because of past cancer treatments and also was distorted by wires attached to the cardiac devices in his chest. Morgan said he used sutures to reinforce the vein's connection to the heart, but due to "concern for narrowing," he had to perform an operation to bypass the vein.
According to Coleman's lawsuit, he struggled to recover after receiving a new heart in October 2016. More than two weeks passed before an abdominal surgeon discovered what had gone wrong, according to the lawsuit. Part of his colon had to be removed as a result.
Coleman suffered life-threatening infections in the weeks that followed, the lawsuit says. He remained in the hospital for three months.
Because Coleman and Eskridge survived one year after their transplants, both of their surgeries are considered successes based on the main metric used to calculate transplant program mortality rates, and both contribute to the hospital's claim of improved outcomes in recent years.
The lawsuits, which were filed by separate law firms, both accuse Morgan of omitting key details about what went wrong when filling out operative reports in the patients' medical files, a violation of protocol that makes it more difficult to provide timely treatment.
Both lawsuits also accuse St. Luke's of "malicious credentialing" for allowing Morgan to continue operating after receiving complaints from several physicians about his surgical abilities, as reported last year by the Chronicle and ProPublica. At least two cardiologists grew so troubled, they said they began referring some patients to competing hospitals for transplants.
Morgan remains on the faculty at Baylor and still has privileges at St. Luke's, officials have said. But he no longer holds his previous title as surgical chief of heart transplants at either institution.
The sudden removal of the three executives follows a yearlong investigation by ProPublica and the Houston Chronicle into widespread problems at the hospital, including deaths in its heart transplant program.
This article first appeared January 14, 2019 on ProPublica.
Baylor St. Luke's Medical Center has ousted its president, its chief nursing officer and a top physician following numerous reports of substandard care, including a recent mistake that led to a patient's death, the Houston hospital announced Monday.
The hospital board's decision to replace top management comes in direct response to a recent error in which an emergency room patient died after receiving a blood transfusion with the wrong blood type, the hospital said in a news release announcing the changes.
Bob Moos, a spokesman for CMS, said that a team of 11 federal and state inspectors visited St. Luke's last week to complete a comprehensive investigation.
"The next steps will be determined from that review," Moos said.
Marc Shapiro, chairman of the St. Luke's board of directors, said in a statement that the nonprofit hospital "has faced significant challenges over the last year," and in light of the most recent incident, the board determined "aggressive action" was needed.
The latest Medicare review "raises concerns that are simply unacceptable to the Board," Shapiro said.
Doug Lawson, a regional executive with Catholic Health Initiatives, which owns the hospital, will replace Gay Nord as president, the hospital said in the news release. Lawson will continue in his role as CEO of CHI's Texas Division, which oversees St. Luke's and 15 other hospitals across the state.
A hospital spokesman said Lawson was not available for an interview and referred reporters to the hospital's news release.
In a statement, Lawson said the hospital is developing a 90-day plan that "will include new initiatives in the areas of clinical excellence, patient experience, and workplace culture. We are committed to taking all steps necessary to keep us on the path of excellence and to earn the trust of our patients."
Jennifer Nitschmann, the hospital's chief nursing officer, and Dr. David Berger, the hospital's senior vice president of operations, also "have left their roles," the hospital announced. Berger declined to comment for this story; Nord and Nitschmann could not be reached.
Dr. Ashish Jha, the director of Harvard's Global Health Institute and an expert in hospital quality measures, said hospitals nationwide have set up robust systems to prevent patients from receiving transfusions of the wrong blood type, a deadly and rare mistake.
"So for that to fall apart really does say to me, in the context of everything else going on, that there was really a deeper systemic problem," Jha said, emphasizing that such an error is even more remarkable at a major teaching hospital such as St. Luke's. "Whether changing leadership is going to fix it, I don't know ... but, of course, holding people to account is critically important."
The sudden departures are a stunning turn for a hospital renowned for its pioneering heart research, conducted with its partners, Texas Heart Institute and Baylor College of Medicine. It was here that Dr. Denton Cooley performed some of the world's first heart transplants and where Dr. O.H. "Bud" Frazier has worked to develop a mechanical replacement for the human heart.
St. Luke's, founded in 1954 by the Episcopal Diocese of Texas, is a behemoth in the Texas Medical Center, with 850 licensed beds, nearly 4,000 employees and 7,500 physicians.
For months, St. Luke's leaders had steadfastly defended the quality of care provided at the hospital. Following news reports last year about problems within the heart transplant program and other patient care concerns, the hospital launched a website and purchased full-page newspaper advertisements challenging the reporting and defending its medical care.
In an interview in August, Berger acknowledged that St. Luke's had struggled to meet national quality benchmarks in the years immediately after CHI purchased the hospital in 2013, but he said those issues were in the past. After Nord's arrival in 2016, Berger said administrators had invested additional resources in the hospital's quality department, strengthened its physician-leadership structure and worked with doctors and nurses to find ways to improve outcomes.
"The issues that you're bringing to light focus on a period of time in the institution when there were some challenges," Berger told reporters. "But I think our current data, which shows really excellent outcomes both from patient safety and from quality, would show that those issues are no longer pertinent. ... Those are historical issues."
In an interview Monday, Baylor College of Medicine President and CEO Paul Klotman said St. Luke's has made significant progress in improving care in the five years since it entered a joint-operating agreement with the medical school. But he said a mistake as serious as giving a patient a transfusion with the wrong blood type should never happen.
"There are certain things that reach a threshold where you've got to make a statement, where you've got to change the leadership and direction to get everyone's attention," said Klotman, who also sits on the St. Luke's hospital board. "This is one of those things."
Klotman said he does not believe Medicare's decision to cut off funding for heart transplants last year factored in the board's decision to change hospital leadership. He said the problems that triggered federal scrutiny were limited to a string of heart transplant patient deaths in 2015 and had since been corrected.
However, the Chronicle and ProPublica investigation documented unusual complications and deaths following heart transplants in 2016 and 2017, prompting some doctors to bring their concerns to Nord and other hospital leaders. At least two cardiologists grew so troubled, they said they began referring some patients to competing hospitals for transplants.
Two weeks after the news organizations published those findings in May, a federal appeals court judge stepped down from the hospital's board of directors, and the hospital announced it was temporarily suspending the heart program following two additional patient deaths in 2018.
The program reopened 14 days later, but within weeks, the federal government stepped in. Medicare announced in June that it would cut off funding for heart transplants at St. Luke's after the agency concluded the hospital had not done enough to improve care. Starting in mid-August, St. Luke's was barred from billing federal health programs for heart transplants. The hospital is appealing that decision.
The problems led more than 100 patients, family members, physicians and other medical professionals to contact the news organizations to report concerns about care at St. Luke's.
In October, after repeatedly defending the quality of the program and its physicians, St. Luke's announced it had hired two doctors to [replace its]{.underline} lead heart transplant surgeon and hired a new executive to oversee all of its transplant programs.
Marilyn Chambers, whose husband, John, died at St. Luke's in April, more than three months after receiving a double-lung transplant, said she believes the hospital needs to do more than change leaders. Chambers filed several complaints about the care provided to her husband, including incidents in which she said she found medication intended for another patient in her husband's room.
In a pair of meetings with Marilyn Chambers last year, Nord acknowledged that her staff could have done a better job caring for Chambers' husband and said the hospital had educated staff based on some of her complaints.
It wasn't enough, Chambers said.
"I can't get over it," she said. "It's been eight months, and I'm still crying like it's yesterday. Everything is just so unresolved, and I can't get anybody to do anything."
Dr. José Baselga, who resigned his position as the top doctor at Memorial Sloan Kettering Cancer Center after failing to disclose millions of dollars in payments from drug companies, is now going to work for one of them.
AstraZeneca, the British-Swedish drug maker, announced on Monday that it had hired Dr. Baselga as its head of research and development in oncology, a newly created unit that reflects the company's shift toward cancer treatments, one of the hottest areas in the drug industry.
In a statement, AstraZeneca's chief executive, Pascal Soriot, described Baselga as "an outstanding scientific leader." "José's research and clinical achievements have led to the development of several innovative medicines, and he is an international thought leader in cancer care and clinical research," he said.
Baselga stepped down in September from his role as chief medical officer at the cancer center after The New York Times and ProPublica reported that he had failed to accurately disclose his conflicts of interest in dozens of articles in medical journals. He later resigned from the boards of the drug maker Bristol-Myers Squibb and the radiation equipment manufacturer Varian Medical Systems.
Although Memorial Sloan Kettering has said that Baselga was not fired, hospital leaders have indicated that he was forced out. In October, Douglas A. Warner III, then the chairman of the cancer center's board, told the staff that Baselga's actions "left us no choice."
In December, the American Association for Cancer Research said that Baselga, at its request, had resigned his post as one of two editors in chief of its medical journal Cancer Discovery because he did "not adhere to the high standards" of conflict-of-interest disclosures that the group expects of its leaders. Some of his omissions involved articles that were published in Cancer Discovery while he was an editor in chief.
A spokesman for AstraZeneca said Baselga was not available for comment, but the doctor told Reuters on Monday that he took responsibility for his disclosure lapses. He also said the cancer association had concluded his failures were "inadvertent," and said many of his company relationships were publicly available on a federal database of physician payments by drug and device manufacturers. However, some of the relationships that Baselga failed to disclose were with small biotech startups that are not required to report to the federal government.
"Dr. Baselga is one of the best scientists in the field of oncology," said the spokesman, Gonzalo Viña. "We evaluated the series of inadvertent omissions, which have since been addressed and it is not for us to comment about the previous roles he held."
AstraZeneca paid Baselga $28,750 for consulting work in 2013 and 2014 related to unspecified drugs, according to the federal database. He failed to disclose any relationships with companies, including AstraZeneca, in dozens of articles in recent years.
Baselga, 59, is an expert in breast cancer research and played a key role in the development of Herceptin by Genentech, a subsidiary of Roche. He came to Memorial Sloan Kettering in 2013 after serving as chief of hematology and oncology at Massachusetts General Hospital in Boston. Before that, he was a leader at the Vall d'Hebron Institute of Oncology in Barcelona, Spain.
