Well, that's one way to keep people quiet:

Below, I mentioned how remarkable it was that the University of California mistreated patients, bodies, and money, and that, for the most part, no one ever talked. Well, here's a story of someone who had apparently begun to talk.

This summer marks 1 year since the death of Denise Denton, the chancellor of UC Santa Cruz. Chancellor Denton had been involved in the "unauthorized compensation" scandal described below. She had been authorized to receive $275,000 per year from the University of California, but it appears that she was actually receiving aproximately 1 million dollars a year in total goods and services while she was the Chancellor of UC Santa Cruz.

Investigators were apparently talking to Chancellor Denton. She was 45 years old, and in a promising academic career. She did have a history of depression, for which she'd been hospitalized, but,on June 23, 2006, she'd apparently been assessed as not a danger to herself or others . As stated above, she was apparently being questioned by investigators regarding her role in the "unauthorized compensation" scandal that was then being investigated. It is unknown how forthcoming she was with those investigators.

Then she fell off a building.

On June 24, 2006, Denise Denton fell 40 stories from the Paramount apartment building where she maintained a San Francisco residence. The official cause of death is suicide.

Read the posts below this one, and, as always, make up your own mind.

Another set of UCLA data points – both obvious and obscure.

OK, today’s LA times has a story about Benjamin Houghton, who had the wrong testicle removed by a UCLA resident surgeon in June 2006. The LA Times makes the obvious points: the proximate cause of the wrong surgery apparently included failure to correctly obtain consent for the planned procedure, failure to mark the correct testicle for surgery, and so on. It’s a catalog of errors, but by themselves this set of errors appears due to simple human failings (although if you read the posts below this one, you might get the idea that the University of California seems to have more simple human failings than might be expected).

The part that appears to have been unremarked on by the LA Times however, is this:

“The VA surgeon, fifth-year UCLA medical resident John T. Leppert, was supposed to remove Houghton's left testicle and perform a vasectomy on his right side for birth control purposes, according to medical records that Houghton and his attorney gave The Times.”

And that sentence says something a little more insidious about UCLA’s attitudes about it’s own interests. As stated in the article, Dr. Leppert is a resident. He’s not the surgeon in charge. He’s supposed to be supervised by an attending physician. There is no doubt that an attending physician billed for services rendered in this case, even if only for supervision (although when I was a resident, the University of California apparently “routinely misbilled” procedures done by residents as if the procedures had been done by attendings. The University agreed to pay $22.5 million in that case, but their billing practices may still be flawed).

It’s the ATTENDING who is ultimately at fault for this wrong surgery. That’s why he’s called an “attending.” From the fact that there’s no mention of an attending, it’s a pretty fair bet that UCLA has left Dr. Leppert to twist in the wind. Note that Dr. Leppert has just been through medical school, and has been working for at least the last 5 years at wages that probably don’t allow him to pay the interest on his medical school debt. In other words, it’s going to be very difficult for Dr. Leppert to hire his own attorney, if he needs one. If UCLA is already attempting to foist the blame on Dr. Leppert, as opposed to one of it’s attendings, then it’s a pretty good bet that Dr. Leppert will need his own attorney. Too bad he might not be able to get one.

For what it’s worth, when I had a patient die from anesthetic misadventure at UCLA, my attending had never had time to leave the room, since the patient had cardiac arrest just after induction. I suspected then, and now believe, that if there had been any way to pin that death on me that the case would have been more vigorously addressed. Once it became clear that only my attending, not the resident (me) could have been responsible for that death, the case seemed to “disappear." There was no formal attempt known to me to determine or address the cause of death.

Anyway, one of the reasons I think it's so sad that Dr. Leppert is apparently being left to twist in the wind is that his part in the chain of errors is exactly in keeping with UCLA practice. According to the story, when it came time to get consent for the surgery, this is what the patient recalled:

"The surgeon said, " 'This is what we talked about before. Just sign here and here' ""

Now that is, in my opinion, a typical UCLA "consent" procedure. Multiple times, when I was at UCLA, I was told that the goal of obtaining consent was to get the signature on the paper. When I tried to do more, I was critisized. Of course, I knew that the actual legal goal (different from the UCLA goal) of obtaining consent was more than simply getting a mark on a piece of paper, but it's easy to believe that Dr. Leppert, after 5 years at UCLA, had internalized the UCLA beliefs. That's why it's so sad, and ultimately pointless, for Dr. Leppert to be the fall guy for this error. At least part of the problem is that he did what he had been trained to do.

