Monday, May 28, 2018
Health

Little is clear-cut on HCA's high rates of lucrative heart procedures

HCA hospitals are among Florida's most prolific when it comes to performing two common — and lucrative — heart procedures, state records show.

The nation's largest for-profit hospital chain performed 22 percent more angioplasties and 41 percent more catheterizations per bed than the average hospital in the state, according to 2011 data, the most recent available from Florida's Agency for Health Care Administration.

That translates into big bucks for HCA. Though medication can sometimes be as effective as invasive procedures, catheterizations and angioplasties are relatively minor surgeries with high profit margin.

The state data, reported by individual hospitals, may reflect nothing more than HCA's reputation for cardiac medicine, which has made the chain a preferred stop for many heart patients.

But this month, HCA revealed that the U.S. attorney's office in Miami has launched an investigation into the medical necessity of cardiac procedures at 10 of its hospitals, including several in Florida.

HCA's disclosure of the federal investigation coincided with an Aug. 7 New York Times story detailing a series of internal reviews the company has conducted over the past decade that found overutilization of heart procedures at some of its Florida hospitals.

In 2004, nine cardiologists at HCA's Regional Medical Center Bayonet Point were temporarily suspended after an outside evaluator criticized their practices. At the time, the hospital in Hudson was doing more angioplasties — inserting stents to open clogged arteries — than all but two other, much larger, Florida hospitals.

And, according to the New York Times, after a nurse complained in 2010 about unnecessary heart procedures at HCA's Fort Pierce hospital, an internal review found that about half of its catheterizations — a diagnostic procedure in which a catheter is threaded into the heart — were done on patients without significant heart disease.

In response to the New York Times story, officials at the Nashville-based HCA said that experts often disagree on when a patient should get a stent. They also noted that their hospitals are performing fewer of the procedures than in years past.

But insurance billing records indicate the procedures continue to be popular with Florida's for-profit hospitals and particularly HCA. State data show that for-profit hospitals as a group do nearly 50 percent more catheterizations and one-third more angioplasties than nonprofit hospitals on a per-bed basis.

HCA, which accounts for about half the state's for-profit hospitals reporting invasive cardiac procedures, performed them at even higher rates than their peers, doing 11 percent more catheterizations and 2 percent more angioplasties on average than other for-profit hospitals in Florida.

Dr. Larry Feinman, chief medical officer for HCA in west Florida, said the hospitals see more Medicare patients than other hospitals and "we believe the reputation of our heart services attracts many patients."

Experts say it's natural to see some hospitals doing large numbers of the procedures.

Profit margins are high and heart disease patients are plentiful, noted Jay Wolfson, professor of public health and medicine at the University of South Florida.

"But institutions or individuals occasionally take advantage of the marketplace and wind up pushing clinical necessity and appropriateness because they can," he said.

The result, Wolfson said, is not just excessive cost to the system but unnecessary risk to patients.

Figuring out which procedures are unnecessary, however, is tricky, Wolfson and other experts say.

Hospitals that heavily advertise their heart units — as many HCA hospitals do — attract more chronic cardiac patients than general hospitals. Indeed, the highest number of heart catheterizations per bed and second-highest number of angioplasties in the state took place not at an HCA hospital but at Florida Hospital Zephyrhills, a small nonprofit facility with the only cardiac unit in a 25 mile radius.

Experts also warn that it's impossible to second-guess a physician's decision to intervene without reviewing a patient's medical charts and films. The suspended doctors at Bayonet Point, for instance, all had their suspensions overturned when another panel of doctors found the procedures were within clinical guidelines. Cardiologists usually look for at least 70 percent blockage in an artery before inserting a stent.

Jeremiah Brown, an assistant professor of health policy at the Dartmouth Institute in New Hampshire, said over-reliance on these heart procedures can be driven by something as simple as patient preference. Patients who could solve their problem over time with medication, diet and exercise may prefer to get immediate relief with a stent.

"There's a potential for overtreatment, but whether it's being driven by cardiologists or patient preferences becomes a very muddy point," Brown said.

Kris Hundley can be reached at 727-892-2996 or [email protected]

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