Doctors who land in hot water with state regulators have a helping hand when it comes to keeping their practices running: the federal government.
At least 216 doctors remained on Medicare rolls in 2015 despite surrendering a license, having one revoked, or being excluded from state-paid health care rolls in the previous five years, a Milwaukee Journal Sentinel/MedPage Today investigation found. In all, these doctors were paid $25.8 million by taxpayers in 2015 alone.
Among them: Glen Marin, a family practice doctor from New York City.
According to New York Department of Health disciplinary records, Marin didn’t contest charges that he was sexually inappropriate with a female patient. In California, as a result, he surrendered his license in 2014 rather than go through a full disciplinary hearing.
He was allowed to keep practicing in New York, but only if he had a chaperone present when he met with female patients.
BAD MEDICINE: Prescription for secrecy
Since 2007, Marin settled at least three separate malpractice cases, including one for failing to diagnose the cancer that eventually killed a patient.
Despite that, taxpayers helped foot the bill for him to practice medicine. In 2015, the year after he surrendered his California license, he was paid more than $280,000 through Medicare.
Other individual doctors who faced serious sanctions were paid as much as $1.4 million that year.
The Journal Sentinel/MedPage Today analysis focused on 2015 because that is the last year for which payment details from the annual $720 billion Medicare program are available.
To identify these cases, reporters from the Journal Sentinel and MedPage Today worked from a list compiled by TruthMD, a Los Angeles-based company that collects information on doctors from state boards, courts and other sources. The news organizations focused on the most serious cases — those in which doctors were stripped of their ability to practice, or barred from state-run health care payments — then compared those names to Medicare payment data to gauge the total cost of looking the other way.
On its website, the U.S. Centers for Medicare and Medicaid Services, which oversees the Medicare program for the elderly and Medicaid program for disabled and low-income residents, pledges to “put patients first.”
But the Journal Sentinel/MedPage Today analysis found a repeated failure on the part of the federal government to connect obvious dots.
Medicare is part of the U.S. Department of Health and Human Services — the same department that operates the National Practitioner Data Bank, which tracks discipline against doctors, including sanctions by state medical boards. Yet connection after connection is missed.
“That’s astonishing to me that HHS allows that to happen,” said Michael Carome, a physician with the watchdog group Public Citizen. “If someone has a pattern of such adverse actions, that ought to be a red flag.”
Attempts to reach Marin were unsuccessful. His profile on the New York Department of Health website shows that he is now retired, but retains hospital credentials. The website says prospective patients can “contact the doctor’s office to see if this doctor is taking new patients.”
The Department of Health and Human Services is required to drop doctors from payment rolls if they are convicted of several specific charges, such as abusing patients, defrauding the system, or are caught improperly prescribing controlled substances.
But there are 16 categories of problems where officials can allow doctors to keep getting payments — including failing to meet basic standards of care or even having a medical license revoked. As a result, while more than 1,500 doctors had licenses suspended, revoked or were put on probation in 2015 by state medical boards, only 305 were prohibited from billing Medicare that year.
George Annas, a professor of health law and bioethics at Boston University, said Medicare officials are enabling bad doctors to continue practicing.
“The last thing you want is Medicare patients to be seeing the worst doctors in the country,” said Annas, who spent six years on the state medical board in Massachusetts. “That’s not right. They should be protecting Medicare patients. That should be their number one job.”
A day’s work, more than a day’s pay
Even when doctors are caught overbilling the Medicare program, they can continue getting money from it.
In 2012, the U.S. Attorney’s office in Colorado accused doctor Steven Spillers of violating Medicare rules by billing for more hours than he actually worked on numerous days — including cases where he billed for more than 24 hours a day.
Spillers performed a service that can be done remotely involving electronically monitoring a patient’s nervous system during surgery. Under Medicare rules in place at the time, a doctor only could bill for monitoring one patient at a time.
“But Dr. Spillers billed Medicare for monitoring multiple patients at one time — in essence, billing each minute of his time double or triple, contrary to the clear rules,” Denver-based U.S. Attorney John Walsh said in a statement issued at the time of the settlement.
On more than 100 days, Spillers billed for more than 24 hours.
As part of the settlement, Spillers was forced to repay $747,000 to the federal government. He was allowed to continue to bill Medicare but was required to have his paperwork monitored by department officials for five years.