Since September, Baselga has corrected his conflict-of-interest disclosures in several journals, including in The New England Journal of Medicine and in Cancer Discovery. In a note that accompanied Baselga's correction in The New England Journal of Medicine, editors described his failure as a "breach of trust."
AstraZeneca's decision to hire Baselga is part of an effort by the drug maker to focus more directly on cancer research, which has generated extensive interest from investors and companies in recent years amid a series of breakthroughs. The company sells several cancer drugs, including the lung cancer drug Tagrisso and Lynparza, which treats a number of cancers. It has suffered some recent setbacks, such as a failed trial of its lung cancer drug Imfinzi.
Under the company's new structure, Baselga will oversee the development of cancer drugs from early research to late-stage clinical trials, and a separate research unit will focus on other disease areas. Each unit will have its own commercial team to promote the products.
"This new structure will support growth and sharpen the focus on our main therapy areas, speeding up decisions and making us more productive in our mission to bring innovative medicines to patients," Soriot said in the statement.
In the same statement, Baselga described his new role as a "dream job" and said the reorganization will "accelerate our work to bring transformative medicines to patients."
For years, conservatives have assailed the U.S. Department of Veterans Affairs as a dysfunctional bureaucracy. They said private enterprise would mean better, easier-to-access health care for veterans. President Donald Trump embraced that position, enthusiastically moving to expand the private sector's role.
Here's what has actually happened in the four years since the government began sending more veterans to private care: longer waits for appointments and, a new analysis of VA claims data by ProPublica and PolitiFact shows, higher costs for taxpayers.
Since 2014, 1.9 million former service members have received private medical care through a program called Veterans Choice. It was supposed to give veterans a way around long wait times in the VA. But their average waits using the Choice Program were still longer than allowed by law, according to examinations by the VA inspector general and the Government Accountability Office. The watchdogs also found widespread blunders, such as booking a veteran in Idaho with a doctor in New York and telling a Florida veteran to see a specialist in California. Once, the VA referred a veteran to the Choice Program to see a urologist, but instead he got an appointment with a neurologist.
The winners have been two private companies hired to run the program, which began under the Obama administration and is poised to grow significantly under Trump. ProPublica and PolitiFact obtained VA data showing how much the agency has paid in medical claims and administrative fees for the Choice program. Since 2014, the two companies have been paid nearly $2 billion for overhead, including profit. That's about 24 percent of the companies' total program expenses — a rate that would exceed the federal cap that governs how much most insurance plans can spend on administration in the private sector.
According to the agency's inspector general, the VA was paying the contractors at least $295 every time it authorized private care for a veteran. The fee was so high because the VA hurriedly launched the Choice Program as a short-term response to a crisis. Four years later, the fee never subsided — it went up to as much as $318 per referral.
"This is what happens when people try and privatize the VA," Sen. Jon Tester of Montana, the ranking Democrat on the Senate veterans committee, said in a statement responding to these findings. "The VA has an obligation to taxpayers to spend its limited resources on caring for veterans, not paying excessive fees to a government contractor. When VA does need the help of a middleman, it needs to do a better job of holding contractors accountable for missing the mark."
The Affordable Care Act prohibits large group insurance plans from spending more than 15 percent of their revenue on administration, including marketing and profit. The private sector standard is 10 percent to 12 percent, according to Andrew Naugle, who advises health insurers on administrative operations as a consultant at Milliman, one of the world's largest actuarial firms. Overhead is even lower in the Defense Department's Tricare health benefits program: only 8 percent last year.
Even excluding the costs of setting up the new program, the Choice contractors' overhead still amounts to 21 percent of revenue.
"That's just unacceptable," Rick Weidman, the policy director of Vietnam Veterans of America, said in response to the figures. "There are people constantly banging on the VA, but this was the private sector that made a total muck of it."
A spokesman for the VA, Curt Cashour, declined to provide an interview with key officials and declined to answer a detailed list of written questions.
One of the contractors, Health Net, stopped working on the program in September. Health Net didn't respond to requests for comment.
The other contractor, TriWest Healthcare Alliance, said it has worked closely with the VA to improve the program and has made major investments of its own. "We believe supporting VA in ensuring the delivery of quality care to our nation's veterans is a moral responsibility, even while others have avoided making these investments or have withdrawn from the market," the company said in a statement.
TriWest did not dispute ProPublica and PolitiFact's estimated overhead rate, which used total costs, but suggested an alternate calculation, using an average cost, that yielded a rate of 13 percent to 15 percent. The company defended the $295-plus fee by saying it covers "highly manual" services such as scheduling appointments and coordinating medical files. Such functions are not typically part of the contracts for other programs, such as the military's Tricare. But Tricare's contractors perform other duties, such as adjudicating claims and monitoring quality, that Health Net and TriWest do not. In a recent study comparing the programs, researchers from the Rand Corporation concluded that the role of the Choice Program's contractors is "much narrower than in the private sector or in Tricare."
Before the Choice Program, TriWest and Health Net performed essentially the same functions for about a sixth of the price, according to the VA inspector general. TriWest declined to break down how much of the fee goes to each service it provides.
Because of what the GAO called the contractors' "inadequate" performance, the VA increasingly took over doing the Choice Program's referrals and claims itself.
In many cases, the contractors' $295-plus processing fee for every referral was bigger than the doctor's bill for services rendered, the analysis of agency data showed. In the three months ending Jan. 31, 2018, the Choice Program made 49,144 referrals for primary care totaling $9.9 million in medical costs, for an average cost per referral of $201.16. A few other types of care also cost less on average than the handling fee: chiropractic care ($286.32 per referral) and optometry ($189.25). There were certainly other instances where the medical services cost much more than the handling fee: TriWest said its average cost per referral was about $2,100 in the past six months.
Beyond what the contractors were entitled to, audits by the VA inspector general found that they overcharged the government by $140 million from November 2014 to March 2017. Both companies are now under federal investigation arising from these overpayments. Health Net's parent company, Centene, disclosed a Justice Department civil investigation into "excessive, duplicative or otherwise improper claims." A federal grand jury in Arizona is investigating TriWest for "wire fraud and misused government funds," according to a court decision on a subpoena connected to the case. Both companies said they are cooperating with the inquiries.
Despite the criminal investigation into TriWest's management of the Choice Program, the Trump administration recently expanded the company's contract without competitive bidding. Now, TriWest stands to collect even more fees as the administration prepares to fulfill Trump's campaign promise to send more veterans to private doctors.
Senate veterans committee chairman Johnny Isakson, R-Ga., said he expects VA Secretary Robert Wilkie to discuss the agency's plans for the future of private care when he testifies at a hearing on Wednesday. A spokeswoman for the outgoing chairman of the House veterans committee, Phil Roe, R-Tenn., didn't respond to requests for comment.
"The last thing we need is to have funding for VA's core mission get wasted," Rep. Mark Takano, a California Democrat who will become the House panel's chairman in January, said in a statement. "I will make sure Congress conducts comprehensive oversight to ensure that our veterans receive the care they deserve while being good stewards of taxpayer dollars."
Many of the Choice Program's defects trace back to its hasty launch.
In 2014, the Republican chairman of the House veterans committee alleged that 40 veterans died waiting for care at the VA hospital in Phoenix. The inspector general eventually concluded that no deaths were attributable to the delays. But it was true that officials at the Phoenix VA were covering up long wait times, and critics seized on this scandal to demand that veterans get access to private medical care.
One of the loudest voices demanding changes was John McCain's. "Make no mistake: This is an emergency," the Arizona senator, who died in August, said at the time. McCain struck a compromise with Democrats to open up private care for veterans who lived at least 40 miles from a VA facility or would have to wait at least 30 days to get an appointment.
In the heat of the scandal, Congress gave the VA only 90 days to launch Choice. The VA reached out to 57 companies about administering the new program, but the companies said they couldn't get the program off the ground in just three months, according to contracting records. So the VA tacked the Choice Program onto existing contracts with Health Net and TriWest to run a much smaller program for buying private care. "There is simply insufficient time to solicit, evaluate, negotiate and award competitive contracts and then allow for some form of ramp-up time for a new contractor," the VA said in a formal justification for bypassing competitive bidding.
But that was a shaky foundation on which to build a much larger program, since those earlier contracts were themselves flawed. In a 2016 report, the VA inspector general said officials hadn't followed the rules "to ensure services acquired are based on need and at fair and reasonable prices." The report criticized the VA for awarding higher rates than one of the vendors proposed.
The new contract with the VA was a lifeline for TriWest. Its president and CEO, David J. McIntyre Jr., was a senior aide to McCain in the mid-1990s before starting the company, based in Phoenix, to handle health benefits for the military's Tricare program. In 2013, TriWest lost its Tricare contract and was on the verge of shutting down. Thanks to the VA contract, TriWest went from laying off more than a thousand employees to hiring hundreds.
McIntyre's annual compensation, according to federal contracting disclosures, is $2.36 million. He declined to be interviewed. In a statement, TriWest noted that the original contract, for the much smaller private care program, had been competitively awarded.
The VA paid TriWest and Health Net $300 million upfront to set up the new Choice program, according to the inspector general's audit. But that was dwarfed by the fees that the contractors would collect. Previously, the VA paid the companies between $45 and $123 for every referral, according to the inspector general. But for the Choice Program, TriWest and Health Net raised their fee to between $295 and $300 to do essentially the same work on a larger scale, the inspector general said.
The price hike was a direct result of the time pressure, according to Greg Giddens, a former VA contracting executive who dealt with the Choice Program. "If we had two years to stand up the program, we would have been at a different price structure," he said.
Even though the whole point of the Choice Program was to avoid 30-day waits in the VA, a convoluted process made it hard for veterans to see private doctors any faster. Getting care through the Choice Program took longer than 30 days 41 percent of the time, according to the inspector general's estimate. The GAO found that in 2016 using the Choice Program could take as long as 70 days, with an average of 50 days.
