Book Review - Coronary by Stephen Klaidman

Throughout the 1990s, doctors on the staff of a hospital in Redding, California routinely performed unnecessary angiograms and coronary artery bypass grafts (CABGs) on unsuspecting patients. Dr. Chae Hyun Moon, a chain-smoking, foul-mouth- ed cardiologist, performed the unnecessary angiograms and told patients with healthy coronary arteries they needed immediate surgery. Dr. Felix Realyvasquez performed the bulk of the unnecessary CABGs without looking at the angiograms that allegedly justified them. The hospital where this happened was Redding Medical Center (RMC), which was owned by Tenet Healthcare Corporation, a for-profit 115-hospital chain with an unsavory past. 

In his new book, Coronary: A True Story of Medicine Gone Awry, former New York Times and Washington Post reporter Stephen Klaid- man describes in excruciating detail the human suffering caused by Drs. Moon and Realyvasquez and how the physicians were busted. 

Zona Martin, for example, was a 78-year-old grandmother who, prior to her unnecessary triple bypass, “enjoyed an active social life” and “had often driven her friends to bingo at the church.” But during the unnecessary surgery by Realyvasquez, the plaque in one of her coronary arteries was jarred loose, traveled to her brain, and she subsequently suffered two strokes. She lay in a coma for a month after her surgery. When she recovered consciousness, she was nearly blind in one eye, she slurred her words, she needed assistance to do the simplest tasks, and her mental acuity was so diminished she couldn’t remember simple things like telling her daughter when she needed to go to the bathroom. 

Thirty-six-year-old Paul Alexan- dre was another victim who suffered severe side effects from his unnecessary CABG. The wire that was supposed to hold his sternum together after it was sawed apart broke (apparently because Alexandre made a living doing strenuous labor which put pressure on his sternum) and the sternum never healed despite three subsequent operations. 

The abuse of patients came to the public’s attention in October 2002 when 40 FBI agents raided RMC. Sad to say, neither the doctors nor anyone at Tenet has been prosecuted for criminal acts against RMC patients. But the bad guys did pay out large sums of money to avoid prosecution. The doctors forked over millions to government agencies and plaintiffs, suspended their practices (at least in California), were prohibited from billing Medicare again, and suffered great public embarrassment. Tenet paid out a billion dollars and sold RMC. 

Klaidman’s riveting account of the scam perpetrated by the doctors and Tenet, and how it was uncovered by a few persistent whistle-blowers and the FBI, is a useful antidote to the ridiculous argument that competition works in the health-care industry and can be relied on to solve the health care crisis. According to the insurance industry and its allies, health- care is not the sort of service (like electricity or national defense) that requires government ownership or regulation, but resembles, rather, simpler commodities for which “market forces” work reasonably well at setting prices and maintaining quality. Dog food, believe it or not, is one of the commodities to which market buffs have compared health care. Coronary documents what all of us with common sense know: “market forces” are incapable of policing medical quality. 

For a market to be competitive, several conditions must be met. One is that buyers must be able to understand the price and quality of what they’re buying. Although Klaidman does not say this, his description of how easy it was for RMC’s doctors to victimize patients and how hard it was for patients to convince authorities they were being victimized, illustrates how difficult it is for patients —the “buyers” in the heart surgery “market”—to know when they’re being harmed, much less discern differences in the price and quality of cardiovascular services. 

The FBI might never have investigated the strange happenings at RMC’s vaunted California Heart Institute (the name RMC gave its cardiology and heart surgery departments) if a Catholic priest named John Corapi, whom Moon misled into thinking he needed surgery, had not been persuaded by a friend to have the surgery done in Las Vegas rather than at RMC. Corapi’s friend did not at first doubt that Corapi needed surgery. He questioned, rather, whether a relatively small hospital in rural California could outperform the larger hospitals in Las Vegas. 

When Corapi showed his angio- gram to two heart specialists in Las Vegas, they told him he had no sign of heart disease. Corapi was still so doubtful that the famous Dr. Moon would have lied to him that he sought opinions from two more Las Vegas doctors. They told him the same thing—he did not need surgery. 

Corapi’s initial inability to shake loose from the influence of Moon’s terrifying verdict on his heart (Moon had told him while he was still lying on the table where the angiogram had been performed, “I’m sorry; there is nothing I can do for you. You need a triple bypass tomorrow morning”), and his need for reassurance from four other physicians, illustrate how difficult it can be for buyers of medical care to know the value of what they’re getting. Corapi was no dummy and he was not easily intimidated. He made a good living delivering lectures all over the country decrying what he perceived to be the gradual adulteration of Catholicism by modern culture. If Moon could have fooled someone like Corapi, it is reasonable to conclude he could have fooled even the smartest, most aggressive “shoppers” for angio- graphy and CABG surgery. 

