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Cardiac Procedures I
2003
Web page
This corporate web site addresses the issues of
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This page written in 2003 describes the exposure of the
scandal at Redding Hospital in California. Two Tenet doctors
led teams that are alleged to have carried out hundreds of
unwarranted procedures and performed 769 major coronary
bypass operations on people who did not need them. The page
examines the doctor's histories and tries to provide an
explanation of why and how this happened.
The series:- Tenet and its
doctors
In July 2003 I wrote a web page titled "Tenet Health Care and its
doctors" which included the story of Tenet's relationship with its
doctors going back into the 1990s. In 2007 I put the material about
Redding hospital into a separate web page and wrote two more about
this revealing scandal within a scandal. The kickback allegations too
had become a major player in the wider scandal. This has also been
moved to a separate web page and updated. More Tenet sagas which
involve doctors have come to light and these throw additional light
on the many problems in Tenet's operations. While they deal with more
than just the doctors they all contribute to the story of doctors and
form a saga. I have therefore arranged them as a series called "Tenet
and its Doctors".
The web pages are
This page written in 2003 describes what happened at Redding hospital. A second page written in 2007 describes how it all worked out.
Unnecessary Cardiac Procedures
In October 2002 a scandal burst and once again enveloped Tenet Healthcare. It began with revelations about hundreds of unnecessary heart operations at the Redding hospital in California. This was followed soon after by the exposure of the outlier scam in which a loophole was used to charge far more for sicker patients. Because of this loophole Tenet had changed its policies. It was specifically targeting major surgery and sicker patients at the expense of conditions which paid less well. Given Tenet's disregard for standards, its neglect of peer review, and its tendency to cut costs to boost profits there must be concerns about what actually happened to many of these patients. In complex and sick patients it is difficult to monitor the standards of care unless this is done continuously by involved and critical peers. The accounts show that this did not seem to happen in Tenet hospitals. Multiple other concerns about Tenet's operations soon emerged. This page deals with the early part of the Redding hospital saga.
On the 30th of October the FBI
raided Tenet's Redding Hospital in California and the offices of a
cardiologist and cardiac surgeon. It was alleged that the two doctors
had carried out large numbers of cardiac procedures that were neither
indicated, nor necessary, some on patients with normal hearts. In
view of Tenet's past history and current business practices it is
likely that the allegations will prove to have substance. For the
purpose of this analysis I will assume that they do.
This raid occurred the same day as an analyst picked up the outlier
problem and Tenet was notified of a Medicare audit. Tenet delayed 24
hours before disclosing the raid and a week before disclosing the
audit. Its shares dropped precipitously.
With so many thousands of patients each of which will inevitably
raise conflicting arguments and opinions prosecuting this problem in
the courts will be a nightmare. It will require many thousands of
hours and disputed analysis on each patient. This is why cases
involving multiple clinical cases are so seldom prosecuted. It will
be interesting to see how this is dealt with.
Nov 2002 The investigation
The investigation apparently began months ago and was led by Redding FBI agent Michael Skeen. FBI Special Agent in Charge Michael Mason said that both doctors were suspected of "health care fraud, making false statements about health care and conspiracy to commit fraud," the Record Searchlight article said.
-----------------------
In the 70-page affidavit for a search warrant, federal agents detailed their investigation and interviews with other cardiologists, who said they had suspicions as far back as 1995 about the unusual volume of heart procedures the doctors logged at the hospital.
Skeen's affidavit said one cardiologist told him a Eureka man had an angiogram that revealed no coronary artery disease, yet Moon had referred him for a bypass. The cardiologist said the bypass had been unnecessary.
----------------------------
The doctors said they ran across dozens of patients who had been diagnosed by Moon and operated on by Realyvasquez, but they couldn't find evidence of damaged hearts.
------------------------------
Skeen said in his affidavit that a cardiologist told him procedures by the two doctors escalated in the early 1990s -- around the same time Redding Medical Center "began to aggressively posture to become known as a top-ranked heart center." He noted that in one two-year period, the hospital spent $2 million on advertising. Two Redding heart surgeons suspected of fraud, unnecessary surgeries The Times-Standard November 02, 2002
Nov 2002 The allegations
In an affidavit made public Thursday, FBI Agent Michael Skeen said the two doctors, who practice at Redding Medical Center, performed an unusually heavy volume of heart catheterizations and other coronary procedures, of which as many as half -- based on the opinions of other doctors -- may have been unnecessary.
-----------------------------------
The FBI affidavit stated that the two doctors derived enormous income compared with other physicians, noting that Realyvasquez ranked as the top Medicare biller in a list of 50 physicians of a similar specialty in the Northern California region.
Moon was ranked No. 2 among doctors of a similar specialty.
----------------------------
In one instance cited in the affidavit, a woman evaluated by a cardiologist in August was found to be in "relatively good health and not suffering from any coronary artery disease."
She went to Moon for a second opinion, and she received a heart catheterization that same day, according to the affidavit. Moon further told the mother that she needed immediate bypass surgery, which she subsequently received at Redding Medical Center, the affidavit stated.
----------------------------
Tenet, which operates 113 acute-care hospitals nationwide, including 40 in California, has openly pursued a strategy of treating sicker patients and increasing the volume of high-acuity specialties, such as cancer and cardiology. Tenet's Stock Hammered on News of Probe ::Two doctors are under investigation over possible billing irregularities and unneeded procedures. LA Times November 1, 2002
Nov 2002 The extent of the problem
Skeen (FBI affidavit) estimated that one-quarter to one-half of the patients underwent unnecessary cardiac procedures and 167 died. Sudden impact :: Tenet reeling after federal raid at Calif. hospital Modern Healthcare November 4, 2002
Oct 2002 The raid and the stock market
Trading of Tenet Healthcare Corp. stock was halted today after it plunged 22% to $32 per share from $38.97 per share on news of a federal raid at Tenet's 188-bed Redding (Calif.) Medical Center. Search warrants were executed on the hospital and the offices of its director of cardiology and director of cardiac surgery. The raid was carried out by some 40 agents and inspectors from the FBI, HHS, the IRS and the U.S. attorney's office in Sacramento. According to affidavits filed in U.S. District Court in Sacramento, investigators were seeking evidence of false billings and unnecessary angioplasties, coronary bypasses and heart catheterizations. Tenet Calif. hospital subject of government raid Modern Healthcare October 31, 2002
Nov 2002 Boxes of evidence
It is unclear what degree of civil or criminal liability the 113-hospital chain, based in Santa Barbara, Calif., faces.
----------------------------
Government agents carted away hundreds of boxes of evidence from quality assurance, medical records, cardiology, catheterization laboratories and the hospital's storage center.
Moon and Realyvasquez have not been charged in the case.
--------------------------------
Teplitzsky, who has no connection to the case, said government prosecutors take a dim view of healthcare organizations whose compliance programs don't work. Sudden impact :: Tenet reeling after federal raid at Calif. hospital Modern Healthcare November 4, 2002
I would like to paint a hypothetical
situation which my reading of the available material supports. It is
an attempt to reconstruct the situation and I may not get everything
right.
This was Tenet's most successful and most profitable hospital. The
company, the hospital's administrators and even the doctors would
have been intensely proud of their performance and the success which
accompanied it. They were all supremely confident and flushed with
success.
I very much doubt that anyone would have considered the possibility
that this success was built on deceiving patients. The doctors may
have known it but I believe that they are unlikely to have actually
confronted this themselves. It would have been compartmentalised and
ignored. The behaviour of all the parties suggests that no one wanted
to know and no one looked. The reality was too frightening so they
denied it.
Tenet staff from its chairman down to junior staff in the Redding
hospital would have been boosted by this success and supremely
confident. They were on a high. They had no doubts about what they
were doing. Their marketplace views were unchallengeable. Marketplace
success and increased status in the community was validation enough.
A host of red flags simply went over their heads.
to
contents
As in 1991 it was a single index case which
blew it all open. Of all people the doctors and the hospital picked a
medical ethicist, hardly the person to deliberately deceive. Instead
of quickly recovering the situation by addressing it they ignored all
of his efforts to tell them that there was something wrong -
incredible stupidity. This is not the way someone who knows that he
is a criminal responds. The administration must have had supreme
confidence in their doctors.
The ethicist went for a routine heart check because of a family
history and must have been advised to have an angiogram. He was then
told that he had heart disease and was in need of urgent bypass
surgery. Friends suggested that he should go to Las Vegas for this as
they could provide support. The surgeon there told him his heart was
normal. Multiple other opinions confirmed this. He repeatedly spoke
to the hospitals administrators and told them of the problem. Instead
of looking into this the administrator advised him to follow the
Redding cardiologists advice. Instead he took his concerns to medical
bodies and then to the FBI. He also lodged a Qui Tam court
case.