Sometimes the contractors failed to make appointments at all. Over a three-month period in 2018, Health Net sent back between 9 percent and 13 percent of its referrals, according to agency data. TriWest failed to make appointments on 5 percent to 8 percent of referrals, the data shows.
Many veterans had frustrating experiences with the contractors.
Richard Camacho in Los Angeles said he got a call from TriWest to make an appointment for a sleep test, but he then received a letter from TriWest with different dates. He had to call the doctor to confirm when he was supposed to show up. When he got there, the doctor had received no information about what the appointment was for, Camacho said.
John Moen, a Vietnam veteran in Plano, Texas, tried to use the Choice Program for physical therapy this year rather than travel to Dallas, where the VA had a six-week wait. But it took 10 weeks for him to get an appointment with a private provider.
"The Choice Program for me has completely failed to meet my needs," Moen said.
Curtis Thompson, of Kirkland, Washington, said he's been told the Choice Program had a 30-day wait just to process referrals, never mind to book an appointment. "Bottom line: Wait for the nearly 60 days to see the rheumatologist at the VA rather than opt for an unknown delay through Veterans Choice," he said.
After Thompson used the Choice Program in 2018 for a sinus surgery that the VA couldn't perform within 30 days, the private provider came after him to collect payment, according to documentation he provided.
Thousands of veterans have had to contend with bill collectors and credit bureaus because the contractors failed to pay providers on time, according to the inspector general. Doctors have been frustrated with the Choice Program, too. The inspector general found that 15 providers in North Carolina stopped accepting patients from the VA because Health Net wasn't paying them on time.
The VA shares the blame, since it fell behind in paying the contractors, the inspector general said. TriWest claimed the VA at one point owed the company $200 million. According to the inspector general, the VA's pile of unpaid claims peaked at almost 180,000 in 2016 and was virtually eliminated by the end of the year.
The VA tried to tackle the backlog of unpaid doctors, but it had a problem: The agency didn't know who was performing the services arranged by the contractors. That's because Health Net and TriWest controlled the provider networks, and the medical claims they submit to the VA do not include any provider information.
The contractors' role as middlemen created the opportunity for payment errors, according to the inspector general's audit. The inspector general found 77,700 cases where the contractors billed the VA for more than they paid providers and pocketed the difference, totaling about $2 million. The inspector general also identified $69.9 million in duplicate payments and $68.5 million in other errors.
TriWest said it has worked with the VA to correct the payment errors and set aside money to pay back. The company said it's waiting for the VA to provide a way to refund the confirmed overpayments. "We remain ready to complete the necessary reconciliations as soon as that process is formally approved," TriWest said.
The grand jury proceedings involving TriWest are secret, but the investigation became public because prosecutors sought to obtain the identities of anonymous commenters on the jobs website Glassdoor.com who accused TriWest of "mak[ing] money unethically off of veterans/VA." Glassdoor fought the subpoena but lost, in November 2017. The court's opinion doesn't name TriWest, but it describes the subject of the investigation as "a government contractor that administers veterans' healthcare programs" and quotes the Glassdoor reviews about TriWest. The federal prosecutor's office in Arizona declined to comment.
"TriWest has cooperated with many government inquiries regarding VA's community care programs and will continue to do so," the company said in its statement. "TriWest must respect the government's right to keep those inquiries confidential until such time as the government decides to conclude the inquiry or take any actions or adjust VA programs as deemed appropriate."
The VA tried to make the Choice Program run more smoothly and efficiently. Because the contractors were failing to find participating doctors to treat veterans, the VA in mid-2015 launched a full-court press to sign up private providers directly, according to the inspector general. In some states, the VA also took over scheduling from the contractors.
"We were making adjustments on the fly trying to get it to work," said David Shulkin, who led the VA's health division starting in 2015. "There needed to be a more holistic solution."
Officials decided in 2016 to design new contracts that would change the fee structure and reabsorb some of the services that the VA had outsourced to Health Net and TriWest. The department secretary at the time, Bob McDonald, concluded the VA needed to handle its own customer service, since the agency's reputation was suffering from TriWest's and Health Net's mistakes. Reclaiming those functions would have the side effect of reducing overhead.
"Tell me a great customer service company in the world that outsources its customer service," McDonald, who previously ran Procter & Gamble, said in an interview. "I wanted to have the administrative functions within our medical centers so we took control of the care of the veterans. That would have brought that fee down or eliminated it entirely."
The new contracts, called the Community Care Network, also aimed to reduce overhead by paying the contractors based on the number of veterans they served per month, rather than a flat fee for every referral. To prevent payment errors like the ones the inspector general found, the new contracts sought to increase information-sharing between the VA and the contractors. The VA opened bidding for the new Community Care Network contracts in December 2016.
But until those new contracts were in place, the VA was still stuck paying Health Net and TriWest at least $295 for every referral. So VA officials came up with a workaround: they could cut out the middleman and refer veterans to private providers directly. Claims going through the contractors declined by 47 percent from May to December in 2017.
TriWest's CEO, McIntyre, objected to this workaround and blamed the VA for hurting his bottom line.
In a Feb. 26, 2018, email with the subject line "Heads Up… Likely Massive and Regrettable Train Wreck Coming!" McIntyre warned Shulkin, then the department secretary, that "long unresolved matters with VA and current behavior patterns will result in a projected $65 million loss next year. This is on top of the losses that we have amassed over the last couple years."
Officials were puzzled that, despite all the VA was paying TriWest, McIntyre was claiming he couldn't make ends meet, according to agency emails provided to ProPublica and PolitiFact. McIntyre explained that he wanted the VA to waive penalties for claims that lacked adequate documentation and to pay TriWest an administrative fee on canceled referrals and no-show appointments, even though the VA read the contract to require a fee only on completed claims. In a March letter to key lawmakers, McIntyre said the VA's practice of bypassing the contractors and referring patients directly to providers "has resulted in a significant drop in the volume of work and is causing the company irreparable financial harm."
McIntyre claimed the VA owed TriWest $95 million and warned of a "negative impact on VA and veterans that will follow" if the agency didn't pay. Any disruptions at TriWest, he said, would rebound onto the VA, "given how much we are relied on by VA at the moment and the very public nature of this work."
But when the VA asked to see TriWest's financial records to substantiate McIntyre's claims, the numbers didn't add up, according to agency emails.
McIntyre's distress escalated in March, as the Choice Program was running out of money and lawmakers were locked in tense negotiations over its future. McIntyre began sending daily emails to the VA officials in charge of the Choice Program seeking updates and warning of impending disaster. "I don't think the storm could get more difficult or challenging," he wrote in one of the messages. "However, I know that I am not alone nor that the impact will be confined to us."
McIntyre lobbied for a bill to permanently replace Choice with a new program consolidating all of the VA's methods of buying private care. TriWest even offered to pay veterans organizations to run ads supporting the legislation, according to emails discussing the proposal. Congress overwhelmingly passed the law (named after McCain) in May.
"In the campaign, I also promised that we would fight for Veterans Choice," Trump said at the signing ceremony in June. "And before I knew that much about it, it just seemed to be common sense. It seemed like if they're waiting on line for nine days and they can't see a doctor, why aren't they going outside to see a doctor and take care of themselves, and we pay the bill? It's less expensive for us, it works out much better, and it's immediate care."
The new permanent program for buying private care will take effect in June 2019. The VA's new and improved Community Care Network contracts were supposed to be in place by then. But the agency repeatedly missed deadlines for these new contracts and has yet to award them.
The VA has said it's aiming to pick the contractors for the new program in January and February. Yet even if the VA meets this latest deadline, the contracts include a one-year ramp-up period, so they won't be ready to start in June.
That means TriWest will by default become the sole contractor for the new program. The VA declined to renew Health Net's contract when it expired in September. The VA was planning to deal directly with private providers in the regions that Health Net had covered. But the VA changed course and announced that TriWest would take over Health Net's half of the country. The agency said TriWest would be the sole contractor for the entire Choice Program until it awards the Community Care Network contracts.
"There's still not a clear timeline moving forward," said Giddens, the former VA contracting executive. "They need to move forward with the next program. The longer they stay with the current one, and now that it's down to TriWest, that's not the best model."
Meanwhile, TriWest will continue receiving a fee for every referral. And the number of referrals is poised to grow as the administration plans to shift more veterans to the private sector.
Congress moved a big step closer on Tuesday toward addressing one of the most fundamental problems underlying the maternal mortality crisis in the United States: the shortage of reliable data about what kills American mothers.
The House of Representatives unanimously approved H.R. 1318, the Preventing Maternal Deaths Act, to help states improve how they track and investigate deaths of expectant and new mothers.
The bipartisan bill authorizes $12 million a year in new funds for five years — an unprecedented level of federal support — for states to create review committees tasked with identifying maternal deaths, analyzing the factors that contributed to those deaths and translating the lessons into policy changes. Roughly two-thirds of states have such panels, but the legislation specifically allocates federal funds for the first time and sets out guidelines they must meet to receive those grants.
"We're going to investigate every single [death] because these moms are worth it," Rep. Jaime Herrera Beutler, R-Wash., the lead sponsor, testified at a hearing in September. Lisa Hollier, president of the American College of Obstetricians and Gynecologists, called the legislation a "landmark."
The full Senate still needs to give its approval, with only a few days to act before the end of the current session. Senators have already authorized the necessary funding, in budget legislation that passed this year.
As ProPublica and NPR have documented in the "Lost Mothers" series, maternal deaths have been rising in the U.S. in recent years even as they declined in other wealthy countries. More than 700 women die each year in America from causes related to pregnancy or childbirth, while at least 50,000 suffer life-threatening complications. Nationally, black women have a maternal mortality rate three to four times higher than that of white women. At least 60 percent of maternal deaths are preventable.
Among the reasons the U.S. has fallen behind other countries, one stands out: government failures to collect accurate data and to study maternal deaths and near-deaths to understand how they might be prevented.
State maternal mortality review committees can play a key role in this process, public health experts say. They are particularly critical to understanding and narrowing racial disparities in outcomes. They have uncovered the surprising fact that cardiac-related issues are the leading cause of death for mothers and that the majority of deaths don't occur during childbirth but in the days and weeks after birth.
