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A Small Indiana Town Scarred by a Trusted Doctor

The New York Times The New York Times 17/10/2015 By JULIE CRESWELL
Debra Davidson learned from the local TV news in Indiana that her heart doctor was being sued by two former patients, accusing him of performing unnecessary operations. Now she is one of 293 patients around Munster who have filed such suits. © Joshua Lott for The New York Times Debra Davidson learned from the local TV news in Indiana that her heart doctor was being sued by two former patients, accusing him of performing unnecessary operations. Now she is one of 293 patients around Munster who have filed such suits.

On a spring evening last year, Debra Davidson flipped on the television to watch the local news. When an item came on about her longtime physician, she perked up and leaned forward. Then she screamed. Her husband rushed into the living room to see if everything was O.K.

Everything was not O.K. The report said that her cardiologist, Dr. Arvind Gandhi, had been sued by two former patients who accused him of performing unnecessary operations.

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Mrs. Davidson had been treated by Dr. Gandhi for more than three decades. She first saw him for an irregular heartbeat when she was 27. For years, she took the medication he prescribed. When Dr. Gandhi said she needed open-heart surgery in 2011, she scheduled it immediately. When he subsequently inserted mesh stents three times to remove blockages from her arteries, she never questioned the procedures.

Only last year did she resist one of Dr. Gandhi’s recommendations: to implant a pacemaker. Instead, he inserted a heart monitor under her skin but asked her to reconsider her resistance to a pacemaker.

Mrs. Davidson is now one of 293 patients around Munster, Ind., who have filed lawsuits against Dr. Gandhi and two other doctors in his practice claiming that they performed needless procedures.

The Indiana state Medicaid program has started an investigation, and one doctor not named in the litigation said he had received a subpoena from the United States attorney’s office and provided the medical charts of several former patients of Dr. Gandhi and his colleagues that he has since treated. Lawyers for Dr. Gandhi and his practice, Cardiology Associates of Northwest Indiana, said they had not received any subpoenas, and the doctors denied any wrongdoing.

In recent years, federal officials have brought several prominent cases against cardiologists and hospitals, accusing them of performing unnecessary procedures like inserting stents into coronary arteries. While medical professionals say there is no indication that cardiology has more unnecessary procedures than, say, orthopedics, they do note that the specialty has come under increased scrutiny by regulators because the procedures tend to be reimbursed by Medicare and private insurance at significantly higher levels than those in many other specialties.

“Cardiology, whether we like it or not, is generally a big moneymaker for hospitals,” said Dr. Steven Nissen, chief of cardiovascular medicine at the Cleveland Clinic and the former president of the American College of Cardiology. “We are still a fee-for-service system, and that creates, in my view, misaligned incentives among some physicians to do more procedures and among some institutions, particularly in areas where there is not tight medical supervision, to turn a blind eye and enjoy the high revenue stream.”

While there are various industry and federal guidelines describing when it is appropriate for a patient to undergo certain procedures — Medicare, for instance, says a patient’s arteries must be 70 percent blocked to justify the use of a stent — in the real world, interpretations vary. In extreme cases, physicians have been accused of falsifying medical records, saying arteries were more blocked than they really were.

Last year, a hospital system in eastern Kentucky paid nearly $41 million to settle allegations, without admitting wrongdoing, that it billed for unnecessary coronary stents and catheterizations after a group of area doctors falsified patient records to justify the procedures. The hospital system, Ashland Hospital Corporation, faces 120 private lawsuits from patients who claim they underwent unnecessary procedures.

At Community Hospital in Munster, Ind., Dr. Gandhi was a star. For decades, he ran a prominent practice in the bedroom suburb of 23,000 people about 30 miles southeast of Chicago. He and his partners not only ran the most popular cardiology practice in Munster but were also the highest-paid heart doctors in the state in terms of Medicare reimbursements, records show.