Nov 2002 John Corapi blows whistle
Last June, shortly after his 55th birthday, John Corapi got the bad news from Dr. Chae H. Moon, director of the cardiology department at Tenet Healthcare Corp.'s Redding Medical Center. Corapi had splits in his arteries, according to Moon's June 11 report. His recommendation: bypass surgery.
-------------------------
Authorities are investigating whether the doctors performed unnecessary heart procedures on hundreds of patients. No charges have been filed against either man. Heart Patient Sues Tenet, Physician :: Lawsuit follows public disclosure of FBI probe. Hospital chain executives try to reassure investors and analysts as shares sink. LA Times November 2, 2002
Nov 2002 Corapi files suit
Now, a malpractice lawsuit filed in Shasta County (Calif.) State Court by the Rev. John Corapi accuses Redding's director of cardiology, Chae Moon, M.D., of professional negligence, battery, conspiracy and fraud and names Tenet and the hospital as co-defendants. Corapi was among the informants who led the FBI and other federal agencies to raid Redding's offices last week for documents related to cardiac procedures and patients. Add malpractice case to Tenet hospital's woes Modern Healthcare November 4, 2002
Nov 2002 Corapi's story
"I'm a lecturer in medical ethics," Corapi said.
--------------------------
"I was scrambling to draw up a will," Corapi recounted in an interview here late Sunday night. "It was a traumatic experience."
Eventually, after the 55-year-old Corapi developed suspicions about his diagnosis by Redding's Dr. Chae Moon, he took his concerns to his health insurer, to the California Medical Board and eventually to the FBI.
-----------------------------
In Corapi's case, rather than agree to the immediate bypass surgery recommend by Moon, he called to seek the advice of a friend in Nevada who had convinced him to have his heart checked out in the first place. The friend suggested that he come to Nevada to have the surgery. He went to a cardiologist in Las Vegas, expecting to soon land on the operating table.
------------------------------
In time, four other Las Vegas cardiologists concurred that there was nothing wrong with his heart and that he did not require a bypass operation. All of the Nevada doctors reviewed the results of tests performed by Moon.
Corapi said that he asked the Nevada doctors if it could have been a simple mistake by Moon or a difference in judgment. The answer he received, he recounted, chilled him: He was told there was no way to look at his tests and legitimately conclude that he needed immediate surgery.
"This was black and white," Corapi said. "It wasn't an error."
Armed with the far different conclusion of the Nevada doctors, Corapi returned to Redding Medical Center looking for answers and an explanation. What he says he got from the medical center's Chief Executive, Hal Chilton, was a strong defense of Moon's diagnosis and another hard sell that he needed the surgery and could be accommodated that very afternoon.
Corapi said that he returned to Nevada again seeking the reassurance of his doctors there, and they again confirmed that surgery was unnecessary. Corapi said that he again contacted Chilton by telephone and that Redding officials again tried to convince him that the surgery was needed.
--------------------------
Barr said that he probably would consult with several cardiologists, adding that those who had contacted him seemed to indicate that "if you went into that [emergency room] complaining about pain anywhere from your chest to your abdomen they would try to do" a heart examination "on you." Priest's Heart 'Trauma' Triggers Tenet Probe :: Consultant will review allegations. Firm also will investigate. LA Times November 5, 2002
Dec 2002 More Corapi
After receiving a physical examination as he turned 55, Corapi decided to have his heart checked because his father suffered from coronary disease, his attorney said.
At the suggestion of a neighbor, he ended up at Redding Medical Center with Dr. Moon, and after being examined "they were telling him if he didn't have surgery he was going to die," Barr said. Suit seeks cut of funds in probe of surgeons The Sacramento Bee December 11, 2002
Aug 2003 The hospital still pressured him to have surgery
He passed the test, but Dr. Moon still suggested a trip to the catheterization lab.
-------------------------
Back in Redding, Father Corapi and Mr. Zerga met with hospital officials, who said that two cardiologists had reviewed the records and agreed with Dr. Moon's findings, though they declined to name the doctors. "I expected the hospital to be extremely concerned over this situation," Mr. Zerga said. "But they weren't."
How One Hospital Benefited on Questionable Operations New York Times (KURT EICHENWALD) August 12, 2003
Did Tenet know? - it should have known
As in the past Tenet frantically tried to
distance itself from the allegations claiming that care was the
responsibility of doctors and that the investigation was of the
doctors and not of Tenet. This is disingenuous. Tenet has a
responsibility to set in place monitoring and oversight processes and
ensure that they work. It should discourage and not encourage
unnecessary treatment. Perhaps it simply did not want to know and was
struggling to comprehend what had happened itself.
The ethicist was not the only one who had warned the hospital.
Doctors, including a cardiologist working in the hospital had taken
the matter up with the hospital administration. In addition to this
there were concerns among other doctors in the town, doctors who
worked at the competing not for profit church run hospital in
Redding. This was conveniently dismissed as petty jealousy because of
Redding's success. Dr Pearce describes these doctors as having a
reputation among other heart specialists across the country of being
"wild" and "cowboys". He doubts that Tenet could have been unaware of
this.
Large numbers of people seem to have known or suspected . The HMO's
knew and were making huge losses as a result. Instead of reporting
this and initiating action they simply closed up shop in the region.
This is the marketplace.
The behaviour of hospital administrators is reminiscent of what
happened in Bristol in the UK. They simply put their heads in the
sand because they did not want to know.
Nov 2002 Tenet shifts blame to doctors
"This is an investigation of doctors, not the hospital or Tenet," said Harry Anderson, a Tenet spokesman. He said the company had no prior indication that there was anything out of the ordinary occurring at Redding Medical Center.
In the FBI affidavit, another cardiologist at the hospital that he took his suspicions about the two doctors to the hospital's chief executive and chief financial officer last spring. (6 months earlier)
The affidavit said the cardiologist believed that both hospital administrators were aware of what was going on and looked the other way "because Moon and Realyvasquez produce tremendous revenue for the hospital." Tenet's Stock Hammered on News of Probe ::Two doctors are under investigation over possible billing irregularities and unneeded procedures. LA Times November 1, 2002
Nov 2002 Tenet should have been aware
Barr and other lawyers in Redding, who reported receiving dozens of calls Friday from former patients of Moon and Realyvasquez, said they found it hard to believe that Tenet officials missed red flags.
"Other cardiologists in town have complained" about the two doctors, said Robert Simpson, who has been a lawyer in Redding for 22 years. How could Tenet deny knowing of problems "when they have two doctors in Redding, a small regional center, producing more income than doctors in large regional centers?" he asked.
-----------------------------
According to state filings by Tenet, the Redding hospital generated pretax net income of $94 million in the 12 months ended June 30 -- the highest among Tenet's 40 hospitals in California. Mercy Medical Center, the other hospital in Redding with slightly more beds, reported pretax net income of about $5 million in the same period. Heart Patient Sues Tenet, Physician :: Lawsuit follows public disclosure of FBI probe. Hospital chain executives try to reassure investors and analysts as shares sink. LA Times November 2, 2002
Nov 2002 Hospital staff had told them
According to unnamed government witnesses cited by the FBI in the affidavit, hospital medical staff members were concerned about the high volume of procedures and told hospital administrators they believed many were unnecessary and put patients at risk. A physician witness interviewed by government agents reported that the hospital's chief executive officer seemed unsettled by the news but initiated no review, Skeen said.
------------------------------
"Our initial review found no failings," Anderson said. "We're taking this very seriously. But we want to emphasize that hospitals have to rely on the professional judgment of their doctors, since they make all the necessary medical decisions, not us." Sudden impact :: Tenet reeling after federal raid at Calif. hospital Modern Healthcare November 4, 2002
Nov 2002 Whisperings for years and the HMOs knew
One thing most everyone will agree on is that for years there have been whisperings in the community and elsewhere about whether Redding Medical was being overly aggressive with heart procedures. In fact, in recent years HMO firms and some medical groups pulled out of the Redding area, saying they were losing too much money because the filing of health-care claims was off the charts.
"Redding is the highest cost of care per population in all of California," said Steve McDermott, chief executive of Hill Physicians Medical Group. McDermott said his doctors group pulled out of Redding at the end of last year, after losing almost $1 million last year serving 22,000 HMO members there.
Blue Shield of California said it would stop providing HMO service to members of the California Public Employees' Retirement System in the Redding area as of early next year. According to a 2000 report prepared for the California Healthcare Foundation, the Redding area had the highest rate of bypass surgeries in California, at 13.55 procedures per 1,000 enrollees -- more than double the statewide average.