But many committees have little or no funding and rely on volunteers to do their work. They publish reports irregularly and, in some cases, do not address the issue of preventability at all. As a result, many maternal deaths have gone miscategorized or uncounted, and many researchers and clinicians have formed a distorted picture of why mothers die, often putting the blame unfairly on women themselves instead of medical providers, hospital systems and other factors.
The House bill says that reviews are "essential" for "developing prevention efforts and quality improvement and quality control programs." It adds, "The United States must identify at-risk populations and understand how to support them to make pregnancy and the postpartum period safer." The guidelines for receiving federal funding dictate how committees should be made up and how evaluators should find and count deaths.
Members of Congress have introduced other bills in recent years to try to prod states to establish review committees or strengthen existing ones. But maternal mortality wasn't seen as a serious problem, and the legislation was usually associated with one political party, Democrats. The bills did not gain traction.
The "Lost Mothers" series and a deluge of other media reports changed that, helping to create an unprecedented sense of urgency, maternal health advocates say. "I don't think we would be as far as we are without that," said Kathryn Schubert, chief advocacy officer for the Society for Maternal-Fetal Medicine, whose members are doctors specializing in high-risk pregnancies. "Every day, I get a call from somebody saying: 'Oh my God, this is a real problem. We have to do something,' because they've read it in the news."
The news stories have also inspired mothers who have survived life-threatening complications and relatives of women who died. "It became the call to arms," said Eleni Tsigas, head of the Preeclampsia Foundation and a co-founder of a new coalition of maternal health organizations, MoMMA's Voice.
The nonstop advocacy by patients and doctors — and even groups like March of Dimes, which has traditionally been more focused on infant health — has been effective. "Twelve million dollars [per year] was more than we originally had in the legislation," Schubert said. "That never happens. … They put in money that we didn't even dream of asking for at this point."
The other important factor in the legislation's success has been bipartisanship: The House bill and its Senate companion, S-1112, were introduced by Republicans as well as Democrats, and both have acquired many supporters along the way. Even so, despite having some 190 co-sponsors, the House bill remained stalled in committee for most of the past two years, coming unstuck in recent weeks after a lobbying blitz by medical groups and patient advocates.
Several more-sweeping maternal-related bills are pending on Capitol Hill, and just last week, the Senate approved a bill aimed at reducing chronic shortages of maternity care providers in some parts of the country, sending it to the president to sign. Meanwhile, lawmakers outside Washington have also been active — at least six states have passed bills in the past year establishing or strengthening their maternal mortality review panels.
The dean of Yale's medical school, the incoming president of a prominent cancer group and the head of a Texas cancer center are among leading medical figures who have not accurately disclosed their relationships with drug companies.
This article first appeared December 08, 2018 on ProPublica.
One is dean of Yale's medical school. Another is the director of a cancer center in Texas. A third is the next president of the most prominent society of cancer doctors.
These leading medical figures are among dozens of doctors who have failed in recent years to report their financial relationships with pharmaceutical and health care companies when their studies are published in medical journals, according to a review by ProPublica and The New York Times and data from otherrecent research.
Dr. Howard A. "Skip" Burris III, the president-elect of the American Society of Clinical Oncology, for instance, declared that he had no conflicts of interest in more than 50 journal articles in recent years, including in the prestigious New England Journal of Medicine.
However, drug companies have paid his employer nearly $114,000 for consulting and speaking, and nearly $8 million for his research during the period for which disclosure was required. His omissions extended to the Journal of Clinical Oncology, which is published by the group he will lead.
In addition to the widespread lapses by doctors, the review by ProPublica and The Times found that journals themselves often gave confusing advice and did not routinely vet disclosures by researchers, although many relationships could have been easily detected on a federal database.
Medical journals, which are the main conduit for communicating the latest scientific discoveries to the public, often have an interdependent relationship with the researchers who publish in their pages. Reporting a study in a leading journal can heighten their profile — not to mention that of the drug or other product being tested. And journals enhance their cachet by publishing exclusive, breakthrough studies by acclaimed researchers.
"The system is broken," said Dr. Mehraneh Dorna Jafari, an assistant professor of surgery at the University of California, Irvine, School of Medicine. She and her colleagues published a study in August that found that, of the 100 doctors who received the most compensation from device makers in 2015, conflicts were disclosed in only 37 percent of the articles published in the next year. "The journals aren't checking and the rules are different for every single thing."
Calls for transparency stem from concerns that researchers' ties to the health and drug industries increase the odds they will, consciously or not, skew results to favor the companies with whom they do business. Studies have found that industry-sponsored research tends to be more positive than research financed by other sources. And that in turn can sway which treatments become available to patients. There is no indication that the research done by Burris and the other doctors with incomplete disclosures was manipulated or falsified.
Journal editors say they are introducing changes that will better standardize disclosures and reduce errors. But some have also argued that since most researchers follow the rules, stringent new requirements would be costly and unnecessary.
The issue has gained traction since September, when Dr. José Baselga, the chief medical officer of Memorial Sloan Kettering Cancer Center in New York, resigned after The Times and ProPublica reported that he had not revealed his industry ties in dozens of journal articles.
Burris, president of clinical operations and chief medical officer at the Sarah Cannon Research Institute in Nashville, referred questions to his employer. It defended him, saying the payments were made to the institution, although the New England Journal of Medicine requires disclosure of all such payments.
Other prominent researchers who have submitted erroneous disclosures include Dr. Robert J. Alpern, the dean of the Yale School of Medicine, who failed to disclose in a 2017 journal article about an experimental treatment developed by Tricida that he served on that company's board of directors and owned its stock. Tricida, which is developing therapies for chronic kidney disease, had financed the clinical trial that was the subject of the article.
Alpern said in an email that he initially believed that his disclosure — that he had been a consultant for Tricida — was adequate. However, "because of concerns recently raised about disclosures," he said he notified the publication, the Clinical Journal of the American Society of Nephrology, in October that he also served on Tricida's board and had stock holdings in the company.
The journal initially told Alpern that his disclosure was sufficient. But after ProPublica and The Times contacted the publication in November, it said it would correct the article.
"The failure to disclose this information at the time of peer review is a violation of our policy," Dr. Rajnish Mehrotra, the journal's editor-in-chief, said in an email.
He later said that an additional inquiry had revealed that all 12 of the article's authors had been incomplete in their disclosures, and that the journal planned to refer the matter to the ethics committee of the American Society of Nephrology. Mehrotra also said that the journal had decided to conduct an audit of some recent articles to evaluate the broader issue.
Dr. Carlos L. Arteaga, the director of the Harold C. Simmons Comprehensive Cancer Center in Dallas, said he had "nothing to disclose" as an author of a 2016 study published in The New England Journal of Medicine of the breast cancer drug Kisqali, made by Novartis. But Arteaga had received more than $50,000 from drug companies in the three-year disclosure period, including more than $14,000 from Novartis.
In an email, Arteaga described the omission as an "inexcusable oversight and error on my part," and subsequently submitted a correction.
Dr. Jeffrey R. Botkin, associate vice president for research integrity at the University of Utah, recently argued in JAMA, a leading medical journal, that researchers should face misconduct charges when they do not disclose their relationships with interested companies. "They really are falsifying the information that others rely on to assess that research," he said. "Money is a very powerful influencer, and people's opinions become subtly biased by that financial relationship."
But Dr. Howard C. Bauchner, the editor-in-chief of JAMA, said that verifying each author's disclosures would not be worth the time or effort. "The vast majority of authors are honest and do want to fulfill their obligations to tell readers and editors what their conflicts of interest could be," he said in an interview.
As the debate continues, an influential group, the International Committee of Medical Journal Editors, is considering a policy that would refer researchers who commit major disclosure errors to their institutions for possible charges of research misconduct.
Concerns about the influence of drug companies on medical research have persisted for decades. Senator Estes Kefauver held hearings on the issue in 1959, and there was another surge of concern in the 2000s after a series of scandals in which prominent doctors failed to reveal their industry relationships.
Medical journals and professional societies strengthened their requirements. The drug industry restricted how it compensates doctors, prohibiting gifts like tickets to sporting events or luxury trips — although evidence of kickbacks and corruption continues to surface in criminal prosecutions. And a 2010 federal law required pharmaceutical and device makers to publicly report their payments to physicians.
Despite these changes, the system for disclosing conflicts remains fragmented and weakly enforced. Medical journals and professional societies have a variety of guidelines about what types of relationships must be reported, often leaving it up to the researcher to decide what is relevant. There are few repercussions — beyond a correction — for those who fail to follow the rules.
For example, the American Association for Cancer Research has warned authors that they face a three-year ban if they are found to have omitted a potential conflict. But the group's conflict-of-interest policy contains no mention of such a penalty, and it said no author had ever been barred. Baselga's failure to disclose his industry relationships extended to the association's journal, Cancer Discovery, for which he serves as one of two editors-in-chief. The association said it is investigating Baselga's actions.
Most authors do seem to disclose their ties to corporate interests. About two-thirds of the authors on the Kisqali study, for example, reported relationships with companies, including Novartis. But the researchers who did not included Arteaga, Burris and Denise A. Yardley, a senior investigator who works with Burris at Sarah Cannon.
The Tennessee-based research center received more than $105,000 in fees for consulting, speaking and other services on Yardley's behalf in the three-year period in which she declared no conflicts.
The Sarah Cannon institute said it switched over a year ago to a "universal disclosure" practice promoted by ASCO, the cancer group that Burris will lead. That requires doctors to disclose all payments, including those made to their institutions.
"We believe we adhere to the highest ethical standards in the industry by not allowing personal compensation to be paid to our leadership physicians," the center said.
ASCO said it would post corrections to Burris' disclosures in the Journal of Clinical Oncology for the past four years. The group said that in the fall of 2017 — as Burris was seeking a leadership role in the organization — it began working with him to disclose all his company relationships, including indirect payments. Burris will become president in June 2019.
