Monday, May 28, 2018

Double Standards for Trojans and USC School of Medicine


University of Southern California (USC) appears to look the other way when male physicians harass or assault women.  In reality, sexual violence spares no occupation, including medicine, but the way an organization responds to crime against women indicates a certain level of integrity.  The World Health Organization estimates sexual violence affects one-third of all women worldwide. In a nation where women make up 50% or more of each incoming medical school class, only sixteen percent of medical school deans are female, making gender imbalance in leadership positions nearly impossible to overcome. 

For the second time in less than a year, USC President C.L. Max Nikias is grappling with sexual misconduct allegations against a physician faculty member.  Complaints go back to the early 1990s from staff and patients about inappropriate comments and aggressive pelvic exams done by Dr. George Tyndall, the only full-time gynecologist for the past three decades at the campus clinic.  USC ignored complaints until a nurse contacted the campus rape crisis center. 

Dr. Tyndall was initially suspended pending inquiry and forced to resign shortly thereafter.  More than 100 complaints have been received and five women are suing USC.  Astonishingly, the founded complaints against Dr. Tyndall were never turned over to authorities or reported to the Medical Board of California.  USC defended this decision, asserting there was no legal obligation to report misconduct. USC has a moral and ethical duty to protect students, staff, and faculty, yet failed on both counts.

USC is no stranger to scandal.  In 2007, Dr.  Carmen Puliafito, MD, a Harvard Medical School graduate, was chosen as Dean at the USC School of Medicine.  His background held clues he would be trouble. Just prior to arrival at USC, Puliafito settled a lawsuit for throwing a “tantrum” and committing assault and battery against an optometrist named Marc Brockman at the University of Miami.  During the trial, Miami University disclosed they had previously investigated sexual harassment complaints against Puliafito too. 

Puliafito was a strategic fundraiser, bringing in over $1 billion in donations for the Trojans; however, he kept company with criminals and documented his illicit drug use on video.  His nightlife came to screeching halt when a 21-year-old female companion overdosed in a Pasadena hotel room and an ambulance transported her to the hospital. Police confiscated more than 1 gram of methamphetamine from the hotel room, but inexplicably, no police report was filed until three months later identifying Puliafito as a witness to the overdose.

An anonymous witness phoned the office of the USC President Nikias and reported Puliafito’s activities.   Ten days later, Puliafito resigned, however President Nikias never filed a complaint with the California Medical Board or the authorities.  When the LA Times discovered Puliafito was still practicing as part of the USC faculty, President Nikias issued a ‘mea culpa’ admitting “they could have done better.”  Unfortunately, his next choice was anything but better. 

Dr. Rohit Varma succeeded Puliafito as Dean at the School of Medicine but resigned amid scandal after less than a year.  He had settled a sexual harassment claim in 2003 and was disciplined by USC.  Varma – then a 40-year-old junior professor – attended a conference with a young international student he was supervising.  He allegedly told his student that the grant they were travelling on only supported staying in a single shared room. When the student protested, Varma took her phone and threatened to have her visa revoked. USC reached a $135,000 settlement with the woman, of which Varma paid $11,000.  He was ordered to complete sexual harassment counseling and denied a promotion, yet one year later, earned full professorship, as if nothing ever happened.

Is USC defending “bad boys” with little regard for women? Or is there something else going on?  One might argue that threatening your subordinate with visa revocation is borderline sociopathic.  Are they being protected because they are physicians or simply because they are men?   

The only way to answer this question is to look at what happens when a female physician and male physician have a hostile interaction.  One evening, Dr. Meena Zareh, a cardiology resident at USC, reported being summoned to a windowless call room by Dr. Guillermo Cortes, her direct supervisor, to discuss a patient. When she attempted to leave, Dr. Cortes allegedly overpowered her, blocked the door, and assaulted her.  Dr. Zareh shared the incident with a co-worker afterward but did not report it to law enforcement or the residency program for fear of reprisal until three months later.  Dr. Cortes denied allegations and was placed on administrative leave pending investigation.

Dr. Cortes was allowed to return to work but was barred from unsupervised contact with Dr. Zareh.  Reprisals toward Dr. Zareh began almost immediately, a signal of mounting institutional pressure to sweep her allegations under the rug.  One male supervisor suggested she take a leave of absence, while others recommended deferring fellowship training or changing residency programs.  Dr. Zareh is suing USC and LA County for mishandling her report of sexual assault, a mistake in which USC seems to be accumulating expertise.   If the pattern holds, Dr. Cortes will get a promotion, a raise, and may become a future Dean at the Keck School of Medicine.