Wow. Los Alamos National Labs (run by the University of California) had yet another apparent breach of national security. A drug raid on a Los Alamos scientist's home in New Mexico turned up what appeared to be classified documents taken from the nuclear weapons lab. This is, of course, after Wen Ho Lee, and after an episode of missing classified disks that the lab later said "never existed."

As always, draw your own conclusions.


Update:
It took a while, but it eventually became clear how this episode fits into the "cut any corner to bill more or pay less" pattern that seems to have emerged from the events documented below. In most of the other posts below this one, the University of California cut corners, and people died (32 in the UC Irvine and UC San Deigo liver transplant non-program) or were left to die in agony but didn't actually die (an unknown number, but approx. 200 in that same program) or ... well, read the posts below. In this post, the University of California cut corners, and national security was compromised (again).

The person who took classified documents home was, it turns out, a Lab archivist. The archivists were supposed to work in pairs, so that each could keep an eye on each other, and so that each would be less likely to take classified documents. The University actually did hire two archivists, and presumably billed the DOE (on whose behalf the University runs the labs) for the two archivists.

The labs then assigned the two archivists to different parts of the labs. This completely negated the point of having archivists work in pairs in the first place. Well, it negated the national-security reason for having archivists work in pairs, anyway. The justification for billing for two archivists probably remained.

Last week, I worked with a nurse by the name of Natalie Dizon. Ms. Dizon has allowed me to tell her story.

Ms. Dizon had a pelvic procedure done by Dr. Schlomo Raz at UCLA. After that first procedure, she claims that she was in agonizing pain, and believed that something had been left in her during the surgery.

After a while, Dr. Raz took Nurse Dizon back to the OR. After recovery from the second visit to the OR, Ms. Dizon says that the previous great pain was gone. Ms. Dizon stated that, during recovery, another nurse, who had been present during the second procedure, told Ms. Dizon that Dr. Raz had taken a surgical sponge (apparently left there after the first procedure) out of her. That would have explained the pain, as well as the sudden disappearance of the pain after another visit to the operating room.

Nurse Dizon then tried to get her medical records to find out what had happened in the OR. Despite the fact that all the information in the medical records is hers, she was not given all the medical records, but only face sheets and billing information. In the meantime, she states that she was told that the presence of the surgical sponge on the second procedure had not been documented, and there was no point in looking for a record to indicate it's existence.

Just another UCLA data point.

Well, now it's more clear why the U. of California needed that money:

From today’s LA Times:

“For the last decade, University of California leaders systematically failed to disclose to UC's governing board the details of pay packages and perquisites granted to senior executives, despite policies requiring such disclosure, according to an audit released Monday.”


In other words, UC administrators spent University money on themselves without notifying thier nominal bosses (the regents), the legislature, or the public. Think about this in the context of a private company for a second; say you owned a business, and the hired help spent the business money on themselves without notifying anyone. In such a case, it could be embezzelment, plain and simple.

Futher:


“The report also noted that some compensation for a number of employees, including the extra income for Dynes, [the current University president] was not reported to the Internal Revenue Service. Officials said amended W-2 forms would be submitted.”

Again, in the context of a private company, that could be tax evasion.

Just sayin’


Addendum: The amount of money involved in the story above was not disclosed by the LA times. According to the NY Times story, "University of California Backs President," published May 18, 2006 (no active link at this time):"A state audit found the extra compensation accounted for $334 million."

334 MILLION DOLLARS. Wow.

Here's a little list (compiled mainly from stories out of the LA Times and the OC Register) of UC Irvine scandals over the last few years, just to help me keep track of all this:

In 2005 came news of the death of 32 patients waiting for liver transplants that were never going to come. The livers were available, but, for two years, UCI did not have a full time surgeon to implant them, in contravention of federal regulations. UCI's surgeon was actually on staff at UC San Diego, almost 100 miles away. UC Irvine never notified the dying patients that they didn't have a full time surgeon on staff. Just before leaving the program with no full-time surgeon, the last UCI transplant surgeon, who had been performing an unusually small number of transplants, with a survival rate below federal standards, is alleged to have threatened staff members with "liability" should "patients find out something and decide to sue."