Spillers, who has licenses in more than 20 states, received more than $240,000 in Medicare payments in 2013, 2014 and 2015 — the first three years after agreeing to repay the money.
In an interview, Spillers said he agreed to settle the case because prosecutors threatened a $13 million lawsuit and the prospect of banning him from the Medicare program.
He said the rules on billing for multiple cases at one time varied in different parts of the country, with some states allowing for multiple billing — although it is not allowed by Medicare. He also said he was paid by a private company, which handled the billing with Medicare.
“It wasn’t under my control, but the government came after me,” he said.
Todd Echols, an official in the Inspector General’s office who reviews such cases, said regulators can only act in cases where a state takes disciplinary action.
“Clearly, there’s a lot more out there that we can do,” he said.
Echols said the pace of enforcement comes down to one thing: Staffing.
His office oversees a variety of health professionals and outlets beyond doctors — nurses, dentists, therapists, clinics, adult care centers, nursing homes.
The agency has over two dozen staff, including investigators, to cover the whole country. California, which alone has more than 150,000 physicians, is overseen by one investigator.
Critics say if the office doesn’t have the resources to investigate cases, it should go to Congress and get additional funding.
“A bad doctor can harm a lot of patients,” said Carome, the physician with Public Citizen.
The Journal Sentinel and MedPage Today were able to find examples by simply comparing two kinds of information the Health and Human Services department already maintains.
That turns up doctors such as Victoria Gaus, who practices in Florida.
In 2012, the Florida medical board said Gaus had prescribed inappropriate and excessive amounts of controlled substances — opioids and tranquilizers — to five patients. That same year, a $50,000 malpractice claim was submitted to the Florida Office of Insurance Regulation involving a patient who died of an overdose.
In 2013, Gaus agreed to a reprimand, a $20,000 fine, a permanent ban from practicing in a pain management clinic, and a permanent ban from prescribing certain opioid drugs as well as a type of tranquilizer known as benzodiazepines.
She did not lose her license in Florida, but Illinois refused to renew her license based on the Florida action and Pennsylvania indefinitely suspended her license.
In 2015, Medicare paid her a total of $60,000. Gaus could not be reached by phone or email and did not respond to a certified letter.
The review also turned up David Martini, who practices in Maryland.
In 2013, Maryland reprimanded Martini and fined him $5,000 after allegations that he performed back and abdominal liposuction on a woman who died as a result of the procedure. Martini is an ear, nose, and throat doctor who was not trained in plastic surgery on other parts of the body, according to a complaint filed with the Maryland Board of Physicians. The board eventually found that Martini failed to properly supervise a nurse anesthetist and that he violated the law by performing liposuction in his office, which was not an accredited facility.
Based on Maryland’s action, Martini permanently surrendered his licenses in New York and Pennsylvania in 2014.
In 2015, he received $272,000 from Medicare. Martini would not comment for this story.
The review also found Sarkis Aghazarian, a surgeon who also practices in Maryland.
In 2003, Aghazarian was reprimanded by the Maryland Board of Physicians in a case in which he allegedly failed to diagnose and treat a serious infection that led to a man’s death.
In a 2011 malpractice lawsuit, he was accused of the 2008 death of a 70-year-old Maryland man after complications arose following an angioplasty he performed.
In each case, Aghazarian paid settlements of $250,000. The doctor says he did so because it was cheaper than going to trial.
In 2012, a Maryland hospital suspended him for 90 days after complaints that included abusive language, angry and intimidating behavior, and rudeness in the operating room toward staff members and patients — in one case yelling at a woman while she was on the operating table.
In Maryland, the allegations led to a reprimand, two years probation, and a $5,000 fine. Based on Maryland’s case, California took action that led to the surrender of his license there in 2014.
In 2015, Aghazarian was paid $321,000 from Medicare.
In an interview, Aghazarian said Medicare has reviewed his record and allowed him to continue seeing those patients.
“I never mistreated any of my patients,” he said.
He said the allegations that he was abusive and disruptive in the hospital were “pure dirty politics” that came about because he complained about patient safety.
“Rather than fixing the problems, they labeled me as disruptive,” he said. “I was trying to protect patients.”
More protections in the private sector
Private insurance companies spend money to make sure they don’t pay doctors more than needed or support bad medicine, said Leslie Paige, vice president for policy and communications for Citizens Against Government Waste, a nonprofit watchdog group that lobbies for reduced government spending.
Medicare doles out far more money and isn’t even using the data the department already gathers on bad doctors, she said.
