“Why?”
“Because backroom all sorts of things are going on. Everybody is cutting corners.”
“Kickbacks?” I said, vaguely excited by the turn in the conversation.
“In slang you can say ‘kickbacks,’ but they have some form of contract, paying sham office rent, something. They are not doing anything illegal, but it amounts to the same thing.” He laughed. “See, Sandeep, you are a good person, a good physician, good at heart. But you are naive about private practice.”
Kickbacks in medicine have long been regarded as improper. The Canadian Medical Association has declared that “trafficking in patients,” implied by “secret commissions” for patient referrals, is “entirely unethical.” However, to judge by recent fraud investigations, kickbacks are becoming more common. In 2006 the Tenet Healthcare Corporation, based in Dallas, agreed to pay $21 million to settle a whistle-blower lawsuit asserting that a hospital it owned in San Diego had paid kickbacks for referrals. (Tenet did not admit wrongdoing.) That same year, a New Jersey teaching hospital was investigated for giving sham salaries to community doctors in a reported attempt to increase the number of referrals to its cardiac surgery program. Two cardiologists pleaded guilty to federal fraud charges.
Chaudhry finally picked up the phone. He told the caller he needed a few more minutes.
“I had a relationship with the internist Neha Bansal for two and a half years,” he said to me, sounding more and more like a spurned lover. “Me and your brother were with her uncle in the CCU till two in the morning on Ramadan. I left the mosque in the middle of prayers. Two months later, she kicked me out of her office. Not because her uncle died, no, but because she developed a connection with somebody else.”
He waited for a response, but I said nothing.
“I told her, ‘Send me your patients. I can do a better echo. I will pay you the same rent.’ But still she kicked me out.”
“Why?”
“Probably she thought I am stepping on her toe, advising her to do business with me and not with the other guy. See, Sandeep, society is corrupt. Remember that heart failure patient I sent you? Patricia—I forget her name. She was so sick. I didn’t worry that I am losing one hundred dollars to Sandeep. She got better care from you, so it made me feel good. Saving life, getting patients better, is also a part of medicine. But if you try to explain this to some of these doctors, you will not be able to make a living.”
He stood up and closed the window blinds, blocking out the swath of sunlight cutting across the desk. “Come, let me show you the office,” he said. We walked through the warren, past an alcove where patients in salwar kameez and sneakers were waiting for their exercise stress tests, past three exam rooms and a room with a treadmill, to a procedure room, where nuclear scans were performed. His setup was not unusual for a private cardiologist. Though doctors are prohibited from referring patients to imaging centers in which they have a financial interest, they are allowed to operate that equipment in their offices, where study results are more readily available to them. “We just got this new camera,” he said proudly, pointing to a solid-state instrument about the size of a child’s car seat. The monthly lease, he told me, was $4,500. He broke down the other monthly costs of doing stress tests: treadmill lease, $400; office space, $1,000; technician’s fee, $1,800; nurse’s fee, $1,000; and miscellaneous expenses of $200.
“Now, say I get eight hundred fifty dollars per stress test,” he said. (Reimbursement for these tests has since been cut by almost 50 percent because of an explosion in medical imaging and in an effort to prevent abuses.) “Then I have to do at least ten tests a month just to cover the costs, no profit going into my pocket.”
“So,” I said, “there’s pressure on you to do more than ten stress tests a month, whether the patients need it or not.”
He shrugged and said, “That is what I have to do to break even.”
A monitoring board, he added, had to authorize the procedures. “Nuclear is such an expensive test. A person sitting at the company decides whether you need it or not. They deny you for whatever XYZ garbage reason. If you make one mistake—wrong number on the address, bill not sent on time, preauthorization not taken on time, anything—you get denied. If you don’t resubmit within ninety days, they say time expired. Now, let’s say there are even a couple of denials a month. Multiply that by all the physicians in the plan and you see how much money doctors are not getting paid. We lost so much money the first few months that now we don’t schedule any tests until authorization is obtained and confirmed.”