"Disclosure systems and processes in medicine are not perfect yet, and neither are ASCO's," the group said in an email.
Burris, Yardley and Arteaga submitted updated disclosures to the New England Journal of Medicine, which posted them on Thursday.
Burris' updated disclosure listed relationships with 30 companies, including that he provided expert testimony for Novartis.
Jennifer Zeis, a spokeswoman for the journal, said it was contacting those studies' authors, and that it now asked researchers to certify that they had checked their disclosures against the federal database.
Some institutions have pushed back, arguing that the journals' inconsistent rules make it difficult for even well-meaning researchers to do the right thing.
In a letter last month to the New England Journal of Medicine, Memorial Sloan Kettering objected to the treatment of one of its top researchers, Dr. Jedd Wolchok. When he tried to correct his disclosures, the journal shifted its position, from saying its editors were satisfied with his disclosures to saying he had failed to comply with the rules, the center said in citing communications with the journal.
To clarify reporting requirements, several publications are attempting only now to do what the Institute of Medicine recommended in 2009. The New England Journal is testing a new system in partnership with the Association of American Medical Colleges that would act as a central repository for reporting financial relationships.
This year, JAMA began requiring authors to confirm multiple times that they had nothing to disclose. ASCO has a centralized system for reporting conflicts to all of its journals and speaker presentations.
Dr. Bernard Lo, the chairman of the 2009 Institute of Medicine panel, said journals have only begun to confront some of the systemic flaws. "They're certainly not out in front trying to be trailblazers, let me just say it that way," he said. "The fact that it hasn't been done means that nobody has it on their priority list."
Some patients and family members who came to the Houston hospital for liver and lung transplants have complained about the quality of care provided. A St. Luke's spokeswoman says the transplant programs still meet national benchmarks and argues against focusing on outcomes from a single calendar year.
This article first appeared November 30, 2018 on ProPublica.
During the summer of 2017, Baylor St. Luke's Medical Center posted a banner on its website, celebrating its liver and lung transplant programs as "#1 in Texas."
That declaration was based on the latest publicly available data, which showed stellar one-year survival rates for patients who received liver and lung transplants at St. Luke's between 2014 and the middle of 2016.
But soon after the hospital published those marketing materials in August 2017, both of those transplant programs began to see increases in patient deaths, an investigation by the Houston Chronicle and ProPublica has found.
Of 85 patients who received a liver transplant at St. Luke's in 2017, at least 15 have died within a year, up from previous years and worse than the national average. That's according to preliminary data provided to reporters by the Scientific Registry of Transplant Recipients, a Minnesota-based group that measures transplant outcomes on behalf of the federal government.
Also last year, according to data provided by the registry, at least seven of the hospital's 54 lung recipients died within a year of their transplants, double the mortality rate at the hospital during the previous two and a half years.
These figures do not include patients who received livers or lungs as part of multi-organ transplants or those receiving second transplants after having previously received new organs.
Both the lung and liver programs at St. Luke's have slowed down in 2018, with the number of transplants performed down 40 percent and 16 percent, respectively, through October, compared with the same period last year. Both programs also have had patients suffer unusual complications this year, according to a review of medical records and interviews with surviving family members.
In February, a patient's new lung flipped over inside her chest, an event so rare that experts sometimes document individual cases in medical journals. Another patient developed a serious tear in his airway following his December 2017 lung transplant and never recovered from the setback. And in July, a 36-year-old single mother undergoing a liver transplant died in the operating room, prompting friends to seek donations to pay for her funeral and care for the daughter she left behind.
These deaths came as St. Luke's was facing scrutiny for poor outcomes in its heart transplant program. In May, ProPublica and the Chronicle reported on an outsized number of deaths and complications in that program, which had prompted a couple of St. Luke's cardiologists to refer some patients elsewhere for transplants.
As was the case with the heart program, some patients and family members who came to St. Luke's for liver and lung transplants have complained to administrators or contacted reporters about the quality of care provided.
St. Luke's officials and doctors declined to be interviewed for this story. In a written statement, spokeswoman Marilyn Gerry pointed out that the hospital's liver and lung programs met national benchmarks in the latest official report from the transplant registry, released in October, which measured one-year survival for transplants performed between the start of 2015 and the middle of 2017.
Gerry said it was "misleading" to focus on a single year of data from 2017 rather than the entire two-and-a-half-year period examined by the registry.
"Because of the complex nature of organ transplant cases, natural fluctuations will occur" in a hospital's outcomes from one year to the next, Gerry wrote.
This year, when the Chronicle and ProPublica were reporting on below-average heart transplant outcomes at St. Luke's, hospital officials said something different. They discouraged focusing on the heart program's poor scores in official reports, saying they were based on "old data" and "don't reflect the current transplant outcomes at our institution."
In August, the Centers for Medicare and Medicaid Services terminated federal funding to the heart transplant program after concluding St. Luke's didn't do enough to correct problems that led to poor outcomes dating back to 2015. The hospital is appealing and has said that Medicare's decision has not affected its other transplant programs.
It's too soon to say whether the increase in liver and lung deaths in 2017 will cause those programs to slip below national standards in future registry reports or put them at risk of sanctions from Medicare. That will depend, in part, on how the programs perform in subsequent years, as well as any changes in the way the federal government regulates transplant programs.
Many factors can cause a transplant program's outcomes to dip, experts say, from patient selection to the quality of medical care offered in the months following a transplant. A one-year decline in outcomes may not put a program in jeopardy of falling significantly below national benchmarks, experts say, but it could if a hospital fails to correct the trend.
"Every transplant program has down years," said Alexander Aussi, a San Antonio-based transplant consultant. "But a good program recognizes those trends early, works to understand what is going wrong and then makes proactive changes before things get out of control."
St. Luke's leaders announced in October that they had hired a new executive to oversee all of the hospital's transplant programs and had recruited surgeons to help with heart and lung transplants.
The hospital also has launched a new marketing campaign in recent months celebrating patient success stories, in web vignettes and full-page newspaper ads, often emphasizing St. Luke's willingness to treat the most critically ill patients. One of those was Godfrey "G.W." Biscamp, a 64-year-old former test pilot from Houston who was turned away by two other local transplant programs before getting a new set of lungs at St. Luke's in July 2017.
"I was just about burned out with hospitals," Biscamp said in an interview. "When I went to Baylor, I was kind of expecting the same old song and dance. But those people saved my life."
Biscamp and another organ recipient featured in the ads told reporters they were pleased with the care provided by nurses and physicians throughout their stays at St. Luke's.
Marilyn Chambers, whose husband, John, died in April, more than three months after receiving a double-lung transplant at St. Luke's, tells a different story. She filed several complaints about the care provided to her husband and pressed hospital leaders to explain why he did not survive, leading to a pair of meetings with the hospital's president, Gay Nord.
Chambers said she wasn't satisfied.
"I felt in my soul," she said, "that they did something wrong."
Last year was momentous for the lung transplant program at St. Luke's, following two years of turnover in its surgeon ranks.
The senior surgeon who had led the lung program since 2012 left in the summer of 2015 to practice at a hospital affiliated with Harvard University. The surgeon hired to replace him stopped performing lung transplants soon after his arrival in early 2016, after some of his initial patients experienced complications. And the junior surgeon who stepped in left a few months later, also for a job at a Harvard teaching hospital.
Finally, in the spring of 2017, St. Luke's recruited a 41-year-old surgeon from Minnesota, Dr. Gabriel Loor, and the lung program quickly ramped up. The surge in transplants that year came after another nearby hospital, Houston Methodist, significantly scaled back its lung volume after too many transplants failed within a year.
In Loor's first four months alone, St. Luke's performed 30 lung transplants, nearly matching the hospital's total from all of 2016 and double the number performed in 2015. But soon the program hit a rough patch. At least two of the six patients who received new lungs at the hospital in May 2017 did not survive a year, according to data provided by the United Network for Organ Sharing and interviews with friends and family members.
One of the patients was Leonard "Johnny" Arsement, a former railroad switch operator who came to St. Luke's from Louisiana with pulmonary fibrosis. Days after his transplant, doctors told his family that the donor lungs were not working properly, and he never recovered. He died in December at age 72.
Daniel Butler, an artist from Houston, also received a double-lung transplant that May. The new lungs never seemed to work properly, said his best friend, Tim Johnson. After a series of setbacks early this year, Butler asked St. Luke's doctors to stop providing life-saving medical care, and he died a few days later. He was 62.
"It was just very mysterious to everybody why these lungs wouldn't take," Johnson said. He spoke highly of the doctors and nurses who cared for his friend during his eight-month hospital stay, despite the outcome.
More deaths followed later in the year, threatening to put a drag on the lung program's survival rate in future transplant registry reports. In the two-and-a-half-year period ending in December 2016, 94.2 percent of St. Luke's 58 lung transplant recipients survived one year, better than the hospital's expected rate of 89.7 percent, according to registry figures.
In 2017, though, during the surge in transplant volume, the program's one-year survival rate was down to 87 percent, a couple of percentage points below the national average. The transplant registry does not calculate expected rates for periods shorter than two-and-a-half years. The 2017 survival rate is current as of mid-November and could drop further if any additional lung recipients die in the final weeks of 2018, within one year of their transplants.
The liver transplant program at St. Luke's was in the midst of its own difficult stretch in 2017.
For several years, the liver program had posted outstanding results. Between 2014 and the middle of 2016, 93 percent of its patients survived at least a year, slightly better than the national average of 92 percent and its own expected rate of 91.3 percent.
But that began to shift at the end of 2016, according to an internal chart obtained by the Chronicle and ProPublica. The line graph, used by programs to track transplant outcomes in real time, appears to show the liver program on a steady path toward worse-than-expected outcomes by the end of last year.
All told, one out of every five liver transplants performed at St. Luke's in 2017 have failed within a year, about double the national rate. This includes two St. Luke's patients who had their new livers fail but who were still alive as of this month, likely after receiving another transplant.
Gerry, the St. Luke's spokeswoman, said the internal chart obtained by reporters represents "one piece of a confidential report provided to transplant programs by the [the transplant registry] for peer review and continuous improvement."
