Fallout After Fata: Loss of Trust in Physicians

Nancy Terry

Disclosures

September 08, 2015

"Trust is the fundamental basis of our relationship with patients, and we are losing it because of unscrupulous doctors like Dr Fata," was a typical reaction to the recent Medscape report that detailed the case of Farid Fata, MD. He was sentenced in July to 45 years in prison for administering excessive or unnecessary chemotherapy to hundreds of patients over a 6-year period and billing Medicare and private insurers for $17 million in fraudulent claims.

The story prompted more than 300 comments from Medscape readers, including the one about losing trust from an internist quoted above, which was echoed in this comment below.

"These events make people lose confidence in their doctors, and if we lose the trust of our patients, we lose everything," commented oncologist Dr Julian García-Espinosa .

"Dr Fata's actions certainly affect the confidence people have in physicians," commented orthopedic surgeon Dr William Cooney.

Anesthesiologist Dr Abraham Kiani agreed: "Doctors like this give the rest of our profession a terrible name."

However, some clinicians thought that Dr Fata's criminal activities would not affect the public's perception of oncologists.

Doctors like this give the rest of our profession a terrible name.

"This guy doesn't represent oncologists," remarked an internist. "He is not even an outlier."

Oncologist Dr Muheez Durosinmi asserted, "Dr Fata is a disgrace to oncology practice in any setting." Others referred to him as a "predator" and a "criminal in the garb of a doctor."

But some commenters turned a more critical eye toward the medical profession and saw Dr Fata as an extreme example of physicians who focused more on profit than on quality of care.

More Concern for Revenue Than for Welfare of Patients?

A registered nurse said, "I did not see the greed in healthcare until I left the bedside and started working closely with physicians. And yes, some are greedy because they want to live like a millionaire. The compassion is not always there. At times I don't trust physicians completely because of what I have seen or heard them say."

"During my time, the medical profession was a service," said a retired physician. "Many doctors now are more interested in making revenues than in the welfare of their patients."

"I see every day unneeded treatments that are used for profits," said a pharmacist.

Some clinicians suggested that the fee-for-service system of reimbursement may contribute to the use of chemotherapy when it is not needed."It is legal for oncologists to garner huge profits from the sale of chemo agents," said Dr. Seth Malin, a general surgeon. "Big Pharma and its lobbyists must be regulated or there will be more acts perpetrated by the likes of Dr Fata."

General surgeon Dr Santhosh Shivabasappa said, "For-profit healthcare with fee-for-service models cannot escape criticism because they contribute to overtreatment and mistreatment, at least in a few cases."

A non-US healthcare provider remarked, "Americans have a very strange health system. No offense intended, but when a doctor makes a profit from selling drugs, you are basically asking for this to happen."

 
When a doctor makes a profit from selling drugs, you are basically asking for this to happen.
 

"Clearly Dr Fata took full advantage of his position here in the US as a physician in a free market—unlike what he would have had available to him in his homeland—and completely ignored the stewardship that goes with being a responsible physician," said primary care physician Dr Miriam Ragab.

'How Was He Able to Do This?'

Among the concerns raised by Medscape commenters, one question surfaced repeatedly: How was Dr Fata able to conduct his fraudulent activities and intentional harm of hundreds of patients for years?

"How was he able to do this?" asked pathologist Dr Madeline Woodward. "I don't understand how other doctors (radiologists, pathologists, and surgeons) weren't involved in some of these cases. We have tumor boards that review nearly every patient, and their care and treatment plan are discussed with a multispecialty cohort."

A pharmacist agreed. "I can't understand, with all the safeguards in place, how he could have gotten away with so much."

 
Where was the oversight in this doctor's practice?"
 

"Where was the oversight in this doctor's practice?" asks oncologist Dr James Hayes.

"How did he falsely diagnose all of these people with cancer and give them chemo?" questioned another oncologist. "In most cases the referrals that we receive are from surgeons and pulmonologists, with a pathologic diagnosis already made...But many patients want a formal report, and many go for second opinions before therapy is started. And he was never caught for years?"

The complaint filed against Dr Fata in 2013[1] charged him with administration of unnecessary chemotherapy to patients in remission; deliberate misdiagnosis of patients as having cancer to justify unnecessary cancer treatment or expensive testing; administration of chemotherapy to end-of-life patients who would not benefit from the treatment; fabrication of other diagnoses, such as anemia and fatigue, to justify unnecessary hematologic treatments; and distribution of controlled substances to patients without medical necessity.

The complaint included statements from one oncologist, three nurse practitioners, two medical assistants, and one business manager, all of whom had been employed at Dr Fata's Michigan Hematology Oncology, Inc., which numbered seven locations in suburban Detroit.

In the complaint, an oncologist who worked for Dr Fata for 18 months claimed that Dr Fata determined the diagnosis and course of treatment for all patients. The oncologist said that in the case of one patient, Dr Fata ordered bortezomib (Velcade®) for a patient whose multiple myeloma was inactive. The oncologist told the patient to seek a second opinion and the patient never returned to the practice.

A nurse practitioner said Dr Fata falsified cancer diagnoses and did this more easily in blood cancers where the oncologist "has more discretion to interpret" the results as malignant. This nurse practitioner also said Dr Fata instructed her to falsify records to justify the administration of intravenous immunoglobulin when there was no history of recurring infections. A medical assistant claimed that if patients expressed nervousness about their treatment, Dr Fata would prescribe alprazolam (Xanax®) to calm them.