I asked him who did that.
“A clerk, the office manager, and my wife. And I myself also check.”
We returned to his office. The stacks of folders now seemed even taller. “People complain that we are overtesting,” he said, gesturing at the clutter. “But if a patient comes to your office and asks if she has mitral valve prolapse”—a common abnormality—“what will you do? On physical exam you will never find it, so what will you do? If she goes for a procedure and gets infective endocarditis, your career is over, so what will you do?” I stared at him blankly. He threw up his hands. “You will get an echo, right? She is already asking, ‘Do you think I have mitral valve prolapse?’” He said it mockingly, with affected high-pitched worry. “People are going on the Internet; then they come to your office and say, ‘I have good insurance. I pay my premiums. Why can’t I have this test?’”
I asked him what percentage of echos performed in private practice was necessary for patient care. He thought about it for a moment. “About fifty-fifty,” he finally replied.
“When I started in practice, I really wanted to do the right thing,” he said with a touch of regret. (At that moment he reminded me of Mr. Kurtz in Conrad’s Heart of Darkness.) “A young woman would come in with palpitations. I’d tell her she was fine. But then I realized that she would just go down the street to another physician, and he would order all the tests anyway: echocardiogram, stress test, Holter monitor—stuff she didn’t really need. Then she’d go around and tell her friends what a great doctor—a thorough doctor—the other cardiologist was.” He laughed dolefully, obviously resigned to the culture in which he found himself. “I tried to practice ethical medicine, but it didn’t pay, from both a financial and a reputation standpoint.”
Before leaving the office, I asked him how we were going to divide the outpatient revenue. “My overhead is fifty percent, but because you are Rajiv’s brother, I will say forty percent for you,” he said. “The billing company keeps seven percent. The remaining fifty-three cents, how do you want to distribute?”
“You tell me,” I replied.
“For office visits, how about seventy-thirty for me? When you order echos and nuclears, we will stick with the same number.”
“That’s fine,” I said, just wanting to leave. I quickly calculated. I’d be keeping about fifteen cents of every dollar I earned, but it would still probably be enough to cover the deficit I was running at home.
“Okay, that’s it,” he said, looking pleased. I stood up. He came around the desk and put his hand on my shoulder. “I will send you a contract in the mail. We will see how it goes for a few months. Just remember, we need to keep the business going.” Then he quickly added, “But I will never tell you how to practice in my office.”
PART II
ASPERITY
NINE
Stress Test
“Up till now,” he said, “life has seemed an endless upward slope, with nothing but the distant horizon in view. Now suddenly I seem to have reached the crest of the hill, and there stretching ahead is the downward slope with the end of the road in sight.”
—Elliott Jaques, “Death and the Midlife Crisis,” International Journal of Psychoanalysis, 1965
It took a year to process all the paperwork, but in the fall of 2007 I finally received permission from LIJ to start moonlighting in Amir Chaudhry’s practice. The hospital agreed to extend my existing malpractice policy to cov
er my work at Chaudhry’s office; that meant I didn’t have to purchase new insurance for the moonlighting work (roughly $17,000 a year, prohibitively expensive given the $30,000 or so per year I was expecting to earn). My regular weeks at the hospital were already long—for months I’d been coming home at eight o’clock to a stack of bills and a sleeping three-year-old—and now I was staying up past midnight to read Chaudhry’s echos and working on weekends, too. As Rajiv had predicted, I hated the work—the assembly line of unsuspecting patients, the constant subtle pressure to order nuclear stress tests and other revenue-generating procedures—but I didn’t know what else to do. Our expenses were growing, Sonia was already talking about having another baby, and the moonlighting, if nothing else, quenched any talk of my going into private practice full-time—at least temporarily. The benefits were obvious, but that didn’t make me despise the work any less. It felt as if I were being carried in a canoe down frothing rapids, and any attempt to paddle out of them was in vain.
