How does a Medicaid block grant proposal like that of Congressman Paul Ryan relate to (1) poor treatment of cancer pain, (2) the epidemic of overdose deaths from prescription opioids, (3) the neglect of preventive medicine in the U.S., (4) unnecessary anticoagulant drug related bleeding deaths, (5) FDA drug regulator unresponsiveness to drug safety concerns, and (6) our broken medical malpractice system? My saga at the Los Angeles County + USC Medical Center (LAC-USC) ties these components of our health care system in crisis together.
In 1997, the LA Times published my op-ed commentary advocating a Medicaid block grant for the Los Angeles County Department of Health Services entitled, “Good Medicine, Fewer Hospital Beds—County-USC: A big new centralized facility will only perpetuate a wasteful system.” In this op-ed, I tried to blow the whistle on the relationship between poor care of medically indigent patients and the hospital-centric Medicaid fee-for-service system. Medicaid overpays for hospitalization (then about $3,800 per hospital day at LAC-USC and now over $6,000 per day) and underpays for out of hospital care.
I described how, as a palliative care/hospice physician, I witnessed how end-of-life “care” for cancer and AIDS patients in intensive care units and in frenetically busy medical/surgical wards was a cash cow while hospice care at home reduced hospital revenues dramatically. Under the cover of a financial crisis threatening the default of LA County, LAC-USC closed my palliative care/pain management service in 1995 because it reduced the hospital census and consequently lost critically needed Medicaid revenue. Training of residents in appropriate pain management, including overdose prevention, greatly diminished. Ironically, in response to the subsequent increasing epidemic of fatal overdoses on prescription opioid drugs, the FDA is considering requiring Pfizer, Johnson and Johnson, and other drug companies to provide training in pain management before issuing physicians prescription pads for controlled substances. Instead, Medicaid’s dysfunctional funding scheme should be changed so that post graduate training programs are incentivized to teach doctors to properly treat pain and prevent overdoses.
In my other role at LAC-USC as internal medicine attending physician supervising physicians in training on the inpatient wards and outpatient clinics, I saw patients with life-threatening complications of alcoholism and drug abuse cycle repeatedly through my inpatient service while outpatient rehabilitation services for addicts were slim to none. Since the hospital had two extremely busy state-of-the art cardiac catheterization labs, I felt pressured to refer my patients with coronary disease to interventional cardiologists for imaging studies and on to have angioplasties and coronary bypass surgeries. No coronary disease rehabilitation program was available for our medically indigent population after leaving the hospital, or, better yet, as an alternative to invasive and risky coronary procedures. For this neglect of health promotion and preventive medicine, blame in part Medicaid’s hospital-centric funding scheme.
My commentary in the LA Times appeared during the time Los Angeles County Department of Health Services (LAC-DHS) administrators and politicians were intensely lobbying the federal government for a new $900 million replacement hospital for the aging LAC-USC facility. To me, the replacement hospital signified continuation of a failed model of fee-for-service care for the poor. In the commentary, I proposed shifting medical care for the poor in LA County from a hospital-centric, high waste, fragmented care system to what is now called an “accountable care organization” (ACO). ACOs provide patients with primary care in outpatient “medical homes.” I suggested scrapping the fancy new hospital and instead leasing hospital beds from local private hospitals and spending the money saved on patient care.
My whistleblowing commentary was met with icy silence from LAC-DHS administrators, politicians, and my faculty colleagues. No one issued a public or private rebuttal. Within a few months, the LA County DHS fired me over a single malpractice allegation, and the California Medical Board subsequently revoked my medical license over the same incident.
To fire me, hospital administrators searched my patient charts looking for clinical errors that I had committed. After an exhaustive investigation, they found a single alleged malpractice case that they thought made my termination justifiable. In an alcoholic patient with liver failure and a deep venous thrombosis (leg vein clot), I ordered the cessation of blood thinners (anticoagulant drugs) because of the high risk of serious or fatal bleeding. When the patient subsequently died of thromboses in his lungs (pulmonary emboli), the administration accused me of gross negligence and incompetence in my judgment call to stop anticoagulants. The fact that anticoagulant drugs are contraindicated in alcoholics and the patient was alcoholic did not dissuade the LAC-DHS administrators, the California Medical Board, or the judges. This is an example of the practice of medical administrators’ retaliating against whistleblowers by falsely attributing deaths or injuries of patients to medical malpractice—called “sham peer review.”
In reviewing the medical literature on deep venous thrombosis and pulmonary emboli (collectively called venous thromboembolism or VTE) to prepare for my case, I found strong evidence that anticoagulants do not save the lives of VTE patients. When confronted with my five peer-reviewed medical journal articles challenging the evidence basis of anticoagulation for deep venous thrombosis (most recent here), Food and Drug Administration (FDA) leaders did not critique, let alone rebut, my analysis or conclusions. Tennis star and pulmonary emboli patient Serena Williams exemplifies the risk of anticoagulants for VTE. She was a recent near fatality from bleeding from low molecular weight heparin.
May 27, 2011 will be my day in LA County Superior Court to plea for the reinstatement of my medical license. My case embodies the failures of both the medical and legal systems. I invite medical reporters to use my well documented saga to explore multiple aspects of our broken health care system, including how Medicaid block grants, such as proposed by Congressman Ryan, would help the poor.
David Cundiff MD’s book, Whistleblower Doctor—The Politics and Economics of Pain and Dying, was just released in paperback.