While double standards remain alive and well in academia, there are rays of hope.  Dr. Laura Mosqueda, a geriatric physician, is one of those.  She is the first woman chosen to lead the Keck School of Medicine since it was established in 1885.  It is about time.  In the race to become a top-tier program, I have no doubt Dr. Mosqueda will achieve a great deal more than her predecessors.  After all, how could she do any worse? 

Wednesday, May 9, 2018

MedStar Franklin Square Hospital: The Case Against Global Capitation

Baltimore County, Maryland is one hour north of Washington DC, where politicians appear impotent to contain runaway healthcare expenditures.  In January 2014, the Centers for Medicare and Medicaid Services (CMS) in partnership with the state of Maryland, piloted an “All Payer Model,” where every insurer, including Medicare and Medicaid, paid a fixed annual amount irrespective of inpatient or outpatient hospital utilization.  Maryland agreed to transition hospitals from fee-for-service arrangements to this global capitation model over five years. 

Capitation, in general, reimburses a fixed amount per patient, unrelated to service volume.  This sets an artificial fiscal ceiling and disincentivizes hospitals, physicians, and other healthcare personnel to provide healthcare. The philosophy is if hospitals or physicians reduce their output and save money, the unused funds can be kept by the organization. The basic premise of capitation pays hospitals, physicians, and others to AVOID providing care, an unfortunate consequence. 

Maryland is experimenting with global capitation, which allots a fixed sum to an institution from each payer, making revenue predictable, while at the same time, encouraging stewardship by the hospital to allocate funds wisely.  When expenses are lower than the prearranged sum, that hospital retains the leftover funds as additional profit.  To ensure care is not withheld to increase revenue, quality measures are assessed and shared publicly.  A 2015 report in the New England Journal of Medicine showed expenditure reductions of 0.64% and inpatient admissions decreased by 5%.   However, with unproven payment arrangements, unintended consequences always occur. 

The unforeseen casualty in this story is the pediatric department at MedStar Franklin Square Hospital.  On April 3rd, 2018, MedStar abruptly announced all pediatric inpatient care and emergency services were closing, effective April 6th, and all pediatric staff, including eight physicians, were terminated.  Sadly, Baltimore County is home to some of the nations’ most vulnerable families, struggling with high rates of drug addiction, domestic violence, and poverty.  The hospital catchment area serves children attending thirty-seven schools, half of whom are covered by Medicaid. In 2017, Franklin Square pediatric ER evaluated 17,000 children and over 800 were admitted as inpatients.

For hospitals in global capitation arrangements, higher profit margins materialize in those service lines with low utilization.  Commercially insured patients bear responsibility for out-of-pocket costs, co-pays, cost shares, and deductibles; therefore, they tend to be low utilizers. It is well accepted that costs generated by Medicaid patients are considerably higher than commercially insured patients.  Following Oregon Medicaid expansion, emergency department (ED) visits increased by 40% and follow up studies determined this upsurge did not dissipate over time.  MedStar Franklin Square has finite monetary resources; the pediatric service line is a “loss leader” when half of the pediatric patients have Medicaid coverage.

In the corporatized medicine world, improving profit margins is essential to justify inflated executive salaries, such as those of CEOs Kenneth Samet and Samuel Moskowitz, who in 2015, grossed nearly $5 million and $1 million, respectively. MedStar Franklin Square, a nonprofit hospital, was granted tax-exempt status in exchange for providing services to local communities, such as charity care and medical outreach.  However, global capitation payment arrangements slim the profit margin substantially, requiring maximum efficiency to optimize revenue. 

When hospitals make short-sighted decisions, the public should know the increased risk they will face.  Pediatricians are specially trained to provide care to children, their expertise lowers mortality rates for patients under the age of 18.  The death of 12-year old Rory Staunton is a cautionary reminder of consequences when subtle signs of disease in children are overlooked by non-pediatric experts.  Medical records released by his parents, showed he had signs of impending sepsis, including fever, elevated heart rate and respiratory rate, and a blood pressure of 103/50, far below normal in an adolescent who is 69 inches tall and 169 pounds. 

The U.S. Department of Health and Human Services (HHS) is condoning hospital systems to sacrifice the lives of children to reduce healthcare costs through global capitation.  MedStar Franklin Health likely prefers treating commercially insured patients over those on Medicaid.  They are not alone.  One year ago, Mayo CEO Dr. Noseworthy encouraged prioritizing commercially insured patients over those on Medicaid to preserve financial strength of the institution.  Small and large communities throughout the nation have lost critical access, including Albert Lea, Minnesota, Kitsap County, Washington,  and Louisville, Kentucky, yet politicians are too distracted by legislative gridlock to see what is happening in their own backyard.  Bob Dylan said it best, “How many deaths will it take ‘till he knows that too many people have died?”  The answer is not to hinder access or discourage utilization; the answer, my friend, is to incentivize hospitals to protect the lives of our most vulnerable citizens.