-----------------------
Mercy Medical also has a cardiology department, but the hospital's profit is just a fraction of Redding Medical's. And some doctors say a bitter rivalry between the hospitals is behind much of the criticism against Redding Medical and the two doctors. Redding's Spotlight Turned Into an Unwanted Glare :: Town is divided over investigation into doctors LA Times November 6, 2002
Nov 2002 Its all about more outlier payments
Although Redding is a relatively small hospital, with 238 beds, it is one of the company's most profitable -- largely because of the high-volume cardiology program the two doctors established.
Among other sources of revenue, Redding Medical Center receives an unusually large share of outlier payments because the hospital performs many specialized and costly heart procedures. U.S. to Audit Tenet Hospital Bills :: Focus will be on large Medicare payments. Meanwhile, state seeks to curb Redding doctors. LA Times November 7, 2002
When the story broke hundreds of patients, particularly those who had not had symptoms prior to invasive procedures began to think about what had happened to them. Many went to lawyers. One lawyer has about 500 past patients wanting to take action.
Nov 2002 Past patients become suspicious
Now, Haggard said, he's convinced that the fear he has long harbored in the back of his mind is completely warranted. "I suspected when it was done to me that I didn't need" an operation, he said. "There's a very good chance I may be a prime example of what Dr. Moon did. The whole thing has made me mad. I'm just waiting here for the FBI to contact me."
--------------------------
He said his misgivings were heightened when the drummer in his band, the Strangers, also checked into Redding Medical Center about three years ago. Biff Adam was back from the road, feeling a little weak and complaining of some chest pain, when he went to see Moon.
After some tests, Adam remembered in an interview Monday, the doctor delivered the bad news: The left muscle in his heart was badly damaged. Moon "went up to my wife and said, 'Your husband needs a heart transplant,' " Adam recounted. "She almost passed out."
Adam said his family doctor in Redding, Morris Ballard, suggested that he get a second opinion. He did, from Dr. Robert Pick, who wound up treating Adam not with surgery but with a drug called Coreg, which lowers blood pressure. "That straightened me out," Adam said. "I didn't need a heart transplant -- that's for damn sure." Haggard Says Heart Didn't Need Fixin' LA Times November 6, 2002
Nov 2002 More cases and major morbidities
The affidavit presents a far more chilling scenario, which is that Moon violated the ancient medical oath to "first, do no harm." One case briefly detailed by the FBI: A 59-year-old male received bypass surgery and, four years later, is still too weak to work. A cardiologist who reviewed the man's records for the FBI "found, at most, evidence of a relatively minor problem," the affidavit says. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Aug 2003 Another life ruined
Complications followed, and Mrs. Wooten, who loved to attend dances with her husband, Bob, and take long driving trips around the California countryside, can no longer write or walk steadily. An independent expert has deemed the surgery unnecessary, and she is suing.
"I had to quit my job to take care of her," Mr. Wooten said. `Our lives came to a screeching halt after that surgery, I'll tell you."
How One Hospital Benefited on Questionable Operations New York Times (KURT EICHENWALD) August 12, 2003
This is one of those situations where protection of the public should take precedence over the rights of the individual, at least until the situation is resolved. This could take months if not years. In November 2002 the Californian Medical Board moved to have the doctors suspended from practice. The court however chose to protect the rights of the doctors who had not been charged with a criminal offence and rejected the move. The council tried again in June 2003. The cardiologist had stopped practicing as he could not get medical insurance. In July 2003 he agreed to temporary suspension of his medical licence.
Nov 2002 Medical Bard acts
On Wednesday, the California attorney general's office, acting on the request of the state medical board, said it would seek a court order to prevent the two doctors, Chae Hyun Moon and Fidel Realyvasquez Jr., from practicing medicine pending the outcome of the probe. U.S. to Audit Tenet Hospital Bills :: Focus will be on large Medicare payments. Meanwhile, state seeks to curb Redding doctors. LA Times November 7, 2002
Nov 2002 Doctors a threat to patients
As part of the petition, there was a declaration from Vincent Yap, chief of cardiology at Kaiser Richmond Medical Center. "It is my strong professional opinion that neither Dr. Moon nor Dr. Realyvasquez can safely practice medicine, and each poses a threat to patients," he wrote. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Nov 2002 Court overrules medical board
Shasta County Superior Court Judge Monica Marlow ruled that the California Medical Board's evidence against cardiologist Chae Hyun Moon and heart surgeon Fidel Realyvasquez was insufficient to stop them from practicing.
-------------------------------
- - - - FBI and the Medical Board describe as the doctors' approach to patients. Moon and Realyvasquez "were able to carry out their scheme by lying and/or misleading and in some cases scaring patients," the board wrote in its court petition. Redding Doctors Keep Licenses :: Medical Board fails to win the suspension of two heart physicians at a Tenet Healthcare facility. LA Times November 14, 2002
Jan 2003 Moon loses insurance and stops practice
The head of the cardiology department at Tenet Healthcare Corp.'s Redding, Calif., hospital, who faces a federal investigation of allegations that he performed unnecessary procedures, is suspending his practice because he is losing his medical malpractice insurance. Tenet Cardiac Doctor to Suspend Practice LA Times January 29, 2003
June 2003 Medical board's accusations
The California Medical Board has accused a doctor, suspected of performing unnecessary surgeries, of insurance fraud, gross negligence, dishonest or corrupt acts and incompetence, a board official said Thursday. Ex-Tenet Doctor Faces Hearing on Alleged Fraud, Misconduct LA Times June 6, 2003
Jul 2003 Moon steps down
The former director of cardiology at 188-bed Redding (Calif.) Medical Center has agreed to a temporary suspension of his medical license pending the outcome of a federal probe into his practice.
--------------------------------
Moon stepped down as Redding's cardiology director and suspended his medical practice earlier this year because he couldn't obtain malpractice insurance coverage. Doc in Calif. probe accepts license suspension Modern Healthcare July 3, 2003
Not surprisingly lawyers saw the opportunities for litigation and were soon advertising their services. Large numbers of past patients were soon lodging law suits. Some lawyers now have up to 500 patients on their books. Other lawyers representing shareholders took action against Tenet and its CEO claiming that the company was or should have been aware of what was happening and the consequences.
Nov 2002 Law suits filed
On Friday, in Redding, three more people filed lawsuits against Tenet, Redding Medical Center and the two doctors, Chae Hyun Moon and Fidel Realyvasquez Jr. All three plaintiffs claimed fraud, and one blamed the death of a 74-year-old man, Cecil Josefsson, on an allegedly unnecessary coronary bypass surgery performed this year at Redding Medical. The suit was filed by the man's son, Peter Josefsson, who, through his lawyer, declined to comment. Shares of Tenet Fall on Cuts in Ratings LA Times November 9, 2002
Nov 2002 Lawyers looking for cases
Lawyers are running ads in the local paper and on television, trolling for victims. One local firm says it will file more than 100 suits all by itself. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Dec 2002 Law firms information
Defendants actually knew that the quality of Tenet's profits were inflated by, among other things, wrongfully inducing patients into undergoing unnecessary and invasive surgeries. Tenet's key profit center was and is Redding Medical Center ("RMC"), a 238-bed, general hospital located at 1100 Butte Street, Redding, California 96001. Defendants knowingly or in conscious disregard for the truth engaged in a scheme to cause patients to undergo unnecessary invasive coronary procedures.
-----------------------------
Interviews conducted by the two Redding doctors with patients and/or other physicians revealed that many of the surgery patients were falsely told by Dr. Moon that they suffered from a serious heart malady and that they would soon die without surgical intervention. Tenet healthcare KMSlaw.com December 2002
Unconscious people in an unconscious hospital in an unconscious company in an unconscious marketplace in an unconscious country in an unconscious civilization?
My view is that in Tenet, its hospital, and
its doctors we are looking at one of the most extreme examples of the
disconnectedness from reality which the Canadian John Ralston Saul
describes so well in his Massey lectures published as "The
Unconscious Civilisation". It is a world distanced from reality by
abstractions. The meaning systems have become more important and
vital for the lives of those in the system than the reality which the
abstract meaning systems fail to represent. Because they are not
attached to reality they can be readily changed to accommodate the
immediate needs of those who need to use them.
Abstractions are of course the way we humans grasp reality. Without
them we would not be human. For us they are more important than
reality because we cannot exist as humans without them. As I have
argued elsewhere we have no choice but to live our lives and we must
have abstract meaning systems to do so. There is no other way. When
there are barriers to the process of living our lives we will develop
unreal abstractions which enable us to do so. We will doggedly defend
them regardless of their tenuous links to reality.