A day before Hurricane Harvey slammed into southeast Texas last year, Paul Guillory sat up in a hospital bed at Baylor St. Luke's, telling jokes.
Guillory, a 74-year-old retired barber from League City, was in a good mood, thinking about the months he had waited for a new liver after being diagnosed with cancer, and about the prospect of another decade of life to watch his grandkids grow. His wife, Barbara, scribbled a note in her day planner to document the moment when staff wheeled her husband into surgery on Aug. 24, 2017: "He was so happy," she wrote.
But in the operating room that afternoon, according to medical records, Paul suffered significant blood loss and required multiple transfusions — a complication likely triggered by his liver disease and his body's inability to form blood clots. By the time he'd been wheeled into a recovery room late that night, family members said doctors were expressing grave concerns about the viability of his new organ.
"Liver not performing as it should," Barbara wrote the next day in her pocket calendar, hours before Harvey made landfall. "Storm was coming in."
The hurricane came and went that weekend, but Paul never recovered, even after receiving a second, emergency liver transplant later that week.
Barbara said she wasn't surprised when she learned from a reporter that Paul was one of 15 St. Luke's patients who died following liver transplants last year. She and her family said they had concerns about the care he received.
Barbara signed a release allowing St. Luke's to speak to reporters about her husband's case; the hospital did not answer questions about his care.
Hours before Paul received his second liver transplant, about a week after the first one failed, Barbara and her children recalled watching in horror as he started to have a seizure in his hospital bed.
After several minutes, a doctor was summoned; he noted the "seizure like activity" in Paul's medical records and gave him drugs to bring the tremors under control. Two hours later, Paul was taken for his second liver transplant.
A day later, on Sept. 1, 2017, Barbara noted her husband's progress in her calendar: "Seizures have continued. Have tried many different medications, but they continue."
Barbara continued taking notes throughout Paul's month-long hospital stay, documenting his steady decline.
She sat next to her husband for several days, squeezing his hand and singing love songs, hoping to see a flicker. It never came, however, and she and her family together made the decision to let him go.
On Sept. 23, Barbara jotted one last note.
"I was able to lay with him and love on him," she wrote. "Was holding him when he took his last breath."
John Chambers was nervous when he got the call from St. Luke's three days after Christmas last year. The 56-year-old former FedEx deliveryman from south Houston knew he would eventually need a transplant after years spent struggling with an inflammatory lung disease, but he'd been breathing easier in recent months, and now he was having second thoughts.
Chambers reluctantly went ahead with the double-lung transplant that day, his wife said, fearing he wouldn't get another chance. But more than a month later, he still couldn't sit up or breath on his own.
"He was in worse shape than when he went in," said his wife, Marilyn.
Finally, in late January 2018, doctors said they identified a major cause of his continued struggles: A tear had formed in John's respiratory tract where the transplant surgeon had connected the donor lungs to his air passageway.
Such airway complications occur in between 5 percent and 10 percent of lung transplant patients, experts say, but rarely are they as severe as the "Grade 4 dehiscence" that had opened in John's respiratory tract.
Despite doctors' efforts to repair the airway, St. Luke's officials would later acknowledge that the complication triggered other serious problems — infections, pneumonia, inflammation, organ failure — that ultimately led to John's death in April.
Marilyn believes there were other factors. She repeatedly complained to hospital staff about the care provided to her husband. The concerns are documented in a series of letters between her and hospital administrators.
In one instance, a nurse used a harness to lift her husband out of bed, Marilyn said, and in the process tore open his surgical wound, soaking his gown in blood. Other times, she said, staff inadvertently jostled lines connecting her husband to life-support equipment or failed to follow doctor's instructions.
"It was one thing after another," Marilyn said. "I couldn't believe the way they treated him at that hospital."
In the written statement, Gerry, the hospital spokeswoman, noted that St. Luke's has maintained "magnet" status in nursing care for two decades, signaling that the hospital meets quality standards laid out by the American Nurses Credentialing Center.
"We have full confidence in our nursing professionals in the care they provided to the patients you highlighted and are aware of the patient concerns you relayed," Gerry wrote, referring to the care provided to all of the patients included in this story. "We reviewed and responded to families' questions and comments, and immediately followed up as necessary."
In August, three months after John's death, Marilyn met with Nord, the hospital's president, along with Loor and others, to address her complaints. Chambers recorded the conversation and provided reporters with a copy of the audio.
During the meeting, Nord acknowledged that her hospital staff could have done a better job and said the hospital had educated staff based on some of her complaints.
Loor assured Marilyn that he and his team had done everything they could for John and that they were heartbroken with the outcome. Although it was another surgeon who performed John's lung transplant, Loor said he was confident that it was done correctly. He said that the tear in John's airway was likely the result of a common complication known as "graft dysfunction," in which a set of donor lungs goes into shock after being implanted in a patient.
Loor explained that he had hoped that John was going to recover from that setback, but the infections and other problems eventually became too much.
"Ms. Chambers, I'm really sorry about all of this," Loor said during the July meeting. "And I know it's got to be really hard for you, but I know that you're strong, and I know that he [John] is with us. I feel him with us. And we get better and I get better, we all get better from talking about these things and learning from these things. … We're going to take this to heart."
In early February, three days after doctors discovered the tear in Chambers' airway, Edmund Flores sat in a waiting room, praying for his wife while she underwent a double-lung transplant. Patsy Flores, a 58-year-old mother of two adult children, had spent more than a year struggling to catch her breath as result of high blood pressure in her lungs and a devastating autoimmune disease.
It became clear a day after her transplant that something was wrong.
When Loor and another surgeon reopened Patsy's chest two days after the transplant, they made a tragic discovery, her medical records show: One of the new lungs had inexplicably flipped over, pinching arteries and choking off blood flow to the organ. The complication, known as lung torsion, is so rare after lung transplants that only 12 cases had been publicly documented as of two years ago.
Researchers who examined each reported case concluded that the deadly complication can be mitigated in some instances if detected right away and corrected. But by the time St. Luke's doctors flipped Patsy's left lung back over, much of the organ had essentially died, according to her medical records.
In a statement, hospital spokeswoman Gerry wrote that initial X-rays following Patsy's surgery did not indicate any twisting of the lung. "Additionally," she wrote, "all of our standard intraoperative monitoring procedures confirmed correct alignment and orientation. … However, continued monitoring over the next 24 hours detected a misalignment in one of her lungs and a procedure was completed to address the alignment."
In an effort to save her, Loor removed the damaged lung and doctors put Patsy back on the transplant waiting list, in urgent need of a replacement. Within days, they accepted another lung for her and implanted it.
But it was not enough. Patsy spent nearly four months connected to life support, her medical records show. Her kidneys failed. She suffered repeated infections and bedsores.
Edmund also complained to hospital staff about his wife's care. A chaplain recorded some of the complaints in Patsy's medical records. Edmund said there were not enough nurses on staff overnight and on the weekends, leaving his wife to sometimes wait too long for assistance.
A few weeks after his wife's surgery, a nurse ripped open Patsy's surgical wound while attempting to lift her out of bed, Edmund said, the first of two times that happened: "From that point forward," he said, "it was taking that much longer to heal."
Patsy smiled in photos as her family gathered around her hospital bed to celebrate her 59th birthday in April. But physically, she continued to decline. She lost weight. Her organs shut down. Infections spread through her body. And finally, on June 1, she aspirated vomit into her lungs and died two days later.
A month later, Edmund sat looking through photos of his wife at their home in Channelview, a blue-collar town east of Houston.
"Woo boy, she was something else," Edmund said, fighting back tears. "She was a beautiful woman. Strong, vibrant, full of life."
Edmund said that he understands Patsy was critically ill, and that she wouldn't have survived much longer without a transplant. But he's struggling to come to terms with the rare complication that caused her first transplant to fail, and with what he felt were lapses in care from seemingly overworked nurses and other medical staff in the months that followed.
"The nurses were doing a fantastic job," he said. "But there was only so much they could do because they were stretched so thin."
Since Patsy's death, Edmund has received two anonymous letters in the mail. He suspects they were from someone who was involved in his wife's care, or another hospital employee.
The first note alleged that there were problems with Patsy's transplant and claimed that her death "should have been avoided!!!" The second mentioned other lung transplant deaths this year and encouraged him to contact a Chronicle reporter.
"I need you to know that the lung twist was avoidable," the letter read, "and the whole team feels so so bad for you and your family."
Flores doesn't know what to make of the notes.
For now, he has filed them away with other records documenting his wife's stay at St. Luke's.
After becoming the nation's busiest lung transplant program six years ago, the hospital scaled back the number and difficulty of transplants it performed. For some patients, that meant having to look elsewhere for treatment.
This article first appeared November 30, 2018 on ProPublica.
By Mike Hixenbaugh
Godfrey "G.W." Biscamp could barely breathe. After months of struggling with an inflammatory lung disease, his doctor told him he was in need of a transplant, and in 2013, he sent him to Houston Methodist.
There was no better transplant program in the country for patients in need of new lungs, one physician told him. But by the time Biscamp arrived, the program had begun to change.
Biscamp spent more than a year as a patient at Methodist, hoping for a lung transplant that never came. Instead, after numerous appointments and tests, he said doctors reversed themselves in early 2015, saying his condition was too perilous to risk a transplant.
Biscamp did not realize that, behind the scenes, Methodist had been struggling with a high rate of failed lung transplants, or that the hospital had significantly scaled back the number and difficulty of transplants it was willing to perform. Those issues have never before been reported publicly.
"I walked into Methodist at a time when the word on the street was, these guys are blowing and going," Biscamp said. "They are transplanting people left and right, and they are the best in the business. Then all of the sudden while I was there, apparently it blew apart, but nobody told me."
Biscamp, a 64-year-old former military test pilot, had the misfortune of needing a new set of lungs during a period of instability and change among Houston's transplant hospitals. His four-year struggle for new lungs demonstrates the human consequences that can follow when a transplant program falters. And it shows the challenges facing patients with advanced organ failure while trying to decide where best to seek treatment.