The woman whose lawsuit eventually led to exposure of this scandal was Elodie Irvine. Ms. Irvine, who had liver and kidney disease, had 95 organs offered to her by UNOS, the United Network for Organ Sharing, while she waited for a transplant at UCI. All those organs were rejected by UCI, while she was told they were just waiting for organs. Only one UCI physician advised her to look elsewhere for a transplant. The rest of UCI allegedly left her, and most everyone else on the “transplant” list, to die.

In the 90s, UCI allegedly stole eggs from women who had come for fertility treatments. The responsible physicians fled the country to escape federal prosecution. At least one UCI trustee claims to have resigned his post largely because (he claimed) that the trustees were planning to support the errant physicians.

In 2006 it was alleged that, for approximately 15 years, the University had been covering up the existence of children from those stolen eggs. In at least one case, it appears that the process of removing eggs from an unwitting young woman, who had come for a fallopian tube procedure, rendered her infertile. That young woman's eggs developed into at least two children, who are now in their late teens, but the woman was never able to conceive. She did not know that she had children until 2005. Another approximately 20 such children, from 20 unwitting "donors," are now in their late teens, and the families are suing for damages and to learn the identity of their children. The University is arguing that the statute of limitations for this case has expired.

In December 2005, UCI settled a lawsuit brought over the (still-missing) body of Anneliese Yuenger. UC employees allegedly tried to pass off a bag of miscellaneous cremated body parts, instead of Yuenger’s body, to the family. This was only a small part of a willed-body scandal that affected many families, UCI, and UCLA.

In 2003, UCI hired Jagat Narula and Mani Vannan as the chief and division chief of cardiology. Neither was board certified in internal medicine nor cardiology, and neither had a California medical license. Narula then allegedly forced out electrocardiologist Michael Brodsky, and hired David Cesario, the son of med school dean Thomas Cesario, to take his place.

In 2003, Dr. Glenn Prevost presented a 13-signature petition alleging anesthesia safety problems. He says that soon after complaining about a supervisor forcing him "to take patients to the operating room without consent, chart, or preoperative check-in by the operating room nurse ... in an attempt to cut costs," he was fired and allegely blackballed.

In Feb 2001, the University of California agreed to pay $22.5 million to settle allegations that it's teaching hospitals routinely submitted false billings to Medicare, Medicaid and other Federally-funded health programs. The whistleblower, who had been at UCI, left UCI, and was allegedly blackballed. She’s since been embroiled in lawsuits against the University of California.

In the last post, I mentioned that there was a pattern regarding the University of California and its tolerance of anything that might threaten its funding streams. To reiterate my own experience: as a resident, I had been asked by the residency program director that if a patient refused a surgery based on what I had told him, "don’t you realize that you would be responsible?" In context, (see my Sunday, June 16, 2002 post) I thought that was a pretty clear, though misguided, warning not to tell patients the risks of anesthesia.

Such a rhetorical question was not, apparently, clear enough for UC Irvine. According to the LA times, Dr. Sean Cao, at the time the only UCI transplant surgeon, actually wrote an email regarding talking to potential transplant patients. Dr. Cao apparently distributed a confidential memo that stated "Anyone who spreads the rumors [that he was turning down organs] ," would be subject to discipline for "professional misconduct" and held "liable, especially if the patients … find out something and decide to take legal action."

The thing is that these "rumors" were apparently true. In 2003, UCI performed just 8 liver transplants, as opposed to the minimum of 18 required by the state to maintain certification, or the minimum of 12 transplants required by the feds. Only 16.2% of patients who had joined the waiting list between July 1998 and June 2001 had received a liver three years later, as opposed to the nationwide average of 42% of patients who got a liver within three years. In any case, I find it interesting that UCI, in the person of Dr. Cao, threatened staff in writing with "liability" if "patients … find out something and decide to take legal action." Wow. Simply wow.