Saturday mornings now evoked a vague melancholy, nostalgia for a time in my life—perhaps before I got married, certainly before Mohan came along—when things were less settled and I was free to chart my own course. Images from my childhood regularly popped into my head: for example, my father getting ready for work, brushing his teeth, clearing his throat, spitting loudly into the sink. I used to feel so sorry for him, for his regimented life, for his failure to relax the constraints that bound him. And now, how were things any different for me?
There was another recurring vision: Dad running after us with a shoe. He had just received his termination letter from the university, and his patience with our sibling catfighting had come to an end. We were sprinting from the living room to the kitchen, just one step ahead of my father, when Rajiv, who was fourteen, cut me off, allowing my father to grab hold of me. He hit me several times hard on the face, stinging slaps on wet cheeks. I was sobbing hysterically, not from the pain but because I had disappointed him. Rajiv flew out the front door, escaping the brunt of the anger but also waiving any right to the near-tearful apology when my father came to his senses or to my mother’s tortured explanation that my father was under a lot of stress.
Chaudhry had me going to various satellite offices, where I would see up to twenty patients in a morning while reading echocardiograms and supervising exercise stress tests in between. In exercise stress testing, patients typically run on a treadmill, have a radioactive chemical injected into their veins, and then get pictures of their heart taken with a special nuclear camera to determine if there are blockages in the coronary arteries. If there are obstructions causing ischemia—a reduction in blood flow to the heart—there will consequently be less nuclear tracer uptake in certain portions of the exercising muscle, which shows up as a paucity of radioactive signals in pictures of the heart under stress. Stress testing allows doctors to determine a patient’s exertional capacity, evaluate chest pain, and obtain objective evidence of myocardial ischemia. A variety of exercise protocols are available, with graded increases in speed and incline on a treadmill being the most widely used.
Chaudhry had been instructed by LIJ to pay me a fixed hourly wage, regardless of how many patients I saw or tests I performed—apparently to remove any financial incentive for me to order unnecessary procedures—a stipulation to which he readily agreed, as it allowed him to keep even more of the revenue. I’d sometimes wake up thinking he was taking advantage of me. I’d work myself into a lather before the day had even begun. It was a loose thread in the fabric of my mind, but I couldn’t let it go, and the more I tugged on it, the longer it grew. Perhaps this is how Dad felt about Dr. Yermanos, I often thought, the colleague with whom he’d had a long-running and self-destructive feud. But no one wanted to hear my complaints—not Sonia, who was busy preparing for her internal medicine board exams, and least of all Rajiv, who believed he had gambled his friendship to set up the whole thing.
I always felt as if I were selling my soul when I went to Chaudhry’s Queens office, a white-shingled colonial in a middle-class neighborhood dotted with Chinese take-out places and storefronts advertising cheap divorces. Inside the building, grimy green carpeting led down a dilapidated corridor, past thin-walled exam rooms and a closet-size toilet, to the nuclear stress lab, where the radioactive isotopes for heart imaging were stored. (I often worried about what would happen if I waved a Geiger counter in there. Best not to know.) I worked with a spare weekend crew: Denis, an overweight Nigerian nuclear technician; Samantha, a pretty twenty-something West Indian office manager with a perpetually cheery disposition; Ali, a physician’s assistant who had a penchant for telling fictitious stories about women he’d laid; Eva, a young Lithuanian sonographer with bright pink toenails and a prominent serpent tattoo on her lower back; and Malik, an aging Pakistani doctor who ran the treadmill.