Whistleblowers Call a Halt to Dr Fata's Crimes

Practice strategies adopted by Dr Fata tended to shield irregularities from scrutiny. Oncologist Dr Soe Maunglay told TheDetroit News[2] that Dr Fata tended to employ younger oncologists, often foreign-born with few ties in Michigan. Dr Fata also carried a huge case load and insisted that he personally care for his patients even when other oncologists could have more conveniently seen his patients. Dr Maunglay added that Dr Fata's reputation as a tireless physician and head of what was then the largest private cancer practice in Michigan made it difficult to call his practice irregularities into question.

Dr Maunglay had submitted his resignation when he discovered that Dr Fata was giving chemotherapy to a patient who did not have cancer. In an attempt to find an ally, he shared his concerns with the practice manager, George Karadsheh, whom he learned had experience in reporting Medicare fraud. The key role that Mr Karadsheh played as the whistleblower in the case did not become clear until July, when ABC News[3] and other news media reported that he had filed a lawsuit under the False Claims Act, with himself and the federal government as co-plaintiffs, a step that triggered swift federal action.

That step, which requires a knowledgeable lawyer, entitles Mr Karadsheh to a significant financial reward. "Government whistleblower laws, including the False Claims Act used in this case, create a path for private citizens to help the government," reported Lauren Effron forABC News.[3]

Was the whistleblower's law the only recourse available to fell Dr Fata? Oncology nurse Angela Swantek, on a job interview at one of Fata's Michigan Hematology Oncology centers in 2010, noticed that chemotherapies were being administered to patients incorrectly, presumably to maximize insurance reimbursement. She filed a formal complaint with the Michigan Department of Licensing and Regulatory Affairs (LARA).

Unfortunately, Ms Swantek's complaint fell through the cracks. Eventually she received a letter stating that the allegations were unfounded and the case was closed. LARA deputy director Steve Gobbo told Detroit's Local 4 News, "If we are not the agency to handle the matter we would tell the person and suggest them to go in a different avenue."[4] Ms Swantek was never directed to a more appropriate agency.

Among the commenters to the Medscape article, oncologist Dr David Young pointed out that there is no easy way to report such treatment abuse. "State medical boards do not know how to prosecute a physician like Dr Fata. State medical boards prosecute cases of straightforward fraud, practicing while intoxicated, overuse of narcotic prescriptions, and sexual misconduct. Why? Because everyone understands that those things are wrong. The average person does not understand that giving someone 2 years of adjuvant chemotherapy when 4 months is plenty is a wrong thing to do. The state board doesn't have the time or ability to prosecute these things."

State medical boards do not know how to prosecute a physician like Dr Fata.

Dr Young said that in the 1990s he tried to report an oncologist who had given breast cancer patients adjuvant chemotherapy at one third the normal dose over the course of many years. He reported that patients did not object because the doses were so low that the side effects were minimal.

"Any good oncologist would tell you that this type of adjuvant treatment is wrong, but there is nothing about this sort of unethical behavior in any textbook," said Dr Young. He reported that oncologist to the state board, and the general surgeon to whom he spoke asked him, "Is there anywhere in a text that you can show me that this is wrong?" There wasn't. Dr Young suggested that if a position statement or discussion of this form of medical abuse were published in a mainstream journal, on a specialty society's webpage, or in a textbook, it would help educate state boards.

Ways to Report Practice Irregularities

The whistleblower law proved effective in convicting Dr Fata, but it required the aid of an attorney and precise understanding of the False Claims Act. What other avenues are available for reporting insurance fraud or intentional harm to patients?

Societies such as the American Society of Clinical Oncology (ASCO) can look into allegations of practice irregularities. "ASCO's membership policies give the society the discretion to review a member's activities for professional misconduct and fraud, and to take action when there is a breach in the ethical practice of oncology," Dr Richard Schilsky, ASCO's chief medical officer, told Medscape. If the clinician is not an ASCO member, Dr Schilsky said that healthcare providers can report questionable practices to state licensing bodies. Suspicious conduct may also be reported to the US Department of Health and Human Services and the Department of Justice, and this reporting can be done anonymously.

"If an oncologist or other medical professional has a serious question regarding clinical decisions of a colleague, such as occurred with Dr Fata, it is appropriate to consult directly with someone within an organization with authority to evaluate, and potentially investigate those concerns," remarked Dr Maurie Markman, president of medicine and science for Cancer Treatment Centers of America. "This might include the chief of staff, the hospital's compliance officer or council, the CEO, or even a member of the hospital board. Outside of an organizational setting, it is reasonable to consult with the local medical society, or their council, regarding how best to handle the concern." He cautioned that there are no simple answers, and that a report of wrongdoing has the potential to seriously damage the reputation of a colleague or get the person reporting the wrongdoing involved in a complex and nasty legal situation.

"As in all walks of life," Dr Markman said, "in oncology there will be those who abuse the trust of patients solely for their personal gain. If this occurs, it is critical that others with objective knowledge of the situation and expertise to question specific actions have an appropriate mechanism to raise their concern."

The question remains: Would Dr Fata's criminal activities have been reported earlier if there were a more accessible and effective means of reporting allegations of this nature?

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