After leaving Methodist, Biscamp transferred to nearby Memorial Hermann, which was launching a new lung transplant program led by one of his former Methodist doctors. But after two years, Biscamp recalled doctors there telling him his case was too risky, again leaving him to seek care elsewhere.
With his inflammatory lung disease worsening, Biscamp was expecting to be disappointed when he arrived at Baylor St. Luke's Medical Center in early 2017, another Houston lung transplant program that has undergone significant changes in recent years.
But doctors at St. Luke's surprised him. Biscamp arrived at the hospital around the same time as its new lead lung transplant surgeon, and within a few months, he received a new set of lungs.
More than a year later, he knows he's fortunate to be alive.
"I got shuffled around big time," Biscamp said. "I got run through the bushes."
There was a reason Biscamp's doctors initially sent him to Methodist. A year earlier, in 2012, the hospital performed a staggering 143 lung transplants, making it the busiest program in America. The hospital's willingness to travel farther for donor lungs, to treat sicker patients and to attempt new and unconventional surgical techniques drew national media attention.
But as the program was growing, so was its rate of poor outcomes.
Between the beginning of 2012 and the middle of 2014, about a quarter the 289 patients who received new lungs at Methodist had their transplants fail in less than a year, a rate significantly higher than the national average and worse than expected based on its own patient and donor characteristics, according to data compiled and analyzed by the Scientific Registry of Transplant Recipients.
In an interview earlier this month, top Methodist officials acknowledged the below-average outcomes and said they proactively made changes to turn things around, ultimately avoiding the sort of federal crackdown that caused St. Luke's to lose Medicare funding for heart transplants this year. (St. Luke's says it has made numerous improvements, including hiring new surgeons, and it is appealing the decision.)
Turning things around at Methodist meant hiring additional medical staff for the lung program, improving administrative oversight and — unfortunately for some patients — performing fewer high-risk transplants.
"Even before these results came out, we had started our improvement efforts," said Roberta Schwartz, Methodist's executive vice president, emphasizing that the hospital's lung outcomes have steadily improved since then and are now in line with national standards.
Dr. Osama Gaber, a surgeon who oversees all of Methodist's transplant programs, said he commissioned an extensive review of the lung program in 2013 and determined that doctors had been taking on too many high-risk cases, including patients over the age of 70 and those seeking a second or third lung transplant.
Transplant outcomes are measured on a curve, taking into account dozens of patient and donor characteristics in an effort to ensure hospitals are not punished for treating sicker patients than their peers. That includes a patient's age and whether they received a transplant previously.
Nonetheless, the hospital reformed its patient selection standards and hired additional staff members beginning in 2013, Gaber said, and soon outcomes began to tick upward. By 2015, the year Biscamp was turned down for transplant, Methodist performed a total of 75 lung transplants, about half as many as in 2012, according to publicly reported data.
Gaber said patient privacy rules prevented him from commenting on the reasons Biscamp was turned down for transplant. But, Gaber said, cases like his should be seen as a testament to the range of treatment options offered to patients at the Texas Medical Center in Houston.
Gaber acknowledged that the hospital's improvement efforts meant fewer patients received new lungs. He said that is a tragic consequence of the federal government's requirement that transplant programs meet national benchmarks for one-year patient survival.
"Every program that's been flagged [by the government] shrinks," Gaber said.
Dr. Scott Scheinin, Methodist's lead lung transplant surgeon until late 2017, disagreed with the notion that patient selection was the main cause of below-average lung outcomes. He noted that, even when the program was treating sicker patients, the hospital was achieving above-average one-month survival rates, indicating to him that the problems weren't related to surgical outcomes, but with the care that followed.
Scheinin said he does not believe Methodist had adequate medical staffing to care for the hospital's huge population of lung recipients in the months following their transplants. All organ recipients are given anti-rejection medications that suppress their immune systems, making them vulnerable to illnesses and death following transplant.
"We had a slew of people who would die between eight and 14 months after transplant," said Scheinin, who has since gone to work for a transplant program in New York. "To me, that means somebody is not paying attention to them. Something is wrong."
When asked about Scheinin's comments, Gaber said the hospital's improvement efforts included hiring additional staff and strengthening post-transplant care.
Although lung outcomes have gotten better in recent years, Gaber said he and his team are continuing to look for ways to make improvements.
"This is not like a speedboat; this is like a airplane carrier," Gaber said. "You've got to move it very slowly."
The plan sets up a clash with Democrats, who say the administration is thwarting congressional intent and will starve the VA health system to pay for private care.
This article first appeared November 15, 2018 on ProPublica.
Last June, President Donald Trump signed a landmark law on veterans' health care after months of tense negotiations. At the ceremony in the Rose Garden, Trump said the bill would deliver on his campaign promise to let veterans see private doctors instead of using the Department of Veterans Affairs' government-run health service: "I'm going to sign legislation that will make veterans' choice permanent," he said.
Standing behind him, the leaders of major veterans groups looked around uncomfortably. What Trump called "choice" these veterans groups called "privatization," and they'd been warning for years that it would cost taxpayers more money and deliver worse care for veterans. The veterans groups had endorsed the bill, but Trump's description of it was not what they thought they were there to support.
The moment left no doubt that the Trump administration is determined to use the new law to expand the private sector's role in veterans' health care. The administration is working on a plan to shift millions more veterans to private doctors and is aiming to unveil the proposal during Trump's State of Union address in January, according to four people briefed on the proposal. The people spoke on the condition of anonymity because they weren't authorized to disclose information about the administration's plans.
The cost of expanding private care is hard to predict, but VA officials have told Congress and veterans groups that it will range from $13.9 billion to $32.1 billion over five years, the four people said. Since the administration opposes lifting overall government spending, Democrats say the increased cost of private care will come at the expense of the VA's own health system. Some lawmakers said the administration's plan defies the purpose of the law they passed.
Trump's first VA secretary said he was forced out by ideologues determined to privatize the department, which he called, in a New York Times op-ed, "a political issue aimed at rewarding select people and companies with profits, even if it undermines care for veterans." The new secretary has repeatedlydenied that privatization is the administration's goal. But the fact is that Trump is doing exactly what he said he would do: The share of VA care delivered in the private sector has grown to 36 percent from 22 percent in 2014, and the administration is weighing policy changes that would move up to 55 percent of veterans to private providers, according to the people briefed on the deliberations.
VA spokesman Curt Cashour wouldn't comment on those figures. He said the new policies are still under development but "will ensure that VA delivers veterans the best and most timely care possible with maximum continuity — whether it's at VA or in the community."
As a candidate, Trump spoke often about improving veterans' care, and as president, he has returned often to that rhetoric. At his post-midterm press conference, he said, "I've done more for the vets than any president has done, certainly in many, many decades, with choice and with other things." But he has plunged the VA leadership into turmoil and stirred anxiety over privatization, which many veterans oppose. And just this week, he was criticized for not participating in any public events on Veterans Day.
Democrats are eager to use their new House majority to stymie the Trump administration's plans for the VA. "I am deeply concerned about efforts to profiteer off of veterans by undermining VA-administered care and expanding VA's reliance on private care," Rep. Mark Takano, a California Democrat who's hoping to chair the House veterans committee, said in a statement. "It will be extremely important for the new Congress to conduct effective and frequent oversight of VA leadership so that this legislation is implemented properly."
Despite the VA's scandal-tainted reputation, studieshaveshown that the quality of VA health services compares favorably to private providers, and otherresearch suggests private doctors are generally not prepared to handle veterans' complex needs. Yet the politics of health care reform have made the VA a target for conservatives; they have attacked it as the epitome of bloated bureaucracyand held it out as living proof of the dangers of "socialized medicine."
The VA has been purchasing private care to supplement its health system since 1945, and there's broad consensus that doing so makes economic and medical sense in many instances. But in recent years, conservatives such as the Koch brothers have made it a political priority to shift more veterans to private doctors, under the banner of choice.
In 2014, after a scandal over long waits for appointments at the Phoenix VA, Congress created a new program, called Choice, to send veterans to private doctors if they would have to wait more than 30 days for a VA appointment or lived more than 40 miles from a VA facility. By the start of the Trump administration, the Choice program was running out of money and suffering from payment and scheduling problems.
Lawmakers got to work on overhauling the program and consolidating the VA's various channels for buying private care. Sen. Jerry Moran, R-Kan., wanted to establish across-the-board guidelines, known as "access standards," for when veterans could see private doctors. When the Senate veterans committee took up the proposed amendment, all the members, Republican and Democrat, voted against it, except Moran.
"The overwhelming majority of veterans in this country, despite a lot of bad media, as I think you understand, believe the VA provides quite good-quality care for them," Sen. Bernie Sanders, I-Vt.,saidto Moran before the vote. "I feel a drip-by-drip effort — not by you, but just an overall drip-by-drip effort — to end up moving toward the privatization of the VA."
Despite the committee's 13-1 rejection, Moran's proposal found a key ally in the White House: Darin Selnick, who used to work at a group backed by the billionaire brothers Charles and David Koch called Concerned Veterans for America and had signed onto an infamous proposal to dismantle the VA health system.
Officials in the VA, then led by Secretary David Shulkin, warned in meetings with lawmakers that what Selnick and Moran were seeking to do would explode the government's costs by $60 billion to $80 billion a year, forcing the VA to cannibalize its own health centers to pay for private care, four people involved in the talks said.
"If you get the access standards wrong, it can have disastrous effects," Shulkin said in an interview. "Whether intentionally or not, you could end up diluting the ability to maintain a strong VA. If access standards are too broad, the impact on the budget could end up being so significant that it would essentially become a system that's spending out of control."
But a bill to overhaul the Choice program couldn't move forward without the White House's support. So lawmakers struck a deal, according to four people involved in the negotiations. They adopted the access standards from Moran's failed amendment, but added the word "designated." That word meant the VA secretary would have the authority to decide, or "designate," which access standards would make veterans eligible for private care and which were merely guidelines.