The patients we saw often already had cardiologists but inexplicably had been instructed by their primary physicians to stop seeing those doctors and start seeing us. Queens was like a black market, where the currency was referrals and poorly health-literate patients were traded back and forth like commodities. Of course, we were paid for each patient we saw in the office—so-called evaluation and management (E&M) fees—but the primary business objective was to order a procedure. A stress test could get you $800, ten times the average E&M payment. I always made a point to ask patients if they had previously undergone stress testing, and they usually had—about six months before, someplace in Queens—but they had almost always forgotten where, and they almost never knew the results. An electronic medical record would have been very useful. So much testing could have been avoided. (But with already slim margins, no doctor I knew was looking to invest $30,000 in a system that could possibly cut revenue.) However, without electronic charts, the easiest thing—the most practical thing—was to repeat the test.
We did stress tests on at least three-quarters of the patients who came in. There is almost no evidence to recommend stress testing in patients with recent coronary stenting, but Chaudhry’s staff did this routinely. There is no evidence that stress testing for coronary artery disease in intermediate-risk adults without symptoms is beneficial, but this was the bulk of the practice. The more tests you perform in a lower-risk population, the more falsely abnormal results you are going to get, leading to further testing and potentially harmful invasive studies like cardiac catheterization. (This is often referred to as an example of Bayesian probability: a positive test result is more likely to be false as the prevalence of a disease drops in the population being studied.) “Thank you for referring your patient for cardiac catheterization after a positive stress test” read a typical letter from an interventional cardiologist to Dr. Chaudhry. “Cardiac cath revealed normal coronaries and normal left ventricular function. The patient was reassured and discharged home under your care.” It was a self-sustaining machine, and a whole network of doctors benefited from it; it was our lifeblood.
Every office procedure generated a follow-up visit so patients could discuss their results. However, a lot of the time the echos or EKG monitors hadn’t even been read—more often than not you could find insurance documents or preauthorization forms but not the test results you were looking for—so you’d have to scramble to interpret them on the spot or promise a phone call or set up another visit. Once, I asked a patient who’d had a normal stress test if she was still having chest pains, and she told me she didn’t have chest pains—she’d never had chest pains!—even though it was written all over the chart. In residency, if you didn’t want to be bothered to admit a patient with chest pain in the middle of the night when you wanted to sleep, you’d push hard on her ribs and ask if it hurt, and if she said yes, you’d diagnose benign musculoskeletal pain and turn away the admission. In medicine we so often choose to see what we want to see, and Chaudhry’s staff was no different. There were few checks and balances. You could document whatever you wanted. Anything to justify a procedure.
I rationalized my involvemen
t by telling myself that I was carrying out orders, that I myself hadn’t requested the unnecessary tests, that I could limit testing in any new patients I evaluated, and that if I quit, Chaudhry would just get somebody else. Still, I felt tainted. I worried about what my colleagues would say if they knew what I was doing. Did the fact that I had opted to work with Chaudhry mean that I was less upstanding than I gave myself credit for? Or that he was simply more honest about the realities of medicine?
One typical Saturday morning I pulled myself out of bed just after eight o’clock, the hour I was supposed to have arrived at Chaudhry’s office. Lead-footed, I stepped groggily to the bathroom. A morass of cotton filled my head. At the mirror I rubbed the detritus of sleep from my eyes. They were bloodshot.
“Sandeep, where are Mohan’s shin guards?”
I splashed cold water on my face.
“Sandeep! Where are his shin guards?”
I applied a dab of toothpaste.
“Sandeep!”
“I don’t know,” I mumbled.
“He can’t play soccer without them.”
“I don’t know where they are.”
“But you brought him back last time.” I started to brush my teeth. “Where did you put them?” I squinted at my reflection. “Sandeep!”
“I don’t know. He just took them off. You’ll find them.”
“But where!”
By the time I got into my car, it was almost eight-thirty, and I was already a half hour late. Traffic on the Grand Central was light; debris jutted out of dirty snow piles on the side of the road. Speeding to Queens on that lonely stretch of freeway, I felt ashamed about how I had lost my temper with Sonia the previous night. The irritations were accumulating. I was juggling too many different things. Spending so little time with my son was gnawing at me. My obligations were like the concrete embankments along the expressway, preventing me from getting off.
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