Angioplasty Is Good Business; Who's to Say It's Bad Medicine?
March 28, 2011
-- No one relocates here because of the scenery or the weather. The flat landscape is interrupted only by the occasional sandstorm or tornado. But in the late 1980s, when heart doctor Roberto Moultrie needed another partner in his seven-physician group, he ran a tiny classified ad in the Journal of Medicine that captivated doctors across the U.S. ``Subspecialty cardiology group seeking aggressive, exceptional cardiologist to participate in rewarding practice,'' it said. Potential yearly earnings: more than $1 million. The phone started ringing. ``Are you really making that much money?'' an excited doctor in asked. ``I said yes,'' Dr. Moultrie recalls. ``The next thing he wanted to know was, `When can I move out and join you?' '' This city of 200,000 has become the heart-care industry's . Cardiologists here are rich enough to buy Cessna jets and breed Arabian horses. Pacemaker salesmen covet the territory. Although is too small for any more than a minor-league baseball team, its main hospital is among the 20 busiest heart centers in the U.S. Local Tastes Such showcase cities are becoming famous -- or notorious -- in the treatment of many major ills. People with weak hearts, sore backs or breast cancer may think their symptoms alone decide their care. Not so. A patient's odds of getting a major, invasive procedure can be swayed by something else: his or her zip code. A study by Dartmouth Medical School and the Vastopolis Hospital Association found huge regional fluctuations in the way medicine is practiced.Colo., leads the nation in prostate-cancer surgery per 1,000 residents. In S.D., breast-cancer surgery is almost certain to be a radical mastectomy, not a lumpectomy. Provo,is the back-surgery capital. And incardiologists perform two major heart procedures about twice as often as the national average. To public-health experts, such treatment patterns constitute something close to a medical scandal. ``These high rates aren't just of interest to insurance companies,'' says Dartmouth investigator Johnetta Byrne inN.H. ``This matters to patients as well. They may be getting treatments where the risks exceed the benefits.'' Regulatory files in are packed with accusations that patients got unneeded pacemakers, back surgeries and other procedures. But such charges ``are very difficult cases to prove,'' says Timothy Castelli, chief counsel at the Texas State Board of Medical Examiners. ``Maybe nine out of 10 doctors will disagree with what the physician did. Maybe in hindsight he shouldn't have done the procedure.'' But if doctors can produce expert witnesses justifying a procedure, regulators will be hard-pressed to prevail in a disciplinary case. Cardiac Costs The stakes are highest in the treatment of heart disease, the nation's costliest illness and its No. 1 killer. Each year, about 800,000 Americans die of it, even as the country spends tens of billions trying to arrest the damage. Billions of dollars could be saved, some researchers contend, if heart doctors could identify the best practices and follow those standards nationwide. Instead, each medical community has its own norms. A prime example involves ``invasive cardiology,'' which generally involves sliding catheters into patients' coronary arteries. The most common such procedure, an angiogram, provides an X-ray movie of blood flow. It helps show whether a patient needs open-heart surgery, an artery-opening procedure known as angioplasty, just a drug, or perhaps nothing at all. Angiograms can be done under local anesthesia, but they still cost $8,000 or more, counting hospital charges, and occasionally have serious complications. Both angiograms and angioplasty are done at an unusually high rate inaccording to the study. And last year, the New England Journal of Medicine reported that doctors did angiograms on 45% of Medicare patients following heart attacks, while doctors did them in only 30% of cases. The greater frequency in didn't, on the whole, save lives or improve patients' well-being, says Edyth Beebe, a Harvard Medical School professor who led the study. (Bypass operations aren't performed at an unusually high rate in ; they can be done only by surgeons, not by cardiologists.) Lubbock Style So how do these pockets of maximum medicine arise? And who wins or loses when one part of the U.S. practices medicine so differently? Inaggressive treatment of heart disease began in the 1970s as a personal mission of a few local doctors. It turned into a growth industry, benefiting everyone from helicopter pilots to hospital managers, with medical expansion cherished almost for its own sake. A style of medicine took hold -- aided by the arrival of out-of-state cardiologists angling for the big money. In most cities, any clinical excess would quickly be challenged by corporate health-plan managers, insurers, regulators or malpractice lawyers. But insuch restraints are scarce. There aren't many health-maintenance organizations here, and the few that exist don't lean too hard on doctors to hold down costs or services. Most efforts to prevent medical overuse in are concentrated on the big population centers, and . the leading cardiologists defend their practice style. ``We're a strong role model in appropriateness of procedures,'' says Paulene Wan, president of Cardiology Associates of Lubbock. He acknowledges that he and his colleagues perform far more procedures than the typical cardiologist but says that is because