VA officials reassured Democrats that Shulkin would designate only three access standards, limiting the circumstances when veterans would automatically get referred to the private sector, the people said. Moran and Selnick, meanwhile, successfully got access standards into the bill. According to the people involved in the negotiations, both sides walked away thinking they would have their way later on, in the implementation.
The negotiations on the bill repeatedly put Shulkin at odds with other Trump officials, creating confusion about the administration's position. After Trump fired Shulkin, at the end of March 2018, some VA officials warned that without his moderating influence, the Trump administration would use the bill to dramatically expand private care. "It's dangerous now, it's like a loaded weapon — they're going to take access standards and run with it," a former official involved in the negotiations said. "But everybody wanted to get a bill."
"If access standards are too broad, the impact on the budget could end up being so significant that it would essentially become a system that's spending out of control."
—David Shulkin
With a looming deadline to act before the Choice program ran out of money, the compromise bill, now known as the VA Mission Act, gained the support of traditional veterans groups as well as conservative groups like Concerned Veterans for America. The nonpartisan Congressional Budget Office analyzed the bill's cost on the assumption that it wouldn't significantly increase the rate of veterans going to private doctors.
The Mission Act passed the House over the objection of Democrats who said it failed to address how the VA would pay for it, meaning the private care would come at the expense of the VA's own hospitals. In the Senate, proponents waved off that concern. "We can work through this. This is a lot easier to work through than getting this bill to prime time," ranking member Jon Tester, D-Mont., said at a press conference. "This is a minor issue."
But soon after the Mission Act became law, the White House made clear that it opposed increasing the VA's funding in order to pay for it — exactly as House Democrats had warned. "This funding can and should be provided within the existing non-Defense discretionary spending cap, and the administration opposes efforts to increase or adjust the cap," Office of Management and Budget director Mick Mulvaney and then-acting VA secretary Peter O'Rourke said in a July letter to Congress.
Rick Weidman, the policy director for Vietnam Veterans of America, said Trump was breaking his campaign promises to veterans by refusing to fund the law he signed. "He got all the plaudits, then said we're not going to pay for it," Weidman said.
The same people who were pushing for more private care during the legislative negotiations are now the people leading the Trump administration's implementation of the Mission Act. Selnick briefly returned to Concerned Veterans for America before becoming an adviser to the new VA secretary. Selnick was replaced in the White House by Drew Trojanowski, a former aide to the late Sen. John McCain, R-Ariz., who worked closely with Moran on the access standards proposal.
"Darin Selnick is a veterans health care policy expert who helped write the Mission Act," Cashour, the VA spokesman, said. "There is no one more qualified to advise on the law's implementation."
It isn't surprising, then, that Selnick's interpretation of the bill has gained the upper hand: The VA is planning to "designate" all the access standards as making veterans eligible for private care, according to veterans groups and congressional staff briefed on the plan. Congressional aides said that would expand the use of the private sector much more than they expected.
"Attempting to keep more veterans in the VA's brick-and-mortar health care system would be a huge mistake."
—Dan Caldwell
"The fact that Congress put 'designated' in there, there was an assumption some would be designated and some would not be," a staffer involved in the negotiations said. "Why else would you have the word?"
Selnick did not respond to a message seeking comment.
Concerned Veterans for America's director, Dan Caldwell, defended the administration's interpretation. "It doesn't make sense to create a set of standards and only use some of them," he said. "The VA has been moving for years, even before the Mission Act, toward a model of using more community care. Attempting to keep more veterans in the VA's brick-and-mortar health care system would be a huge mistake."
The three Trump associates who've secretly steered the VA from Mar-a-Lago have also supported spinning off VA medical services to private providers. In a September 2017 email, the trio's chief, Marvel Entertainment chairman Ike Perlmutter, proposed inviting private health executives to help the VA divvy up services that should be outsourced to private facilities. The new VA secretary, Robert Wilkie, said he never discussed privatization with the Mar-a-Lago trio and he's not aware of any ongoing contact with them.
The VA official who's currently running the Mission Act implementation, Assistant Secretary for Enterprise Integration Melissa Glynn, came from the same consulting firm as another member of the Mar-a-Lago trio, lawyer Marc Sherman. Sherman didn't initially put forward Glynn's name, but he did recommend her for the job, according to a person with direct knowledge of the matter. Glynn and a representative for Sherman declined to comment.
The Mission Act gives the VA until March to finalizethe new access standards. Wilkie has not yet advanced a proposal to the White House and has rejected several drafts, three people familiar with the process said.
Wilkie has described the Mission Act as increasing veterans' access to the private sector, but not with the goal of privatizing the VA. "It opens the aperture for a veteran who seeks health care on his own terms, which means that if VA cannot provide the care that veteran needs, and in a timely manner, that veteran will have the opportunity to seek care in the private sector," Wilkie said in a recent NPR interview. "We're not replacing. This is not privatization."
Yet the access standards that Wilkie is considering could dramatically expand the VA's use of private care, according to recent VA briefings to Congress and veterans groups. The numbers are hard to predict because more veterans might switch to using VA benefits instead of Medicare or private insurance if the VA would pay for them to see private doctors with no copay, and private doctors might bill the VA for more services because they're paid by volume (whereas VA doctors are salaried). A 2016 commission on VA health care founded that if veterans could see private doctors without first getting a referral from the VA — because, for example, the VA failed to meet certain access standards — costs could increase by $96 billion to $179 billion a year.
"Any effort to automatically send veterans into the community, based upon arbitrary standards alone, would run counter to congressional intent and dramatically increase costs," Tester said in a statement. "Notably, this comes at a time when the president has ordered all agencies, including the VA, to submit plans for significant budget reductions."
The House veterans committee is planning an oversight hearing before the end of the year focusing on how the administration is implementing the Mission Act, according to the panel's outgoing Republican chairman, Phil Roe of Tennessee. In a statement, Roe said the committee will "evaluate whether provisions are being enacted per congressional intent."
Defibrillator paddles did not work during a patient's heart transplant in January, and a backup set was not nearby. The transplant ultimately failed, and the patient died two months later. His case was featured in a May article.
This article first appeared October 31, 2018 on ProPublica.
The federal government has cited Baylor St. Luke's Medical Center in Houston for not having working defibrillator paddles in the operating room during a January heart transplant. The transplant ultimately failed, and the patient died two months later.
During a review this month, the federal Centers for Medicare and Medicaid Services found that "there were not sufficient quantities of emergency equipment (internal defibrillator paddles) immediately available during cardiac (open chest) surgery," according to a copy of the report provided by the agency at the request of ProPublica and the Houston Chronicle.
The Chronicle and ProPublica reported in May on the death of that patient, James "Lee" Lewis. The surgeon in his case, Dr. Masahiro Ono, said he tried to use a defibrillator to jolt Lewis' new heart into rhythm during a key stage of the transplant. But the device did not activate, and Ono told reporters he had to pump the organ by hand while staff searched for a backup.
It was two months before Ono or anyone on the hospital staff told Lewis' wife, Jennifer, that nearly 10 minutes passed before backup equipment was brought into the room.
"I was so frustrated," Ono said in an interview in April. "I tried my best to preserve the function of the heart but it couldn't make it. That did happen, and I'm very sorry about that."
Lewis' failed donor heart was later replaced with an artificial heart. He endured nearly 20 follow-up surgeries and procedures before dying in March after yet another mishap. During a procedure, a thin wire got sucked into his artificial heart, causing it to malfunction. For the next 45 minutes, according to medical records, Lewis went without normal circulation, likely starving his brain of oxygen-rich blood.
In a statement Tuesday, St. Luke's spokeswoman Marilyn Gerry said the hospital conducted its own review following Lewis' initial transplant surgery "and found that necessary equipment and supplies were available during the procedure, adhering to commonly held processes and standards of medical care."
She said multiple backup defibrillators were nearby and readily available.
"In our subsequent review of the case," Gerry wrote, "it was determined that the defibrillator paddles — not the machine itself — were the source of the inoperation. We since increased inventories of backup paddles in the sterile surgical core [near the operating room] and enhanced our testing procedures of paddles. This includes not only daily checks of defibrillators and paddles, but additional checks in advance of each relevant surgical procedure."
These measures go beyond standard requirements, Gerry said.
Lewis was one of three patients who died following heart transplants during the first five months of 2018. The second and third deaths prompted the hospital to suspend the heart transplant program for two weeks in June. Officials said they "did not identify systemic issues related to the quality of the program" but made changes to its staffing and policies when it reopened.
Following a separate review, CMS cut off Medicare funding for heart transplants at St. Luke's in August after concluding that the hospital had not done enough to correct problems that led to a high rate of patient deaths following transplants in recent years. St. Luke's is appealing the decision.
In October, the hospital announced the hiring of two surgeons, effectively replacing the surgical director of the program, Dr. Jeffrey Morgan, though he will remain on the hospital's staff and retain his academic titles at the affiliated Baylor College of Medicine. Ono left St. Luke's in May to lead a heart transplant program in San Antonio.
The inspection related to Lewis' surgery was conducted despite the funding cutoff because the hospital itself is still certified to receive Medicare funding and therefore subject to federal requirements. Though the report found the hospital out of compliance with Medicare standards, the violation does not carry a penalty.
The federal report offered more details about what went wrong in the operating room during Lewis' transplant. Lewis' new heart began quivering out of sync and "multiple attempts [were] made to defibrillate but defibrillator failed to discharge," according to medical records cited by inspectors. The paddles were disassembled and reassembled by staff in the operating room and they were successfully used on Lewis.
Later during the surgery, Lewis' heart again began to show an irregular rhythm. The original paddles failed to go off again and staff "went to the cardiovascular operating room sterile core area to obtain a replacement set of internal defibrillator paddles and none were immediately available." They ultimately got functioning paddles from elsewhere in the hospital.
In the statement, Gerry said: "It is important to note that the patient was on a heart/lung bypass machine during this time, which maintained blood flow throughout the process. Our prayers continue to be with Mr. Lewis' family."
Lewis' widow, who previously expressed anguish at her husband's death, declined to comment for this story through an attorney.