No abstraction perfectly represents reality and ideally abstractions
change to accommodate more closely to reality. The farther the
abstraction is from reality, the more we have to employ closed minded
or one eyed strategies to shield out the contradictions.
Ultimately the conflict between reality becomes so great that actions
become too harmful for society and it all implodes. For NME this
first happened in 1991. As in 2002 they were like stunned mullet.
They had set up a solid barrier between themselves and the real world
out there in the hospitals. They were totally impervious to what was
happening. They accepted every possible explanation except the real
one. They saw it as a media beat up. Instead of visiting the
hospitals to see what was happening when they flew to Texas they went
straight to public relations firms - then went home to their comfort
zone in California! Three months later there had been no changes in
the hospitals.
The imperative for those in the company to hold on to and live out
these abstractions was not removed by the criminal pleas. They
responded by feeling that they had been victimised. This was perhaps
the only way these people could protect themselves and live out their
lives and so realise their ambitions. There was perhaps no other way
for them. The abstractions endured, then flourished and finally it
all imploded again in 2002.
Redding hospital represents the last cog in the corporate chain. The
hospital administrators and the doctors are the unconscious
individuals whose unconsciousness builds the culture and ultimately
our civilisation. It is one of the unconscious subcultures which
makes up this bubbling unconscious civilisation which Saul describes
so well. Like the marketplace this unconscious civilisation then
props up leaders blinded by their abstractions but I am not going to
start on that!
In the confused and struggling people in this hospital we should see
ourselves. In imposing their certainties and protecting them they are
responding and behaving as we all do in our lives.
Technologically mankind took a giant step through space and
technology barriers in the 20th century. Perhaps there is
an even greater barrier to step through in the 21st -
ourselves.
to
contents
I will fill in the gaps with my own understanding of what I think
probably happened.
Redding hospital in a relative backwater is the product of Tenet's
market policy and its partnership (marriage) with consenting doctors.
It is the real consequence of the abstractions. If we believe
something to be real, however false it is, then it is real in its
consequences. If those abstractions which create the baby do not
approximate reality then the real baby which is born is likely to be
a grotesque monster.
Redding was proof of Tenet's revival and its success. Here was a
hospital where Tenet's policy of generating profits by targeting
sicker patients, complex cases and partnering with doctors to provide
more services was proven. It was widely recognised as a centre of
excellence for heart disease and Tenet poured more and more money
into it. Tenet was about to double the hospitals size when the
scandal broke.
Redding seems to be a small city, not the sort of place where you
would expect to find a high level specialist hospital. That it became
one was because of the marketing skills of its administrators and the
personality of its doctors.
It is a reincarnation of some of NME's psychiatric hospitals in the
late 1980's and early 1990's. In evidence to the US house of
Representatives hearing "The Profits of Misery" in April 1992 Mr Lou
Parisi, a fraud investigator from New Jersey gave
evidence. (4.2)
He indicated that a situation had
developed where " some hospitals and substance abuse centres can
achieve a reputation for professionalism and a high level of patient
care and that reputation is only a facade" He could have been talking
about Redding.
This hospital and its administrators were intensely proud of what
they had accomplished. They had followed Tenet's policies to the
letter, buying in the latest equipment, attracting doctors who would
use it heavily, marketing their facilities to the public and reaping
the financial benefits of all their effort with high pricing and
outlier payments.
Their success spoke for the quality of the service they were
providing. They and the doctors they supported enjoyed stature in the
hospital, in the company and in the community. It would have been
obvious that other doctors who complained about the doctors were
simply jealous of their success and the support given to
cardiology.
The hospital's marketing seems to have been little different to that
used in the
1990's scandal (3).
The reports suggest that it was designed to create anxiety and
encourage patients to come for cardiac screening, a new industry with
great potential. The risk was that in the market enthusiasm and the
eagerness of the doctors to meet the "demand" large numbers of
anxious people would be treated for something they did not have. This
happened in 1990 and the allegations suggest that it happened again
in 2002.
Aug 2003 Hospital feted Moon
In turn, Redding did all it could to keep its heart specialists happy. The hospital began an advertising campaign, with mailings and billboards that used tombstones and other images invoking death to persuade Redding residents to be checked for heart disease. It paid nurses to dictate charts for Dr. Moon, who colleagues and former administrators said made little time for record keeping. It sponsored golf tournaments to promote the heart institute, and sometimes offered Dr. Moon use of its helicopter to fly to the golf course, administrators and doctors said. How One Hospital Benefited on Questionable Operations New York Times (KURT EICHENWALD) August 12, 2003
There is a marked similarity in the way these
doctors emerged and the way the market selects and fosters
dysfunctional people and personalities
as leaders. In much the same way Tenet at least seems to select and
foster doctors with similar characteristics. They are not mainstream
members of the profession and the hospital is not interested in their
qualifications or abilities. They would probably have been
nonentities in a critical university hospital. Tenet is interested in
their marketplace performance. It is interested in their patients and
the money they bring in. It will help and encourage those who produce
these goodies for them.
The situation in Redding is a consequence of Tenet's policy of
partnership with doctors - doctors who are able one way or another to
identify with its values and norms. They might well have difficulty
in finding skilled and well qualified doctors who will do so. These
would have no need of Tenet's assistance to build their lives and
would not go along with Tenet's practices. That one of the doctors is
not a qualified cardiologist, not even a qualified internist would
not concern Tenet's businessmen. They are doctors and they are the
source of patients. If they bring a profit they must be good. This is
the way they thought in 1990 and they still do. Many businessmen are
self made men and perhaps critical of academia and academic
institutions. In the 1990's Tenet/NME fired people because they were
"too
clinical". Could medical critics have
been denigrated as "too academic"?
The second doctor is a board registered cardiac surgeon but does not
seem to be widely recognised as a leader by his own profession.
Tenet turns these doctors into leading experts widely admired and
trusted by the community. This is done by marketing. Success in
bringing in and treating patients is evidence enough of expertise and
standing. What is more they all identify with the illusion they have
created. Little wonder that they defend it and reject any suggestion
that all is not what it seems.
There is a report which indicates that a complaint of unnecessary
surgery was made against one of these doctors in 1992. A complaint
like this would normally alarm everyone in a hospital. This does not
seem to have rung any bells with this hospital or caused it to take
note of all the red flags a few years later.
The many press reports tell the story far better than I
can.
Dec 2002 Not properly certified
Dr. Moon is the Director of Cardiology at RMC. Dr. Moon is neither board-certified in cardiology nor in internal medicine. Dr. Realyvasquez is the Chairman of the Cardiac Surgery Program at RMC. Dr. Realyvasquez is a board-certified cardio-thoracic surgeon. Dr. Realyvasquez is one of only two known cardiac thoracic surgeons at RMC. The other RMC cardiac thoracic surgeon is a junior associate of Dr. Realyvasquez. Tenet healthcare KMSlaw.com December 2002
Nov 2002 Volume of work
According to the Redding Medical Center's Web site, the hospital performs about 200 heart catheterizations a month and 700 open-heart surgeries annually. Residents of Redding said the hospital frequently advertises its California Heart Institute as a highly rated center with low morbidity rates. Heart Patient Sues Tenet, Physician :: Lawsuit follows public disclosure of FBI probe. Hospital chain executives try to reassure investors and analysts as shares sink. LA Times November 2, 2002
Nov 2002 Complaints go back 10 years
Complaints against Tenet doctor date back a decade. The San Francisco Chronicle reports on a 1992 complaint to the California state Medical Board over unnecessary heart surgery performed by one of the Redding Medical Center doctors now under investigation. SEIU web site Saturday, November 16, 2002:
Nov 2002 Tenet promises to audit other hospitals
Tenet added that the company plans to extend its internal review to other hospitals that have a high volume of specialized services, such as cardiology and neurology. The company has been pursuing a strategy to build up these programs, and some analysts have questioned whether that may have fostered a culture of aggressively treating patients at Redding and other hospitals. By handling more critical and complicated cases, Tenet has received an unusually large share of special Medicare reimbursements, which also have come under scrutiny. Priest's Heart 'Trauma' Triggers Tenet Probe :: Consultant will review allegations. Firm also will investigate. LA Times November 5, 2002
Nov 2002 Hospital an integral part of Redding town
But in the last decade, the town became a magnet for a different kind of visitor. Patients from as far away as Sacramento, the Oregon border and eastern Nevada have descended on Redding, drawn by Redding Medical Center's growing reputation as a leading center for heart surgery.
In 1993, the 238-bed hospital, owned by Tenet Healthcare Corp., embarked on an ambitious plan to build a heart institute. Two years later, a five-story medical wing rose up in the center of town, intensifying a rivalry with Redding's other hospital, Mercy Medical Center, and setting up what would become an economic boon for Tenet but also for the town.