“They need to do a better job of tracking these people down and stopping them before they abscond with taxpayer dollars or hurt patients,” Paige said. “Seniors should not be sitting ducks for predators simply because they’re on Medicare.”
Consider the case of James McGuckin, who was the target of a Washington state investigation and an FDA letter into his use of a risky and unproven vein-opening procedure on people with multiple sclerosis. McGuckin was part of an earlier Journal Sentinel/MedPage Today investigation that found states often did not take immediate action against doctors who performed the procedure.
In a statement to an evaluator for an ethics course that was required as part of his Washington state discipline, McGuckin noted that several private insurers had cut ties with him.
But he has not lost his license and is still eligible for payments from the Medicare system. In 2015 alone, he was paid $8.8 million, the Journal Sentinel/MedPage Today analysis found.
According to Echols of the Inspector General’s office, workers managing Medicare payment rolls can be overwhelmed by a flood of information about shady health providers — in part because computers are now involved.
For decades, the process was driven by relationships investigators had with state medical boards. The state boards kept an eye out for cases that fit the criteria for exclusion from the federal system, then passed them along.
Last year, the Inspector General’s office started getting a data feed from the Federation of State Medical Boards. In the first year alone, the group sent more than 2,000 referrals — actions that might lead to a doctor being kicked off Medicare rolls — to investigate.
“We can’t get through 2,000,” Echols said. “There are some actions that we just don’t even have a chance to get to.”
Even if they could, though, under the law they likely wouldn’t be able to take action in the vast majority of those cases.
Some of the situations that require kicking a physician out of Medicare only come into play if the doctor’s behavior impacted a patient on Medicare or Medicaid.
Echols said documents in such cases — whether they be from state medical boards, court filings, or other sources — have to clearly indicate that a doctor’s action affected a patient in one of the two programs.
The problems must also match those in the federal law describing the exclusion process. They have to document issues with “professional competence” or “financial integrity” to result in an exclusion.
“We have seen variation across the country as to when a licensing board will take action,” Echols said. “They know if they put these actions in there, it’s going to hurt (physicians).”
Echols said his investigators pursue cases that demonstrate a doctor is dangerous or fraudulent, not merely incompetent.
Consider Lindsay Brathwaite, a dermatologist in Delaware.
According to medical board filings from Delaware and California, Brathwaite ran an office in Delaware where investigators say health care took a backseat to profit. He didn’t use diagnostic tests or sterilize instruments. His office had open bottles with needles in them and allowed for cross-contamination of blood products.
“Respondent exposed patients to the possibility of contracting hepatitis, AIDS and other blood-borne pathogens,” said a complaint filed by Kimberly Kirchemeyer, executive director of the Medical Board of California, where Brathwaite also had a license.
Two of the three states where he was licensed revoked his privileges in 2015.
That year, Medicare still paid him $100,000 to treat seniors.
He was prevented from receiving money through the program in May 2016.
“We take our time, we’re really careful,” Echols said. “We want to make sure we’re excluding physicians that deserve to be excluded.”
Federal regulators have not excluded Adelfo Pamatmat, a doctor who was part of an elaborate pill mill operating in the Detroit suburbs.
His office, Compassionate Doctors, purported to be a physician’s practice. In actuality, “marketers” paid people to pose as patients, who then received fraudulent prescriptions for controlled substances, mostly opioid painkillers. The drugs were then sold on the streets.
According to federal charges following his 2013 arrest, Pamatmat illegally prescribed 200,000 dosages of oxycodone and 1 million units of hydrocodone. All told, he was behind $4 million in health care fraud between 2009 and 2013.
Pamatmat was arrested in 2013 and barred from Michigan’s federally-funded Medicaid program for low-income patients. While on bond, he was ordered not to prescribe controlled substances.
Federal records show he kept right on doing so. Medicare underwrote prescriptions he gave out for tranquilizers and amphetamines after his arrest.
In 2014, taxpayers paid him $114,000; the next year, $118,000.
Last May, he was sentenced to 19 years in prison and is currently behind bars.
His name still does not appear on the list of doctors barred from Medicare payments.
John Fauber is a reporter for the Milwaukee Journal Sentinel. Matt Wynn is a reporter with MedPage Today.
This story was reported as a joint project of the Journal Sentinel and MedPage Today, which provides a clinical perspective for physicians on breaking medical news at medpagetoday.com.