In my last post (the one just below this one) I mentioned how remarkable it was that none of the UCI empoyees happened to mention to "transplant" patients that there was no transplant surgeon generaly available from July 2004 onwards. (Dr. Cao left the program, and was not replaced, so UCI had no full-time transplant surgeon. Transplant candidates were not notified, however.) I think that this memo might indicate the source of the problem. After all, what sort of highly educated, trained, and mobile professionals would stay with the program after getting those sorts of email threats? For that matter, what sort of people would stay working at UCI after the long string of scandals? Answer to both questions: the sort of people who are working there right now. Related answer to both questions: largely the sort of people who will be there as the next scandal occurs. I think that says a lot.

I’ve noticed, as have you if you’ve been reading this site, that the last few posts seem to revolve around the University of California. That’s not really what I had in mind when I wrote my June 16, 2002 post; I originally thought I was being a little bit more universal, and writing about residency / training programs in general. However, the title of the blog is "trying to make sense of (some of) it all," and perhaps this blog has helped me understand a little bit more of what I was writing about.

It’s become pretty obvious to me, after re-reading some of my posts on this blog, that there may be a problem at the University of California in particular. That became more evident lately when it emerged in a series of stories spearheaded by Charles Ornstein and Alan Zarembo of the LA Times that, over at least the last two years, the University of California, Irvine has been involved the worst crisis in medical ethics since the Tuskeegee Experiments. I’m going to replicate the gist of the news stories here, even though I don’t have any new information of my own to add.

According to these stories, since at least July 2004, the University of California has been running a sham liver transplant program, in which UCI:

recruited patients with liver disease
told patients that they were on the list for liver transplants
obtained federal funding for running a liver transplant program
presumably charged insurance companies for pre-transplant evaluations
… and didn’t actually have a full-time liver transplant surgeon available.

[the original version of this post stated that UCI didn't have a transplant surgeon available. I decided that was unclear, since they sometimes had a surgeon available. Therefore, I've changed this post a little bit to refer to the lack of a "full time" transplant surgeon, as opposed to the lack of "a transplant surgeon." ]

UCI had a website in which they named Dr. Marquis Hart and Dr. Ajai Khanna as their transplant surgeons, and did not mention that those two surgeons were actually on staff at UCSD, almost 100 miles away. Federal inspections of UC Irvine revealed that there was no liver transplant surgeon "in the immediate vicinity of the hospital."

UC Irvine did make their facilities available on an occasional basis to transplants, doing 8 transplants each year from 2002-2004, and five transplants in 2005 (as opposed to the federal requirement that at least 12 transplants be done each year by a liver transplant program in order to maintain certification), with a 2002-2004 1 year survival rate of 68.8%, as opposed to the near-85% national 1-year survival rate. Meanwhile, UCI recruited more patients with liver disease (28 in 2005), refused organs made available to those patients (apparently since there was generally no surgeon available to transplant those organs) and, except for the occasional transplant recipient, allegedly waited for everyone else on the list to die. In fact, according to the LA times, at least 30 patients died over the last 2 years while waiting for liver transplants. The livers were apparently available (contra what had been told to the patients). It was the transplant itself -- in particular, a transplant surgeon -- who was not.

The story came to light due to a lawsuit filed by Elodie Irvine, who had fruitlessly been on the UCI waiting list for years before moving to Cedars-Sinai, where she got a transplant. During the time that Ms. Irvine was at UCI, UCI turned down 38 livers and 57 kidneys on her "behalf," while telling her that UCI was simply waiting for organs for transplant. "They left me to die," said Ms. Irvine.

Well, that’s most of the story. However, I am certain that, during the time that Ms. Irvine was on the "transplant" list at UCI, she was attended to (and billed for):

Gastroenterologists for GI symptoms
Nephrologists for renal symptoms
Anesthesiologists / pain management specialists for her pain
General internists for non-hepatic non-renal problems
Fellows, residents, interns, and medical students
Nurses, nursing assistants, phlebotomists, and lab techs
Multitudes of administrative personnel including "transplant" coordinators and billing specialists

And apparently, except for one eventual, apparently informal, referral to Cedars Sinai, not one of those people happened to mention to this old woman on the "transplant" list, nor to anyone else "waiting" for a transplant … "hey, you know … UCI doesn’t really have a full-time transplant surgeon. If you’re waiting for a transplant, that’s something you’d like to keep in mind."