The two hospitals "are a real key component of the economy here," said Doug Latimer, Shasta County's chief administrative officer.
But now, Redding Medical has put an unwanted glare on this town of 88,000 on the Sacramento River, which appears deeply divided about the hospital and the two doctors who built up its cardiac practice and now are being investigated for allegedly performing numerous unnecessary procedures and surgeries.
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Today, Redding Medical Center is a thriving medical center with a strong local marketing campaign replete with billboards, advertisements and even a "put a little love in your heart" campaign in 2001. At the entrance, patients and visitors are greeted with free peppermints and chilled bottled water. A Yamaha player piano plays softly in the background in the lobby, where the private and soundproofed patient consultation rooms are located.
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Just about everyone in town seems to know someone or is related to someone who was operated on by Moon or Realyvasquez. Redding's Spotlight Turned Into an Unwanted Glare :: Town is divided over investigation into doctors LA Times November 6, 2002
Nov 2002 An aggressive screening program
For all the advances in technology, cardiac care can still be as much art as science. Redding Medical was home to the best machines and receptive to the latest ideas. To his admirers, and there are still many here, Moon saw further and knew more. He prevented heart attacks, extending the life and health of many patients.
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In this former logging community turned vacation jump-off point, Moon is a more personal matter. The Redding Medical Center draws patients from the entire northern half of the state, and Moon is its star. Everyone, it seems, knows someone who's been a patient or who works for the hospital. It's the most dominant building downtown, except for the jail, and was going to get even bigger. Before the events of the last two weeks, the 238-bed center was to double in size.
In a search for more business, Redding Medical recently mailed out fliers that showed a trim woman with a basketful of healthful groceries.
"After grocery shopping, a few errands and one load of laundry, a 42-year-old woman collapsed of a heart attack," the flier warns. "And you thought heart disease was just a man's problem."
The "lifestyle risk factors" listed are very broad, including "increasing age."
Such an approach can save lives, but it's also ripe for abuse. When does aggressive prevention cross over into unnecessary operations? It's a question many of Moon's former patients are being forced to ask themselves. Some are emerging with their faith intact. Some are uncertain what to think. And some are filing lawsuits. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
The press reports give a fascinating insight
into the doctors and their lives. We can see here the doctor
equivalent of Richard
Scrushy, Andrew
Turner and perhaps Richard
Eamer. There are some gaps and I will
fill these with hypotheses - describing the sort of people and the
sort of behaviour which I have seen myself so it is possible. I may
well be wrong. I am trying to show how and why situations like this
arise because I don't believe this is isolated. There may be other
better explanations which fill the gaps in the press reports.
to
contents
It is I think relevant that the cardiologist
and possibly the surgeon were not educated in the USA. In some
developing countries 30-40 years ago education was primarily by rote
learning. This is a cultural problem and in fairness this has
improved enormously over the last 40 years. I have called this the
"form" of learning rather than its substance. It does not equip
students for success in the Western world.
These students do not learn to think, understand or challenge so are
unable to handle the vast quantities of knowledge which they acquire
- however erudite and impressive they seem. They can accumulate a
long list of degrees. Good medical practice depends much more on
knowing how to use knowledge than on having it, and on knowing when
you don't have the knowledge yourself. Medicine carried on without
understanding simply results in the outward "form" of medicine rather
than its "substance". It looks very impressive to everyone except
those with real understanding. It is disaster prone.
It is like the child who can't yet write but who scribbles a letter
to its mother. The child believes that it is writing a letter and
unless you can read and write yourself you might think so too. The
child knows what writing a letter looks like and how to make marks
with the pencil. It acts out the process and believes that this is
what it is doing. It does not yet possess the abstractions which
enable it to understand the nature of writing.
I have had experience with postgraduate doctors in training who have
had a university training like this. Lovely people they may be but
there is very little you can do to help them. Even doctors who have
had this background in their schooling remain deficient. I have seen
it in doctors who subsequently got their medical degrees at the best
of United Kingdom universities and hospitals. I have struggled to
confront and challenge this in foreign students at our university and
it has been traumatic for them. I have seen this in successful
doctors in private practice, but these are doctors who have also
isolated themselves from criticisms by their peers.
All of us have strengths and weaknesses. These doctors need a niche
working with others where they can realise strengths but be protected
from their weaknesses. The lost art of management is not about
creating ever bigger incentives but in recognising and understanding
people. It comes through organising the system so that people and the
system can together realise their potential through strengths while
protecting the system from weaknesses.
We know that the cardiologist obtained his education and basic
medical training in Korea in the period 30-50 years ago and he may
have received the sort of education I have described. The surgeon
very probably had some of his schooling in Mexico but his medical
training was in the USA.
Nov 2002 Moon's background
Moon, 55, was born in Seoul, the son of an orthopedic surgeon and a volunteer for the Korean Red Cross. He studied medicine at Yonsei University, one of the preeminent schools in the country.
His goal was to be a surgeon like his father, he told the Redding Record Searchlight in a lengthy interview in 1994, but back trouble made it impossible to stay on his feet for hours at a time in the operating room. After coming to the U.S. in 1972, he decided to specialize in heart disease, the leading cause of death. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Aug 2003 His religion
The son of a family practitioner, Dr. Moon told associates that his decision to become a doctor had been dictated to him by God when he was a boy.
How One Hospital Benefited on Questionable Operations New York Times (KURT EICHENWALD) August 12, 2003
Both doctors received their specialist
training in the USA. In the cardiologist's case his training was in
two different centres and it seems that he never properly completed
this. He was never board certified in internal medicine or in
cardiology. He then flitted through several other posts before ending
up in Redding.
It would be very interesting to find out more about this doctor's
training and what his mentors really thought of him. I would
hypothesise that he was assertive, confident and resentful of
criticism. He went his own way. He would have been a skilled
technician, much more so than his seniors and would have used this to
boost his ego and counter criticism from his mentors whom he probably
considered inept.
His failure to complete his training and become board certified may
have been because of their failure to support him. He then flitted
about for a bit. This may have been his choice, because he did not
fit in, or because those who trained him would not support him in his
ambition to be a cardiologist. Tenet did - perhaps they saw his
potential in the marketplace. Instructions
to NME staff (5.5)
interviewing potential employees in the 1980's were headed "Look for
a Shark". These might have been current at this time.
One of the problems created by our present system is that the right
of individuals is supreme and they are protected from wrongful
dismissal. They must commit a series of frightful bloopers to earn
dismissal and when trainees are properly supervised this is
prevented. They have the right to appeal a decision to terminate
their training. Specialists in charge of training cannot remove
trainees from the program because they think the trainees personality
is likely to lead to problems for patients in the future. Some of us
have tried to find other reasons to do so in people like this. The
second problem is that we are sometimes wrong in our assessment.
There seems little doubt that these two doctors were skilled
technically and that their results were good. They should have been
excellent if, as alleged they were operating on healthy people with
no disease.
Nov 2002 His training
Moon trained in New York, moved to Cleveland and then made a rapid transit of Orange County, working in seven hospitals in little over a year. In 1979, he arrived in Redding, which he said reminded him of Korea: clear skies, mountains, quiet. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Tenet would have inherited NME's practices.
NME targeted doctors who already had or who were likely to develop
big practices and formed partnerships with them. They spent large
sums of money supplying the latest and best equipment for them to
use. They then turned them into overnight experts sending them on
lecture tours and marketing their expertise.
Would they have done so if these people were conservative doctors who
were more selective than their peers in carrying out invasive
procedures? I suspect they would have pushed out these doctors
(called economic credentialing) and brought in the others. This is
illustrated by the events in a Tenet hospital in St Louis in 2000
described
on another page.
The problem I see is that some doctors accepted this imposed
expertise uncritically and then hid behind the credibility and
authority which this sometimes illusionary expertise gave them.
To maintain this illusion audit, peer review and other quality
assurance processes, which hospitals boasted of in their marketing
were present in a form that satisfied accreditation requirements but
lacked substance. This certainly happened in the earlier 1990
scandal. In practice some corporations have stacked these processes
with team players and used them to isolate non-team players and drive
out often prickly square cornered whistle blowers and critics.
Critics can be classified by administration as "disruptive doctors"
and be dealt with as such.
to
contents
Here is a man burning with ambition, which he
himself admits dates from his childhood. He has a childhood image of
the successful and beneficent doctor which he wants to be and of
being recognised as such. He is ambitious and driven. He is dedicated
and by dedicated I mean that he is committed to helping others and
preventing disease. He is not a crook in the sense that we normally
use this word.