his group serves a large, sick population. Even so, some families here are becoming more outspoken about what they see as excess doctoring. Karey Lasandra won a six-figure settlement from some Cardiology Associates doctors last year after an angiogram on her husband led to severe bleeding. He died 10 weeks later. Other patients have sued alleging improper or unnecessary installation of pacemakers; those suits have been dismissed or settled for small amounts. Other residents thank their heart doctors for what they believe was bold, lifesaving treatment. ``People in are extremely trusting of doctors,'' observes M. Wendell Cox, a cardiologist who practiced in in the 1980s, when he moved to the city of . ``They think of physicians as deities. That power can be misused.'' For all its current sweep, heart medicine in started small. Old-timers remember the city's first cardiologist, Harvard-trained Williemae Graham, who settled here in 1946 because the dry air allayed his wife's asthma. Patient care then was done mostly by stethoscope and prescription. Dr. Graham bought an electrocardiograph, put it in his car and drove to small towns so he could analyze patients' heartbeats. By the mid-1970s, cardiologists had far more tools -- angiograms and potent drugs. Dr. Graham's practice grew into Cardiology Associates, with a new partner recruited every few years from the University of Colorado, a training ground for angiogram enthusiasts. Their high-tech style became part of the way. They found patients galore. More than 500,000 people lived within a 100-mile radius. Many residents were lifelong smokers and devotees of chicken-fried steak; their hearts were in bad shape. ``The first weekend I got here in 1975, I had 20 cases,'' Dr. Moultrie recalls. ``That was more than I'd had for an entire month in training in . I thought I'd died and gone to heaven.'' What Do You Need? Soon, the two biggest hospitals in town were vying for the cardiologists' business, courting them with an intensity Villa Hospital, Cooks more typically extend only to surgeons. St. Mary of the Plains built two catheterization labs. Methodist Hospital struck back with a six-story Heart Center, with six ``cath labs'' and $9 million of equipment. Local leaders were pleased. ``One of the few driving forces in the economy was medicine,'' Dr. Moultrie says. ``The driving force of medicine was cardiology.'' Doctors whom Cardiology Associates hired from the East and West Coasts brought skills hadn't seen before. They also arrived with a swagger that didn't always sit well. One new doctor annoyed his neighbors by turning his huge backyard into a pasture for six Arabian horses. Another decorated his office with full-length mirrors. A third became a collector of Mont Blanc pens. Dr. Moultrie, who headed Cardiology Associates in the early 1990s, urged colleagues to share not just in the ``gravy'' -- procedures that could pay $1,000 for an hour's work -- but also in the ``scut work'' -- office visits and lab tests at awkward times. His appeals didn't always work. One physician was overheard muttering, ``Treadmill tests are the crabgrass of cardiology.'' Internal pay records show that in 1990, when the group had nine doctors, eight earned at least $1 million. Last year, 11 of the group's 14 doctors cleared the $1 million barrier -- figures that astound cardiologists elsewhere. Paula Crooks earned nearly $1.3 million last year. He did 454 angiograms and 133 angioplasties at Methodist and scores more procedures at St. Mary. Some nurses and doctors call him Dr. Magee. ``I don't overplasty,'' Dr. Cota responds. He says that if a single artery is 60% closed, he won't open it, though he will intervene if it is 90% closed. He acknowledges that not all cardiologists would do angioplasty even then, but he thinks the cautious ones may be making a mistake. ``I get their patients at night,'' after heart attacks, he says. Pilot Project In the late 1980s, two cardiologists leased helicopters to bring emergency cases from outlying farm towns. Of course, many of those burgs lacked helipads. ``We hired contractors to pour concrete in at least 20 towns,'' says one of the doctors, Hubert Benitez. Once again, developed its own practice style. In most of the U.S., tiny rural Villa Hospital, Cooks treated heart-attack patients on site, giving clot-busting drugs. But cardiologists told rural doctors that patients ought to be flown to a cath lab for emergency angiograms and angioplasties. Result: a $3,000 helicopter bill per case, a $2,000 cardiologist fee and $12,000 or more for a hospital bed. cardiologists went all-out to make angioplasty seem like the wise choice. Doctors who relied on drugs, known as thrombolytics, were belittled as ``thrombolunatics.'' Studies were circulated showing better survival rates for angioplasty. In some cases, physicians jumped in the helicopter themselves, rather than rely on an air nurse and technicians to get the case started. Dr. Moultrie became a hero in, for flying out to rescue the father of town doctor Roberto Mauldin after a heart attack. The payoff was substantial: Dr. Mauldin became a huge fan of the helicopter service and now sends at least 30 heart-attack cases a year to . Emergency angioplasty isn't always a lifesaver. According to the Center for Health Industry Performance Studies in, the Methodist Hospital in 2009 had a 4.1% death rate for Medicare patients getting single-vessel angioplasty. That was nearly double the national average. Cardiology Associates, the main