Once, I would have wondered how that could be possible. If you’ve read my earlier posts, however, particularly the June 16, 2002 post, you already have a good idea as to how that could happen. I objected to the apparently needless (but profitable) hospitalization of not-really-sick people during my internship through UCI, and I was told to shut up and do my job. I told people the risks of anesthesia at UCLA, and they rearranged my residency schedule so I would not have any contact with liver transplant patients, then forced me out. One of the trustees at UCI objected to the University’s defense of the reproductive endocrinology program that stole the eggs of patients, and, according to him, he had little choice but to resign. The whistleblower who notified the HCFA (health care financing administration) that the UC medical centers were billing for services provided by attendings who were not in the hospital was apparently fired, blackballed, and was involved in lawsuits for years. There’s a pattern there. It's not the pattern I originally thought it was, but I think I’ve figured it out now. You are welcome to do the same.

Presented without comment: one (of many) stories about UC Irvine residency alum Dr. George Steven Kooshian

Here's an interesting story based on this data. This study looked at MI, pneumonia, and CHF, which generally have well-understood treatments with well-documented mechanisms and goals of treatment. In the words of Dr. Ashish K. Jha, the study's lead researcher and an assistant professor of health policy and management at the Harvard School of Public Health "These are all really relatively simple things."

And yet, according to the LA Times, "hospitals serving the Inland Empire overall ranked worst in the country last year in their treatment of patients with heart attacks and pneumonia, according to a new study," and "care provided by the Inland Empire market ranked 34th among the 40 largest hospital markets in the nation [for CHF]." "[hospitals in] the San Diego area ranked in the bottom five for their treatment of congestive heart failure and pneumonia, and [hospital care in] Los Angeles was next to last for its pneumonia care.No region in the state ranked among the top five in treating any of the three medical conditions studied."

I might comment on this later, but, for now, there's a major clue as to the problem in the quote of Jim Lott, executive vice president of the Hospital Assn. of Southern California. According to Mr. Lott, '"These people are trained the same places everybody else is trained,' (Mr. Lott) said, referring to the medical staffs." Uh, no. California doctors tend to be Californians, and tend to have been trained in California. That's one of the reasons people pick a residency program, particularly if they plan to go into private practice ... because it's in the area, or at least the state, in which they plan to practice. In other words, the people responsible for this poor showing are likely to have trained in California, and particularly likely to have trained at the University of California (since the U. of California is the 800 pound gorilla of academic medicine in California).

As per the other posts further down this page, I invite you to draw your own conclusions.

The rabbit hole gets a little bit deeper

Whoa. According to this article, Filipino veterans of WWII are asking for VA benefits from the US department of Veteran’s affairs. According to the article, last year (2004) was the year that Filipino veterans were allowed into the US VA health care system.

That’s a surprise to me. In 1992, while I was an intern at the Long Beach VA Medical Center, which is partially administered by UC Irvine, one of my inpatients was a Filipino veteran who was never a member of the US regular armed services, but of the Filipino armed services. This man lived in the inpatient units of the VA for, to the best of my knowledge, months at a time, and had been a long term patient of the VA before I was hired, and continued to be a patient after I left. I asked about this at the time, and was told that President Roosevelt had authorized Filipino Vets to be treated in the US VA system, so it was legit.

On the other hand, according to the Sun-Times article linked above, the US Congress elected not to recognize Filipino veterans as "active veterans" in 1946. So, if my reading of the the Sun Times article is correct, from 1946 until 2004, barring unusual circumstances (and, based on the other irregularities I’ve described in the posts below this one, and the fact that no other unusual circumstances were described when I first asked about this back in 1992, my first guess as to the most likely set of operative "unusual circumstances" is fraud), Filipino veterans were not authorized for treatment at the VA medical centers. And yet, there he was. Makes me wonder about the other VA patients I met who were not US veterans. Also makes me wonder about the elderly woman whose records and ID had a man's name (her husband's name, according to her) on them, and who was also a long-term patient of the VA.

Anyone from the Long Beach VAMC or UC Irvine want to explain this? (bearing in mind that I’ve already gotten the "President Roosevelt gave them this, so it’s OK" explanation from the VA, which is apparently not true) I’m at pbanos[at]yahoo.com

Since the time I wrote my last post below, describing my experiences at the University of California, people have asked me if I know of any other problems there. Indeed I do. So, over the next few postings, I will describe a few examples of what I believe to be large-scale insurance fraud that I saw, or otherwise know of, at the University of California medical system.