He is driven to succeed but his problems prevent him from achieving
among his peers. He is clearly a superb technician but his cardiology
peers do not rate his other skills highly. In fact if the allegations
have substance he is clearly very deficient and lacks insight. In
Redding he can escape from his peers and build his life and his
reputation. His patients, nurses, and some peers will reflect back to
him the image which he projects and which he assumes. He is like the
child writing to its mother. He is gods gift to the administrators
who boost his image and the illusion he demands by marketing his
skills across the region.
Supremely confident he seizes on new technology and the hospital
assists in implementing its use. He becomes a leader in introducing
this. He is active in the community promoting health care and talking
about cardiology and technology in public lectures, perhaps arranged
by the hospital.
He builds his ego and soon he can do nothing wrong. He is driven and
hard working and presents himself in this way. He earns the
admiration of staff and patients alike. He identifies fully with this
image of himself. His opinion soon becomes unchallengeable. Others
are fools and incompetents. He builds a large following of devoted
patients. That his own judgments and understandings are flawed and
that he is seeing disease where there is none never occurs to him. He
is justified in charging maximum rates for his expertise.
Moon's credibility and his expertise are his life - his very essence.
In a typical closed minded manner he aggressively attacks and
denigrates anyone who questions his status or challenges his ego. He
takes legal action against his critics and when he loses challenges
their competency.
His financial success and status enables him to play out his role as
a successful and gracious philanthropic pillar of society. He relates
well, indulges his hobbies and other skills and goes to lengths to
help the people around him. In this he mirrors Richard
Scrushy in a smaller way.
Over 40 years ago I went into practice in a smaller city where there
were some doctors who had some many of these characteristics. They
were worshipped by their patients and highly regarded in the
community, but distrusted by worried specialist peers. Some practices
like Tenet mushroomed then self-destructed and we were left to tidy
up the problems they left behind. These problems in doctors have now
been recognised and in Australia the profession has become much more
cohesive in creating a professional environment where this sort of
behaviour is better controlled.
Competition policies and pressures seek to break this professional
cohesion, and focus doctors' perceptions on what their patients and
the market thinks of them. This is probably more so in the USA. This
is not to suggest that either the costs of medicine or the views of
patients are irrelevant. These after all are the people we serve.
What is missing is perspective and balance. Safety ultimately depends
on the integrity of peers and not on patients, although their
concerns and actions lead to the exposure of failings in
this.
Nov 2002 Moon the man
Chae Hyun Moon might have wanted to be a doctor since he was a little boy, but his staunchest supporters agree with his sharpest critics: He missed the class on bedside manners.
--------------------------------
So many patients, so little time for chitchat. In his 23 years as a cardiologist here, Moon has worked on as many as 35,000 people. On some days, he would perform 10 catheterizations, where a thin tube is inserted to open clogged arteries or obtain diagnostic information. Another doctor would consider it a full day's work to do three.
For a long time, Moon had the respect, if not love, of his patients at Redding Medical Center. Twelve days ago, that image abruptly darkened when the FBI filed an affidavit detailing an investigation of Moon and the center's chairman of cardiac surgery, Fidel Realyvasquez. The affidavit outlines a conspiracy to commit health-care fraud by allegedly billing Medicare for unnecessary procedures. Forty agents raided the doctors' offices, carting away boxes of patient records.
-------------------------
"This is a horror story, at best," said Gary Oxley, a nurse who works with Moon and believes the allegations are untrue.
Moon, who has told colleagues that everything he did was in the best interests of his patients, did not respond to requests for an interview at the hospital, his office or house here. But conversations with colleagues and former and current patients as well as a review of court documents describe an assertive, often arrogant doctor, one who couldn't be bothered with pleasantries, hobbies or critics. For better or worse, his patients have been his life.
----------------------------------
To his admirers, and there are still many here, Moon saw further and knew more. He prevented heart attacks, extending the life and health of many patients.
--------------------------------
Such an approach can save lives, but it's also ripe for abuse. When does aggressive prevention cross over into unnecessary operations? It's a question many of Moon's former patients are being forced to ask themselves. Some are emerging with their faith intact. Some are uncertain what to think. And some are filing lawsuits.
---------------------------------
High Self-Esteem
When Moon plays golf, he does it on Sunday morning. By 10 a.m., he's at the hospital, still in his golf clothes, bragging about how well he played or joking about a missed shot.
"He's a workaholic day and night-- He can be there in five minutes at 3 in the morning," said Robert Hansen, an anesthesiologist. "I don't think he knows how to take a vacation. If I were him, I would have burnt out a long time ago."
------------------------------
He and his wife, Sun, raised two boys and a girl here, all now grown. Moon contributed to the symphony and funded a high school science scholarship. But mostly he worked.
His self-esteem never seems to have been low, but over the years it blossomed.
"How dare you get a second opinion," an "enraged" Moon is quoted in a wrongful-death lawsuit filed Friday as saying to a 74-year-old patient with no prior history of heart disease. "I built this heart program!"
Moon also has clashed with the other hospital in town, Mercy Medical, suing it in December 1997 for violating federal anti-trust statutes. In September 1999 the suit was dismissed, but Moon continued to rag on the competition a few blocks away.
"Those boys at Mercy don't even know" what the latest heart technology is, he is quoted telling one patient in the FBI affidavit. "They have an 8% mortality rate; we have 2%."
------------------------------
"He has a terrible, terrible personality," said Betty Cook, who now believes that Moon's insertion of a stent to widen her husband Lee's artery was unnecessary. "He doesn't talk like you and I are talking. He shouts and yells and demands."
---------------------------------
"They were doing the work-up on me when I started having pains. Dr. Moon walked in. He wasn't even supposed to be there that day. He came in and said, 'This man is having a heart attack,' " Martinez said. "I was lucky he wasn't out buying shoes like he intended to do that day."
----------------------------------
The FBI affidavit speculates that at least half of Redding Medical's patients really did need surgery, and another quarter fell into a gray area of having a minor amount of heart disease. As for the rest, "there existed no indication of any heart disease that would warrant surgical intervention of any kind."
That means thousands of patients are wondering about their own cases. One of them is Larry Clifford, an electrical engineer who saw Moon because of his tendency to fall asleep at odd times.
"I felt I was in good hands," Clifford said. "He was very arrogant, always saying, 'I'm the best.' He said he was one of the best cardiologists in the United States. He had a pretty bad beside manner, but that was OK. Zing-zing and he's gone."
Clifford ended up having a five-way bypass. "When I was leaving there, they convinced me I was a ... lucky person that they happened to find this. And maybe that's the case. But I don't know."
------------------------------
Moon's abstract canvases are the most unusual thing about him, colleagues say; such a contemplative activity doesn't seem to fit in with his type-A personality. But Moon's interest in art is long-held. His sister, his parents-in-law and other relatives are artists. He recently sponsored an art show here, one friend said. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Nov 2002 First in with new technology but ? without training
In 1991, for example, Moon is said to have been the first doctor in Redding, and one of the first in Northern California, to use a cold laser treatment for unclogging blocked arteries. His apparent eagerness to be one of the first to master state-of-the-art heart surgery tools dovetailed with the plans of Redding Medical and Tenet to establish the facility as one of the premier heart hospitals in the nation.
Every breakthrough development and Moon's place in being among the first to use it were chronicled in Redding's hometown newspaper. On parallel tracks, Tenet's ambitious expansion of Redding Medical Center continued apace with the creation of the heart institute in 1993, the five-story medical wing in 1995, and an addition in 2002 that expanded the hospital by nearly two-thirds in size.
------------------------------------
Moon, born in Seoul in 1947, has lived in Redding since 1979. He has been very active in the community, giving free lectures on medical care and cutting-edge technology, endowing a science scholarship for Shasta High School graduates and organizing fund-raisers for the Redding Symphony.
"He's really given back to this community," said Redding resident Betty Prince, 64. Redding's Spotlight Turned Into an Unwanted Glare :: Town is divided over investigation into doctors LA Times November 6, 2002
Dec 2002 More about Moon the man
Moon, 55, is the son of an orthopedic surgeon who practiced in Korea. Moon moved 23 years ago to Redding, a place he considered "an underdeveloped area" where both the incidence and mortality rates for heart attack were high, according to his own account in a video clip on a special Web site launched in the wake of the investigations.
Unlike Realyvasquez, who is board certified in his specialty, Moon is board certified in neither internal medicine nor cardiology. In fact, Moon never completed a post-medical school residency program in any specialty, which is typically needed for certification.
He graduated from New York Medical College, then did a one-year internship at Cleveland Clinic Hospital, according to biographical information provided on the Redding hospital's Web site.
Moon's lack of a specialty credential does not seem to have limited his outspokenness on medical issues, including his own billing practices, which came under federal scrutiny long before the recent controversy erupted.