Conservatives and insurance industry officials claim to have an answer to the problem of medical care’s great complexity. That problem, they say, can be remedied by “report cards” on all the players in the health care sector—insurance companies, hospitals, clinics, individual doctors, and other providers of health care. Report cards will make insurers and health care providers “transparent” to the public, they say, and enable purchasers of insurance and medical care to “shop” more intelligently and thereby hold insurers and providers “accountable.” Because the logic of this fantasy is the same as that behind George W. Bush’s No Child Left Behind report cards on schools, I refer to the medical report card fantasy as No Patient Left Behind. 

There are numerous problems with this fantasy. The most intractable of these problems, at least for services more complex than flu shots, is the extraordinary difficulty of grading the quality of medical care accurately. The hospital report cards on heart surgery that were available in the 1990s and early 2000s perfectly illustrate the problem: they failed to warn the public about the shoddy care RMC was providing its heart patients. 

In fact, some of them led the public to think RMC’s services were superior. The most commonly used measures of quality in those report cards were (and still are) the number of heart surgeries done by a hospital or doctor, and mortality rate within 30 days of surgery. In RMC’s case, both measures misled the public. 

The number of surgeries performed at a hospital is a common measure of CABG surgery quality because several studies have found a rough negative correlation between the number of CABG procedures a hospital or surgeon does and the mortality rate. That is, the more surgeries a hospital performs, the lower the mortality rate usually is. But, of course, in RMC’s case, the high volume of CABGs masked the terrible problem that the high volume was being caused by Moon’s practice of declaring healthy people to be in need of surgery. This practice not only created high CABG volume for RMC, it also artificially lowered RMC’s mortality rate. 

At least three of the more prominent report cards available in the late 1990s and early 2000s gave RMC’s heart surgery department satisfactory or superlative grades at a time when RMC was performing hundreds of unnecessary angiograms and CABGs annually. “HealthGrades, a nationwide online rating service, consistently ranked RMC’s heart program among the best in the United States,” reported Klaidman. Solucient, another U.S. corporation making money off the report card craze, listed RMC as one of the 100 top cardiovascular hospitals in 1999. 

The most publicized heart surgery report card in California, the California Report on Coronary Artery Bypass Graft Surgery, started in the mid-1990s by a group of Fortune 500 companies that calls itself the Pacific Business Group on Health (PBGH), did not explicitly label RMC’s heart program as superior, but it was nevertheless very misleading. Its report card for 2000-2002, for example, reported that RMC did an astounding 2,098 CABGs during that period. That placed RMC, a relatively small hospital, number 4 among the 77 California hospitals that reported their CABG data to PBGH. The PBGH report card also stated that RMC’s mortality rate was 1.6 percent for 2000-2002 compared with the national rate of 2.9 percent and a rate of 2.7 percent for the 77 participating California hospitals. 

Tenet and RMC eagerly exploited these misleading report cards. For example, in a press release dated October 9, 2002 (21 days before the FBI raid would give the lie to RMC’s boasts), RMC stated: “Redding Medical Center was ranked by Health- Grades, a national healthcare quality solutions company, as the top-ranked hospital for cardiac care in far Northern California, and earned a five-star rating, putting RMC in the top five percent of hospitals nationwide for cardiac care.” 

What RMC’s patients needed was not more report cards (a topic Klaidman does not discuss), but more aggressive enforcement of the laws and regulations already on the books (a topic Klaidman does touch on). It was clear to anyone who looked at the data that RMC was doing angio- graphy and CABG surgery at very high rates years before Father Corapi filed his complaint with the FBI. Because Medicare was paying such a large portion of RMC’s bills (Medicare is the largest source of revenue for most U.S. hospitals), it was the government agency with the clearest window into RMC’s operations. It was almost certainly the agency with the greatest clout over RMC. 

Although Medicare initiated an investigation of RMC years before the FBI got involved, the investigation was too slow and timid to be of any use to RMC’s patients. This was uncharacteristic of Medicare. Since the early years of the first Clinton administration, Medicare has had a reputation among doctors for being too aggressive at sniffing out fraud. I would like to have seen Klaidman examine why Medicare failed to expose Moon and Realyvasquez before Father Corapi did. 

Kip Sullivan writes frequently about health policy.