There are a variety of treatment modalities to treat blocked coronary arteries: drugs, bypass surgery, and vessel-clearing procedures like angioplasty. In Elyria, Ohio, doctors are four times more likely to direct patients towards angioplasty. This procedure typically involves threading balloon catheters through arteries and sometimes placing drug-coated stents to unblock them.
Virtually all the procedures at the Elyria hospital are performed by a group of cardiologists who dominate cardiovascular care in Elyria. These doctors have a unique enthusiasm for angioplasties which, relative to the other available treatment options, is the most profitable. Medicare pays Elyria’s community hospital, EMH Regional Medical Center, about $11,000 for an angioplasty involving the use of a drug-coated stent.
There is no medical malpractice action to be had for this high rate of angioplasties which is probably why this practice has gone on unchecked (although the insurance companies and Medicare are growing concerned at the cost of these procedures and have investigated). This reminds me that medical malpractice lawyers in Maryland and around the country serve a great public utility to keep patients safe. You often hear how doctors complain that medical malpractice lawyers make them practice medicine too defensively. This seems like a tough argument because the federal government’s data shows that 100,000 people die from medical malpractice every year. But perhaps this is so. But if this also means that doctors will take a little extra care to avoid committing medical malpractice, I do not care what the motive is. It is a good thing. In fact, one would think even doctors themselves, considering this medical malpractice statistic, would not mind the legal community keeping them on their toes with so many lives at stake.
Some medical experts say Elyria’s high rate of angioplasties — three times the rate of Cleveland, just 30 miles away — raises whether some patients may get procedures they do not need or whether some could have been treated just as effectively and at a lower cost and less risk of heart drugs that may cost only several hundred dollars a year. Or whether, sometimes, patients might be even better off with bypass surgery — even though a bypass is a riskier, more invasive, and more expensive procedure. At EMH Regional, Medicare pays the hospital about $25,000 for bypass operation and as much as $2,200 to the surgeon.
The Elyria cardiologists do not perform bypasses. Because they are not surgeons, the North Ohio cardiologists must refer a patient to another doctor if they conclude that bypass surgery is that patient’s best option. The bypasses are performed at the Elyria hospital by surgeons from the Cleveland Clinic who have operating privileges there.
But even in cases of extensive disease where other doctors might typically recommend bypass surgery, the Elyria doctors say they frequently favor the use of stents.
For patients with less serious diseases, the doctors say they do prescribe drug-only treatment.
But Dr. Schaeffer argues, the group’s aggressive use of angioplasty provides the best results for its patients. “We have excellent outcomes,” he said.
No Definitive Studies
When it comes to treating blocked arteries, there are no definitive studies showing which approach most benefits patients in the long term. And some local insurers agree that the Elyria hospital provides high-quality care.
But there is little doubt that hundreds of Elyria patients each year are getting angioplasties that they would not be getting if they lived elsewhere in Ohio — or any other part of the country — at a cost of millions of dollars a year to Medicare, the federal insurance program for the elderly. Elsewhere in the state, some of the sickest of these patients might have received bypass surgery, while many others might have simply been treated with drugs. Or, for those whose conditions were not diagnosed or were not deemed serious enough, there might have been no treatment at all.
Experts know that changing financial incentives can change the way medicine is practiced.