In an article published in the Redding newspaper in April, Moon called health maintenance organizations "a total scam -- an administrative bonanza." Of a Medicare audit at the time on his claims for reimbursement, he reportedly said, "Why not pat me on the back instead of growling at me? We are not crooks. We are dedicated, proud humanitarians."
Moon's business acumen appears to have paid off. Property records connect the cardiologist to an expansive, rambling estate west of Redding, posted with "No Trespassing" signs. A nurse at the hospital said Moon's wife, Sun, is an artist and the couple have two teenage children.
-------------------------------
Moon has been known to donate money on the spur of the moment.
Debbie O'Riley, a critical care nurse who has worked at Redding Medical Center since 1988, recalled that when a hospital housekeeper won a car but couldn't afford to pay taxes on the vehicle, Moon gave her the money.
O'Riley said Moon also paid to send a nurse diagnosed with prostate cancer to Loma Linda University in Southern California.
Every year for the past eight, Moon has donated $5,000 in college scholarship money for Shasta High School graduates interested in science or medicine, said Principal Milan Woollard.
Four years ago, Moon gave the school's art department $10,000 for display boards for art shows. And he has been supportive of the girls' tennis team.
"If a girl's racket needs to be restrung, (the Moons) come get it, take it to a tennis shop and get it done," Woollard said. "At matches, they will show up with an ice chest full of sandwiches and drinks for all the players."
All told, Woollard said, the Moons have given "$50,000, plus incidental things along the way. That is unusual for one family to provide that kind of financial support."
For Woollard, his school is not the only important beneficiary of Moon's presence. His own father, 74-year-old Keith Woollard, sees Moon for cardiac troubles.
Some patients consider the doctors arrogant, saying that they balk when patients ask for second opinions, and that they do not always inform patients that procedures have benefits, risks and alternatives.
"Three-hundred and twenty-five people have contacted this office," said Redding personal injury attorney Robert Simpson, who has filed several lawsuits against the doctors on behalf of patients. "Not one of them has said the doctors explained (the procedure) to them or told them to get a second opinion."
Of the two, Moon is most often criticized for a poor bedside manner. Several patients -- including some of Moon's defenders -- said he delivers his diagnoses in terse outbursts that frighten them.
Simpson, himself a Moon patient, said when Moon looked at the results of a diagnostic heart catheterization, he turned to his nurse and said, "Look at this ----. This ----is terrible."
Simpson said Moon then turned to him and said, "Sorry, young man. Bypass. Now. You were going to have a heart attack."
Other patients, however, turn even that tendency into a strength.
He doesn't "talk about small talk with you," said 75-year-old Louella Swayze, who moved to Redding from Citrus Heights to be closer to Moon after he performed her angioplasty in 1996. "I'd rather have a doctor that got down to business." Beleaguered doctors are heroes to many The Sacramento Bee December 1, 2002
Nov 2002 Moon's response
When Moon first saw it (enormous banner signed by vast number of his supporters), one witness said, he broke down in tears, sobbing uncontrollably, saying he couldn't believe what was happening. Two colleagues had to hold him. Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Aug 2003 Moon and the rival Mercy hospital
In that year, Medicare records show, he billed for 876 catheterizations for the left side of the heart, at least four times the number performed by any of his colleagues in Northern California.
---------------------
Across town, Redding's chief rival, Mercy Medical Center, also took admissions from Dr. Moon. But the staff there was far less impressed with him.
-----------------------
Staff members in Mercy's catheterization lab complained to the hospital's medical division, saying that Dr. Moon's care had fallen below appropriate standards.
According to court records, the staff members said that Dr. Moon left the hospital while the patient was unstable, leaving nurses without clear instructions. A review of the medical chart found no indication that Dr. Moon had taken basic preparatory steps to ensure that Mr. Brown was well enough for the procedure, according to written findings of the medical division.
As a result, the medical division ruled that Dr. Moon would have to be monitored by another doctor.
---------------------------
Dr. Moon struck back, announcing in an advertisement in the local newspaper that he would no longer admit patients to Mercy. He then sued the hospital, claiming defamation and financial harm. The suit was later dismissed.
How One Hospital Benefited on Questionable Operations New York Times (KURT EICHENWALD) August 12, 2003
July 2005 Moon and his patients
Five other patients recounted similar stories. They said Moon or another doctor insisted they risked imminent death without open-heart surgery and got defensive if the diagnosis was questioned.
---------------------------
Looking back, Frank (a patient), now 48, remembers Moon as arrogant. "He told me I was fortunate to have him and no other cardiologist would be able to spot the problem," Frank said.
CHRONIC CONDITION The Waste in Medicare Spending: At California Hospital, Red Flags and an FBI Raid: State Regulators Cited Concerns but Say They Couldn't Force Change by GM Gaul The Washington Post July 25, 2005
We know much less about the surgeon. He was
properly trained and clearly technically skilled and so earned the
regard of colleagues. Why he ended up in Redding is not clear.
In some areas like cardiac surgery, the work up and skills in
diagnosis are concentrated in the hands of cardiologists who are more
skilled in this. The surgeons are more likely to act as skilled
technicians. In this they differ from other surgeons who do most of
their own diagnostic work up and decide when to operate. It is
obvious that this surgeon accepted the cardiologists diagnoses and
carried out the procedures he advised.
He would certainly have been capable of critically examining the
images generated by the cardiologist but did not do so. He would have
been under very considerable pressure from the cardiologist and the
administration had he tried to do so. It seems likely therefore that
he established the patterns of his practice along the lines of least
resistance and chose not to see what he did not want to see.
My own experience offers some sort of an explanation. I encountered a
very similar situation within a few weeks of entering private
practice in a small city comparable to Redding. There was a system of
government contracts with doctors which paid lower rates in return
for guaranteed referrals. There were economic pressures to
over-service but under-provide and to cut costs. It attracted some of
the dregs of the profession.
As the new surgeon in town I was asked to do a two week locum for a
surgeon who held a contract with the police and railways to provide
services to staff. The radiology was provided by a large credible
group of radiologists under a similar contract. The films provided by
the radiologists were minimal and were not adequate for diagnosis -
cost cutting.
My often very tentative clinical diagnosis were always reflected back
positively in the radiologists report. Had I wished to look the other
way I could have congratulated myself on my clinical skill and done a
lot of unnecessary but profitable surgery.
It would have been very difficult for the original surgeon to have
taken on this group and challenged them. The radiologists were
politically linked to the administration which would not have
supported him. He would have lost the contract, and most of his
practice as his reputation would have been questioned in the process.
I have little doubt that he took the soft option and treated on the
basis of the diagnoses he was given. He left town for other reasons
soon after. I like to think that his successor did better.
There is another possible explanation here. In my own experience of a
Tenet/NME hospital I noted that the specialists never intruded into
the domain of another specialty. It was, I felt part of the wall put
around each specialist to shield his or her ego. They did not
question the opinions of other specialists or criticise their views.
Critical interaction between specialists would not have been good for
business. It would have challenged the omnipotence of the
specialists. Their body language may have revealed doubt to the
patients and undermined their credibility among staff. Credibility is
the key to corporate success and fostering confident experts may well
be part of the Tenet culture. Challenging the cardiologist's
expertise may simply have been the sort of thing which a professional
person did not do - not as they understood it in this
hospital.
Nov 2002 The surgeon and the Redding community
Realyvasquez, born in La Union, Mexico, in 1948, did not move to the Redding area until 1990, but he more quietly established the similar tradition of community involvement, most notably donating 50 original Ansel Adams prints to Redding's new Turtle Bay Museum.
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"These doctors have done a tremendous amount of good, but they have also done a tremendous amount of unnecessary surgery," Barr said. "When they weren't busy doing surgeries that needed to be done, they were busy with surgeries they didn't need to do." Redding's Spotlight Turned Into an Unwanted Glare :: Town is divided over investigation into doctors LA Times November 6, 2002
Dec 2002 Realyvasquez public face
Realyvasquez, 54, and originally from Mexico, came to the medical center in 1987 from Mercy General Medical Center in Sacramento. He heads the cardiovascular surgery department at the 238-bed Redding hospital.
According to a brief profile on the hospital's Web site, he received his medical education and specialty training at UC Davis, UCLA and Stanford.
Realyvasquez is a "nationally acclaimed cardiovascular surgeon," and "well-known as one of the top surgeons in his field," the Rottman Group, Inc., a recruiting firm, claimed in an advertisement for a job opening in the heart surgery department.
The online ad stated that Realyvasquez pioneered new procedures and instrumentation, and that Redding Medical Center "supports these endeavors wholeheartedly." One of those procedures is the "beating heart" bypass operation, which -- unlike traditional bypass -- does not require a heart-lung machine.