The largest case of which I am aware involved large scale ... umm ... mistaken billing for intern and resident services. I did my medical internship through the University of California, Irvine. I made $29,000 for one year of work, for which I worked approximately 80 to 100 hours / week. The University, however, apparently didn’t bill for my services as if I was making $29,000 / year. Instead, they allegedly billed for the services provided by the interns and residents, as if the services had been provided by attending physicians. (note: I don't know if services I personally performed were billed "incorrectly," just that large numbers of services around the time I was working for UC Irvine were "incorrectly" billed. I assume that some of what I did was billed "in error.") They even billed for attending physicians doing procedures at times when those attendings were documented to have not been in the hospital at all.

In February 2001, after years of appeals, but with new federal DA's on the way after the 2000 federal elections were eventually finalized, the University of California settled those
"erroneous" billing claims (referred to as "routine misbilling of medicare, medicaid, and other federal health care programs") for $22.5 million. (!) The last I read about this, in the LA Times, the whistleblower, from the University of California, Irvine billing department, was still wading through lawsuits and trying to get her life back on track.

So, since I’m blogging today, I thought I’d describe one more apparent impropriety at the University of California. This one doesn’t involve the University of California directly, but is about the Long Beach VA Medical Center, which is partly staffed by UC Irvine. The content of this post comes in 2 parts:


PART 1:
As an intern, I rotated through the Long Beach VA Medical Center Emergency Room. After a while, it became obvious that the VAMC ER was admitting a lot of people who didn’t need to be admitted; people who weren’t really sick. I asked about that (made a stink is more like it), and eventually was summoned to the office of the director of Emergency Medicine at the Long Beach VA. She basically told me to shut up and do my job, but she also told me that the department of emergency medicine there was contracted (apparently in an unwritten contract) to admit at least 30% of their patients to inpatient units. It was implied that this was whether 30% of the ER patients were really all that sick or not.

OK, that’s possible fraud right there. But still, it was possible that 30% of the ER visits were legitimate admits. However, while working in the ER, and later while working in inpatient VA units, I noticed that some of the admits were not even close to being legitimate. I am not referring to old men with bronchitis who could have been treated as outpatients, but who were admitted for observation, or similar judgment calls. I am, instead, referring to the practice I observed of simply making up a serious diagnosis for ER patients, then using that diagnosis as an admitting diagnosis for inpatient admission.


PART 2:
For example, I had a patient, admitted by Dr. Queeda Draine of the VA, who was admitted for digoxin overdose. Digoxin is a medicine given to people for certain heart diseases; in overdose, it can cause arrhythmias and death. Admitting someone to the inpatient units for dig overdose is perfectly reasonable. However, this patient had no signs of digoxin overdose. His EKG was normal. He had no cardiac history which would have required digoxin therapy. He was not on digoxin. He claimed that he had never taken digoxin in his life. His serum dig level, which was available to me as the patient was being wheeled out of the ER to the ward, and which therefore should have been available to the ER attending Dr. Draine, was zero. To me the conclusion was inescapable: the admitting diagnosis of digoxin toxicity had been simply made up. Before admitting this patient, I called Dr. Draine to ask how the patient could have digoxin toxicity with a dig level of zero; Dr. Draine hung up on me.
Under orders from my attending, I admitted this patient for observation. The patient, as healthy in the morning as he had been on admission, was discharged at morning rounds, after I opined in morning report that this admission constituted pretty obvious fraud. I don't think it was the "fraud" part that caused the patient to be discharged; I think it was the "pretty obvious" part.

The patient never really knew why he'd been admitted; according to him, he spent the night in the hospital because 'that doctor in the ER thought I should.' As for why he had come to the ER in the first place, it is my recollection that he had come with complaints of "being tired." Being tired is a problem, but is generally not justification for an emergency admission.
Nevertheless, I have no doubt that the hospital billed for my services in admitting this patient for an apparently made-up diagnosis, and for observing him overnight for a disease which he did not have. In fact, based on the events referenced in the post immediately above this one, I have no doubt that the hospital overbilled for that work.


I observed a lot more examples like part 2, and was left with my own conclusions about inpatient admissions at that facility. I invite you to draw your own conclusions.