The lawsuits against him have divided the town’s medical community, with some doctors finding themselves in the unusual position of speaking against a fellow doctor, working with the medical malpractice lawyers who are their usual foes.

Besides the doctors, the malpractice lawsuits also name Community Hospital, through the foundation that oversees its operations, as a defendant. Dr. Gandhi was a high-ranking member of the medical staff at the hospital, and the lawsuits charge that the superfluous procedures were done “with the authority and consent” of Community Hospital, one of the largest and most respected institutions in Munster. Lawyers for the hospital deny any wrongdoing.

Some doctors said there had been repeated warnings over the years about Dr. Gandhi’s practice, but those concerns were largely ignored.

When Dr. Mark Dixon, then the medical director of Community Hospital’s electrophysiology lab, where defibrillators were implanted, raised concerns to a hospital executive in 2005 about whether Dr. Gandhi and other physicians were qualified to implant the devices, he said he was shut down.

“The response to me was, ‘I understand your concern, but we have a very large producer here who wants the privilege,’ ” Dr. Dixon said last year in a deposition in a lawsuit. He said he was later told to stop reviewing implants performed at the hospital by the nurse manager of the lab. Dr. Dixon did not return calls seeking comment.

In an email responding to questions, the hospital said Dr. Dixon was never told that Dr. Gandhi was a large revenue generator whose practice was too lucrative to curb, nor was he told to stop reviewing the implants.

Lawyers for Dr. Gandhi, his practice and the hospital, say the lawsuits are without merit. The legal actions, they say, are being driven by envious physicians eager to take patients from Dr. Gandhi and by greedy lawyers seeking a big settlement.

“The physicians at Cardiology Associates have exemplary records as outstanding cardiologists and leaders in their field,” the lawyers said in a statement.

Last fall, Dr. Gandhi retired.

Dr. Arvind Gandhi moved to Munster in 1981 after completing a cardiology fellowship in Chicago. In more than 30 years of practice in the area, he gained a reputation for an attentive but efficient bedside manner. He did not lack for confidence. His mantra was “I saved your life,” several former patients said.

“He was supposed to be the best cardiologist in the area,” said Phil Probus, 86, a retired railroad worker and World War II veteran. In 2013, Mr. Probus had a defibrillator implanted by Dr. Gandhi that a paid consultant later told him was unnecessary, and he is now one of the plaintiffs. “I never questioned anything he did.”

Medicare reimbursement records show that Dr. Gandhi and his partners, Dr. Wail Asfour and Dr. Satyaprakash Makam, received nearly $5 million in combined Medicare payments in 2012, making them the three most reimbursed cardiologists in Indiana. How much they earned from treating patients who had private insurance is not in the public record.

The partners invested in real estate, including luxury apartments in Chicago, and a local restaurant. Dr. Makam was often seen driving around Munster in a blue Porsche with the license plate “Tick Doc.”

“It was a nice car,” said David Wiening, a retired road construction inspector and patient of Dr. Makam’s who is a plaintiff. Over five years, Dr. Makam performed 24 procedures on Mr. Wiening’s legs. Pulling up his pant legs, Mr. Wiening shows off his “ugly walking sticks,” two legs that are bloated and hairless, covered in parts with small lesions. A vascular surgeon paid by the plaintiffs’ lawyers in the case told Mr. Wiening he did not need many of the procedures performed on him.

When asked why the three highest-billing Medicare cardiologists in the state would be found in the same town and the same practice, lawyers for Cardiology Associates of Northwest Indiana said the population in the area was older and sicker than in larger Indiana cities.

Munster’s population is older than those of Indianapolis and Fort Wayne. But David Malenka, a professor of Medicine at the Dartmouth Institute for Health Policy and Clinical Practice, said an examination done at the request of a reporter by researchers of inpatient and outpatient claims for defibrillator implants, adjusted for age, sex and race, showed that Munster’s rate per capita was in the top 10 percent for the country for 2010, 2011 and 2012. The region showed up with some of Indiana’s highest rates per capita for cardiac catheterizations and coronary angioplasties, procedures that, in many cases, can be elective.

