Ed note: In the 1970’s I was interviewed by a medical group in Seattle and was told I could become their “thyroid guy!” I was confused because I was note trained in endocrinology, but that made no difference. They’d just purchased a thyroid scanning device and said they could refer their patients to me and that the revenues would be top dollar. I quickly walked away from that offer, but that was my introduction to the problem of financial incentives for procedures, especially when linked to equipment manufacturers. This article in the NYT highlights one of the many areas in medicine where the ethics of the medical-industrial industry have gone awry.
Kelly Hanna, whose leg was amputated in 2020, received at least 18 artery-opening procedures on her legs. She was told they would improve blood flow and prevent amputations.Credit…Cydni Elledge for The New York Times
By Katie Thomas, Jessica Silver-Greenberg and Robert Gebeloff
Kelly Hanna’s leg was amputated on a summer day in 2020, after a Michigan doctor who called himself the “leg saver” had damaged her arteries by snaking metal wires through them to clear away plaque.
It started with a festering wound on her left foot. Her podiatrist referred Ms. Hanna to Dr. Jihad Mustapha. Over 18 months, he performed at least that many artery-opening procedures on Ms. Hanna’s legs, telling her they would improve blood flow and prevent amputations.
They didn’t — for Ms. Hanna or many of his other patients. Surgeons at nearby hospitals had seen so many of his patients with amputations and other problems that they complained to Michigan’s medical board about his conduct. An insurance company told state authorities that 45 people had lost limbs after treatment at his clinics in the past four years.
Dr. Mustapha is no back-alley operator working in the shadows of the medical establishment, an investigation by The New York Times has found. With the financial backing of medical device manufacturers, he has become a leader of a booming cottage industry that peddles risky procedures to millions of Americans — enriching doctors and device companies and sometimes costing patients their limbs.
The industry targets the roughly 12 million Americans with peripheral artery disease, in which plaque, a sticky slurry of fat, calcium and other materials, accumulates in the arteries of the legs. For a tiny portion of patients, the plaque can choke off blood flow, leading to amputations or death.
But more than a decade of medical research has shown that the vast majority of people with peripheral artery disease have mild or no symptoms and don’t require treatment, aside from getting more exercise and taking medication. Experts said even those who do have severe symptoms, like Ms. Hanna, shouldn’t undergo repeated procedures in a short period of time.
Many people with peripheral artery disease also have heart disease or diabetes, which present serious risks. Such patients, already anxious about their health, are susceptible to warnings from doctors that, absent intrusive medical procedures, they could lose their legs.
Some doctors insert metal stents or nylon balloons to push plaque to the sides of arteries. Others perform atherectomies, in which a wire armed with a tiny blade or laser is deployed inside arteries to blast away plaque. Rigorous medical research has found that atherectomies are especially risky: Patients with peripheral artery disease who undergo the procedures are more likely to have amputations than those who do not.
The volume of these vascular procedures has been surging. The use of atherectomies, in particular, has soared — by one measure, more than doubling in the past decade, according to a Times analysis of Medicare payment data.
Atherectomies Have Soared
The number of atherectomies billed to Medicare has risen significantly over the past decade.
There are two reasons. First, the government changed how it pays doctors for these procedures. In 2008, Medicare created incentives for doctors to perform all sorts of procedures outside of hospitals, part of an effort to curb medical costs. A few years later, it began paying doctors for outpatient atherectomies, transforming the procedure into a surefire moneymaker. Doctors rushed to capitalize on the opportunity by opening their own outpatient clinics, where by 2021 they were billing $10,000 or more per atherectomy.
The second reason: Companies that make equipment for vascular procedures pumped resources into a fledgling field of medicine to build a lucrative market.
When doctors open their own vascular clinics, major players like Abbott Laboratories and Boston Scientific are there to help with training and billing tips. The electronics giant Philips works with a finance company to offer loans for equipment and dangles discounts to clinics that do more procedures.
The Times searched a database of state loan filings for the 200 doctors who have billed Medicare the most for atherectomies since 2017. At least three-quarters either received loans from the device industry or work at clinics that have. Some loans have gone to doctors with well-documented histories of endangering patients.
The device industry rewards high-volume doctors with lucrative consulting and teaching opportunities. And it sponsors medical conferences and academic journals to bolster a niche medical field that favors aggressive interventions.
This self-sustaining ecosystem is worth $2 billion a year, analysts estimate. Insurers pay doctors per procedure. And because new equipment is needed each time, the companies also profit from repeat customers.
Dr. Mustapha declined to comment on Ms. Hanna’s case, citing health care privacy law. But he strongly defended his treatment of the seriously ill patients who form the bulk of his practice. He said his clinics have “very low” rates of complications, including 1.3 percent of patients having “major amputations” within 30 days of treatment.