The two doctors are renowned for their huge volume of heart procedures, including catheterizations, angioplasties and open-heart surgeries. But while that volume is a matter of suspicion in the federal probe, it has long been a matter of boasting for both physicians.
A Web site for Realyvasquez's surgery group in Redding says the group has performed "over 8,700 cardiac surgical interventions ... since 1987. We are very proud of our statistics and you will be too!" Beleaguered doctors are heroes to many The Sacramento Bee December 1, 2002
Dec 2002 Realyvasquez life style
Realyvasquez lives east of town, on an equally grand stretch in Palo Cedro, an older community with a growing reputation as a residential haven for successful doctors.
There, a tree-shaded lane lined with mailboxes abruptly ends in electronic gates anchored to terra cotta pillars. A touch pad on a matching column keeps the uninvited from entering the Realyvasquez property.
The two doctors have shared their wealth with their adopted community, too.
Realyvasquez recently donated his collection of 50 original Ansel Adams prints to Turtle Bay Exploration Park, the local museum complex.
"He's not just a collector, he's a collector who cares a great deal about this community," museum President Judy Lalouche told the Redding newspaper in May. Beleaguered doctors are heroes to many The Sacramento Bee December 1, 2002
The effect on Redding and the staff in the
hospital was not dissimilar to the impact
we saw in Birmingham when the scandal
surrounding Richard Scrushy broke. The community polarised. Worried
past patients rushed to their lawyers. Loyal patients rallied behind
the doctors. The community formed groups to support them refusing to
believe the allegations. Hospital staff also refused to believe. They
defended the doctors and offered explanations. Those who had raised
the issues kept their heads down.
Inevitably when something like this blows open some get the wrong end
of the stick and exaggerate, distort and fail to tell the whole
story. Insiders use this to help themselves draw together against the
accusations - even when they have doubts themselves.
Nov 2002 Other doctors support Moon
He (Dr. Shishir Dhruva, an anesthesiologist at Redding Medical Center) added that the higher number of coronary procedures reflects Redding Medical's early adoption of new technology. Redding's Spotlight Turned Into an Unwanted Glare :: Town is divided over investigation into doctors LA Times November 6, 2002
Nov 2002 Community support
The faithful have had no trouble making their feelings known on an immense banner outside the hospital's catheter lab.
"We Support Our Doctors," it proclaims. By Saturday, there was no space left to add comments. Some were grammatically suspect, but the meaning was always clear. "Dr. Moon your great." "Thank you for saving the life of my father-in-law and my wife." "Your #1." "Keep the faith. This too shall pass." "I trust you. You saved me." Mixed Views of Doctor at Heart of FBI Probe LA Times November 11, 2002
Dec 2002 Community support
In Redding and in small towns many miles from this Northern California city's boundaries, the medical prowess of Drs. Chae Hyun Moon and Fidel Realyvasquez Jr. verges on the legendary.
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But in the tight-knit Shasta County community, the two are heroes to many who say they have benefited from the doctors' life-saving medicine or financial generosity -- or both.
The doctors' community involvement, through donations of art, scholarship funds and even tennis team money, has contributed to a groundswell of support: a candlelight vigil within days of the raid; a jubilant celebration on the courthouse steps after a judge refused to strip them of their medical licenses.
From the hospital's chief of staff to the Superior Court judge who ruled in their favor, it seems that nearly everyone in town knows, or is related to, a patient of one doctor or the other.
And, in the weeks since the FBI's Oct. 30 raid of the doctors' offices, supporters have flooded the local newspaper with letters heralding their integrity and commitment.
"How lucky we have been that Dr. Moon chose this country to practice in," wrote Old Shasta resident Jennifer Cutili in a letter to the Redding Record Searchlight.
Moon and Realyvasquez together form the backbone of the burgeoning California Heart Institute at Redding Medical Center, a program that the hospital and its owner Tenet Healthcare Corp. tout as nationally recognized, and which has made millions for the company.
Lawyers for the doctors would not grant interviews with their clients for this story, but much can be gleaned elsewhere, from conversations with co-workers and patients and from Internet postings by Redding Medical Center and other organizations. Beleaguered doctors are heroes to many The Sacramento Bee December 1, 2002
When we pull all this together we see a human
tragedy which is perhaps not dissimilar in some ways to what happened
in Bristol in the UK. The situation is different but the human
behaviour is similar. I find it difficult to believe that these
doctors deliberately set out to deceive and misuse patients, or that
these hospital administrators did so. Their responses ring too true
and are all too human. Even though the allegations have not been
proven it is difficult to believe that these things did not happen.
Their lives have been ripped apart and destroyed and I feel they are
all in a sense victims too - victims of the market system and Tenet's
policies.
But their suffering is less than the
suffering of relatives whose loved ones died needlessly and all of
the patients who had needless procedures. There are vast numbers of
victims and we have so far looked only at one hospital. Given Tenet's
policies this is likely to be only the tip of the iceberg. While
Redding hospital may be the most glaring example the possibility that
similar but perhaps less confronting things have happened across the
Tenet empire and perhaps in other corporate hospitals must be quite
high.
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It is difficult to conceive of anything that
could so seriously undermine the health system. This is a system
where people are vulnerable and exploitable. It can only work for the
community when citizens are trusting and the system is trustworthy.
Trust in the system and in the medical profession has been breeched
in an appalling fashion. It will take years to rebuilt and may never
be the same again.
The lesson most will take from this will be
"Buyer Beware". This is unfortunate because there are other more
important lessons for us all whether doctors or citizens.
Could it be that the way these doctors behaved is the way so many of
us behave in our lives when circumstances challenge our drive for
status and recognition. Does this happen in the profession wide of
corporate medicine; and in the community in other areas? How many of
us have not done this in a little way? - or perhaps just a bit more
than that!
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Undoubtedly we will have a witch hunt and a
number of people will be crucified. There will be fines, perhaps
prison sentences, faces will change and there will be a plethora of
integrity agreements. We do need to hold up people who do these
things to public condemnation and ridicule. It re-emphasises to the
community that this sort of behaviour is abhorrent and will not be
tolerated. If this is all that happens then we will soon be back to
business as usual and it will happen again.
Corporate response is likely to follow that in the past, denial, then
reluctant acknowledgment selecting scapegoats and promising reform.
Incentives are the key to success and also the process through which
patients are exploited. In the last scandal Tenet/NME promised to
link this to quality but instead of doing so linked it to patient
satisfaction. The fallacy of this is well illustrated in the Redding
debacle.
1993
He (Eamer, NME's founder and CEO) has linked incentive pay - - - to factors such as patient satisfaction instead of merely to profits - - - . Abiding Suspicion Wall Street Journal January 8 1993
What NME did not want in 1990, and Tenet does
not want now is a united and cohesive integrated medical profession
working independently together in its hospitals and critically
examining all of its business decisions and practices. - particularly
a profession supported by an organisation of peers which is highly
suspicious of its actions and in partnership with the community and
not the hospital. If market medicine is not to be abolished then this
is what is needed to reduce the risks of a re-occurrence.
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An establishment deeply wedded to market
ideology will not challenge the role of the market in health care.
They will do nothing to stop the use of incentives or the emphasis on
market forces and competition as a driving force for health care. No
one will take health away from the share market.
Surely the community should now take back the
health system from the share market and from politicians who have
betrayed their trust. They should run it as a cooperative integrated
primarily not for profit system. The corporate health care
marketplace has not worked and we must accept this.
The whole community should be challenging this health care ideology
and re-applying well established frames of understanding which see
health care as a beneficent service provided in the community by the
community and oriented to care of the community rather than to
profit.
The profession might try to rebuild professional cohesion,
cooperation, and integrity developing an integrated system. Its
members might work together cooperating with the community in a
cohesive, supportive, and integrated manner which ensures that
outlier doctors are included and watched.
These might be some starting points.
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The page above was written as part of the the page "Tenet Healthcare and its Doctors" in July 2003. In 2007 I moved the material to a separate page. The text is almost completely unchanged and reflects my assessment at that time. I have found no reason to revise it. I have added three or four additional press extracts from subsequent articles. These have thrown further light on what happened.
The saga continued to unfold and work itself out over the next few years. A host of investigations followed. Court actions were settled during 2006 and Tenet was forced to sell the hospital which is now called "Shasta Regional Medical Center."
These matters are recorded and documented with further insights into what happened on another page written in 2007. It is a continuation of the Redding hospital story.
Tenet Healthcare's Redding Hospital
Unnecessary Cardiac Procedures II
Second 2007 web page
top
of page Web Page
History
This material written July 2003 by
Michael
Wynne
Put into a separate page with minor adjustments in
July 2007