When investigators at the Dartmouth Institute studied rates per capita for procedures that must be treated — a hip fracture, for instance — Munster was below average in the state.

“What that says is that for procedures that are more discretionary, they are at the top,” Dr. Malenka said.

Community Hospital, a nonprofit institution, benefited immensely from the flourishing cardiology practice. As at other hospitals, heart procedures are one of its leading revenue engines, according to the 2012 tax filings for the foundation that oversees the hospital.

The foundation that oversaw Community and two other, smaller local hospitals was controlled by one of Munster’s most prominent families. Until his death in April at the age of 95, Donald S. Powers, a local real estate developer, was the foundation’s chief executive. For years, Dr. Gandhi was one of Mr. Powers’s personal cardiologists and treated him after a heart attack. “Dr. Gandhi controlled his medications, did testing and performed several procedures on Mr. Powers,” the hospital said in a statement.

The Powers family still oversees the foundation, the Community Foundation of Northwest Indiana. Mr. Powers’s daughter, Frankie Fesko, is the foundation’s chairwoman, and his grandson, Donald P. Fesko, is the chief executive of Community Hospital in Munster. The hospital declined to make any of its executives or members of the Fesko family available for this article. While one of the foundations, doing business as Community Hospital, is named in the malpractice litigation, no members of the Fesko family have been accused of any wrongdoing in the lawsuits.

A whistle-blower lawsuit brought by a physician and a hospital employee against the hospital, Dr. Gandhi and his practice in 2008 raised similar accusations that the hospital had billed for unnecessary defibrillator and pacemaker implantations that were performed by doctors without the proper credentials to implant the devices.

But the suit, eventually joined by the United States attorney’s office in Hammond, Ind., just north of Munster, was settled without anyone admitting wrongdoing. The hospital paid a $48,942 settlement.

The hospital and the doctors say that the settlement shows that the issues have been investigated and that they have been absolved of many of the same allegations contained in the current malpractice suits.

A little more than a decade ago regulators expanded approval for a combination pacemaker-defibrillator device that, overnight, practically made pacemakers obsolete. Since then, there has been a growing battle over the qualifications necessary to implant the device, which is connected with electrodes to the heart and can send electrical pulses to restore a normal heart rhythm.

A study published in 2009 showed about 71 percent of the new defibrillators were implanted by electrophysiologists — cardiologists who have received specific training in the rhythms of the heart. But, like other hospitals, Community Hospital allowed its medical staff to set credentialing requirements, and it allowed doctors who were not electrophysiologists to implant the devices.

“It’s quite questionable to have complex electrophysiology procedures being done by people who are not formally trained,” said Dr. Nissen, who said he was not aware of the particulars in Munster.

In 2005, after Dr. Gandhi had obtained privileges to implant combination pacemaker-defibrillators, Dr. Mark Dixon, then the director of the electrophysiology program at Community, reviewed some of Dr. Gandhi’s cases. He found several cases in which the patient’s indications, or test readings, did not meet national guidelines for necessity, according to a deposition Dr. Dixon provided last fall for one of the patient lawsuits.

Dr. Dixon said he reported Dr. Gandhi to the hospital’s quality assurance committee. That committee, according to the hospital, had been set up to improve documentation, but not to question whether procedures were necessary. In its statement, the hospital said Dr. Dixon never brought any complaints regarding Dr. Gandhi’s quality of care or appropriateness of implants to the quality committee’s attention. “None of the records were being reviewed for medical necessity of the implant,” the hospital said.

Sitting in the corner of a Starbucks near Community Hospital, Dr. Scott Kaufman nervously sipped a Frappuccino. An electrophysiologist, Dr. Kaufman had concerns about Dr. Gandhi dating back more than seven years when he encountered Gloria Sargent in an emergency room of a nearby hospital. Ms. Sargent was in rough shape, vomiting and with a sustained rapid heart rate.