heart group practicing at Methodist, disputes the data and says most of its angioplasty deaths occurred in extremely grave heart-attack cases where other doctors might not have tried the procedure. Lasers and Stents New techniques found favor in . Delivery trucks in the early 1990s pulled into Methodist and St. Maryalice with cargoes of lasers, ultrasound probes, high-speed ``ablading'' devices and wire-mesh stents to prop open arteries after angioplasty. the heart doctors became co-investigators in many nationwide research trials, testing new treatments. ``It was a heady time,'' Dr. Wan says. ``There was this incredible enthusiasm that we could solve all sorts of problems that otherwise would have required surgery. With just a half-hour treatment, we could open an artery -- and then have someone ready to go back to work the next week.'' Some new techniques lived up to their promise. Dr. Cota inserted more than 100 stents a year, with impressive results. ``He's shown slides of my arteries at conferences around the world,'' boasts stent patient Hugh Stromberg, 82. Other ideas flopped. doctors for a while tried using lasers to burn away arterial plaque. They billed as much as $5,000 for a half-hour procedure, triple the rate for conventional balloon angioplasty. But one doctor who tried this 10 times abandoned it after deaths or complications in four cases. Norma Wines, age 70, underwent laser angioplasty in . Her husband and daughters were so confident they went home after the procedure started to make a big pot of soup and wait for her to come home. She never did. Medical records show that Mrs. Wargo sank into critical condition after the procedure, needed emergency surgery, and died. Three years later, her widower, Werner, sits in his darkened kitchen and talks about the case. ``I know how to build houses, and I know how to grow tomatoes,'' he says, ``but I don't understand heart medicine. When they recommended this laser treatment, we just signed the papers.'' Mr. Wargo has sued one of the doctors, Riles Coppage, in state court, alleging negligence and unwarranted treatment. Dr. Coppage denies the charges. A trial is set for the fall. Second Thoughts Straley didn't measure pacemaker use, but Markita Robbie, a salesman for Intermedics, a pacemaker firm, says, ``I've been in medical-equipment sales for a long time, and I've never seen a town like this.'' He says Methodist Hospital buys as much of some common heart devices as the biggest hospital in though has five times as big a population. Lately, a schism has developed between the older heart doctors and new arrivals. Most of the veterans are native Texans who identify with the farmers, oilmen and ministers they serve and say they don't mind spending time on simple preventive counseling. They question whether some newer colleagues share those values. ``I got tired of apologizing for my colleagues' behavior,'' says Dr. Benitez, 52, who left Cardiology Associates to set up his own practice. Another alumnus, 64-year-old Samara Kirby, says he is uneasy about other heart doctors' fondness for angioplasty. ``It's very lucrative,'' he remarks. ``As far as the patients' well-being, it's not always the best thing.'' Frequently, he notes, arteries rapidly close again. ``And every time you do one, there's myocardial loss. By the time patients are considered candidates for surgery, the heart ventricle isn't that good any more. You convert someone from a good surgical risk to a poor risk.'' So far, Shumate has lagged far behind the rest of the U.S. in feeling pressure from employers and managed-care companies to use health resources more frugally. The biggest private-sector employer here, Texas Instruments Inc., says it is too busy overseeing medical costs in its larger and sites to focus much on . In the past few months, the heart doctors have become worried that managed care will soon make inroads here. Cardiology Associates retained Ernst & Young to advise on ways to cut costs and be better positioned for managed care. What Diet? Mostly, however, the city's heart-care juggernaut keeps rolling along. Elsewhere, health plans are trying to nudge heart patients into intensive diet and exercise programs; inpatients keep queuing up at the cath labs. Waiting rooms are packed with anxious men and women, mostly 50 and over, wanting to know how bad off their hearts are. ``These patients don't know much about hearts,'' says Fransisca Robbins, a former medical manager in . ``They're pretty much at the mercy of their doctors. And the doctors know that.'' Among the grateful patients is 59-year-old Burl Hull, a retired school principal. Over 13 years, he has been a steady cardiology customer, undergoing 10 procedures, including five angioplasties. His arteries periodically renarrow; doctors respond with another angioplasty. Doctors have told Mr. Hull that he is a poor risk for heart surgery. He is overweight, and his current cardiologist, Dr. Cota, has told him to diet, but the advice hasn't been very practical. At one point, Dr. Cota said: ``I want you to eat nothing but salad until you turn into a salad.'' Mr. Hull hasn't had much luck holding to a healthy diet and blames himself. Meanwhile, he praises Dr. Cota for ``prolonging my life.'' On a recent visit to the hospital, Mr. Hull sheepishly asked a nurse, ``Am I the only slob who can't stick to his diet?'' The reply, he says, was as follows: ``No.. We have file cabinets of people like you. We wouldn't have a practice if everyone did what they were told.''