In late 2006, Dr. Gandhi upgraded Ms. Sargent’s pacemaker-defibrillator device from a more basic one implanted by another doctor just a few months earlier.

Dr. Kaufman turned off the device’s pacing, which sends an electrical shock to the heart to convert it to a normal heartbeat. He studied her electrocardiogram in the emergency room, and it showed she had normal electrical impulses going to her heart’s lower chamber. “She did not qualify for the upgrade and all of the surgeries she went through,” Dr. Kaufman asserted.

Ms. Sargent became patient zero in the litigation against Dr. Gandhi. Last fall, after the plaintiffs’ lawyers handling her case began holding news conferences and running ads in the local newspaper, former patients of Dr. Gandhi began trickling into Dr. Kaufman’s office. So he began working with a group of medical malpractice lawyers, the same lawyers who had twice sued him. Those cases were settled; the Indiana Medical Review Panel found that Dr. Kaufman had done nothing wrong.

“I’m O.K. with working with these guys,” Dr. Kaufman said. “I just want this to stop.”

Angela Webb, 52, had a pacemaker implanted by one of Dr. Gandhi’s associates when she was in her 40s. A new doctor removed it, and her condition improved markedly. “I was so happy to have it out,” she said. © Joshua Lott for The New York Times Angela Webb, 52, had a pacemaker implanted by one of Dr. Gandhi’s associates when she was in her 40s. A new doctor removed it, and her condition improved markedly. “I was so happy to have it out,” she said.

Dr. Kaufman says that of the 15 former patients of Dr. Gandhi and the Cardiology Associates doctors he has seen, at least 11 did not need the various procedures performed on them. One of those is Angela Webb, 52, who had a pacemaker implanted by one of Dr. Gandhi’s associates when she was in her 40s. After Dr. Kaufman observed her for a few months, he removed it.

“When they took the pacemaker out, they couldn’t understand how I recovered so quickly,” said Ms. Webb, who said she could finally pick up her grandson and have the magnetic resonance imaging tests needed to treat her multiple sclerosis. “I was so happy to have it out.”

Lawyers for Cardiology Associates say Ms. Webb’s lawsuit and others are riddled with errors, including, in her case, pages of accusations against Dr. Gandhi, who was not her physician, and lists of procedures that she did not undergo. When asked how her pacemaker could have been removed without medical problems, they said that in cases where devices had been removed because of infection, the devices did not need to be reimplanted in 25 percent of the cases.

The lawyers also note that Dr. Kaufman and Dr. Dixon work together at a practice owned by another hospital.

It will take years for the lawsuits to wend their way through the legal system. In Indiana, each individual case must first go through a medical review panel, a process that can take more than two years. So far, however, the first two cases heard by the panel of physicians, including Ms. Sargent’s case, found Dr. Gandhi and Cardiology Associates “failed to comply with the appropriate standard of care” and that conduct “was a factor in the patient undergoing unnecessary procedures.” The panel did not find Community Hospital negligent.

Debra Davidson is still searching for answers.

Doctors and medical consultants paid for by the malpractice lawyers have now told her she did not need the many angiograms or stents because her heart had no blockages. When she stopped taking the medication she had been on for decades, she lost 30 pounds and began to feel better, she said.

“But did I need this?” she asked, her hand hovering over the five-inch scar on her breastbone where surgeons entered for her open-heart surgery. Mrs. Davidson was sitting in her kitchen, and one of the lawyers present responded with a sad shrug. A physician who had reviewed her medical charts said it is unclear. It does not appear a stress test was done, which could have indicated whether her heart was getting adequate blood flow and whether the surgery was necessary.

She now has advice for friends and family with medical problems.

“If they have a feeling that they don’t believe what the doctor is doing for them is for the best, don’t do what I did and depend on the doctor,” Mrs. Davidson said. “Get a second opinion.”

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