On call contracts: physician convenience trumps patient care?

February 23, 2010

Editor’s note: This is the last of a series on profit share versus patient care on the Central Coast.

By KAREN VELIE

Based on a dozen interviews and other material, CalCoastNews has learned that numerous local physicians are threatening patient care in San Luis Obispo County by not showing for emergencies even though they’re paid to be “on call” at local medical facilities.

Some see this as part of a scheme to shut down one of the two major hospitals in San Luis Obispo.

The focal point of these concerns, according to physicians who are appalled at some doctors’ practice of not showing up for work, is that these offending doctors are taking advantage of federal laws that require hospitals to have certain specialists “on call” to treat specific emergencies.

Although dozens of local doctors collect compensation of between $200 and $400 a day to be “on call” at local hospitals, CalCoastNews has learned that some fail to comply with their contractual agreements. Thus, according to critics, their “on call” pay helps provide a lucrative practice without disrupting the doctors’ personal lives.

In their defense, some doctors claim they are not making enough money because of the area’s rural rating, which means lower medical reimbursements are paid here as opposed to urban areas like Los Angeles or San Francisco.

CalCoastNews tried to get authoritative information from medical professionals in “on-the-record” interviews, but many were uncomfortable with that approach out of fear for their ability to make money.

Hospitals by federal law are required to have physicians “on call” for emergency treatment; forcing the doctor to comply with an “on call” contract is the hospital’s responsibility. Paying doctors to be “on call” whether they show up or not may open the hospital up to fraud charges.

“Hospitals are required to maintain a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition,” according to Medicare statute 42 USC §1395cc(a)(1)(I).

Medical staff contractual failures are reviewed by peer physicians, meaning that doctors who have a monopoly on a specialty are responsible for policing their business partners. Even so, after repeated absences, hospital administrators have the ability to report the doctors’ shortcomings to the medical board.

Because many of the county’s medical groups are monopolies, hospitals are forced to balance the need to hold doctors to their contracts with the necessity to maintain relationships with these same doctors who could choose to take their business elsewhere.

For example, while a physician may be “on call” at Sierra Vista Regional Medical Center in San Luis Obispo, the doctor could actually be out of town, working at Marian Medical Center in Santa Maria, or otherwise unavailable to treat patients as required by the “on call” contract.

Also, a doctor who is “on call” at one hospital may cause a patient to be transferred to another hospital for the convenience of the physician, not the patient.

Independent cardiologist  Kenneth Tway and doctors from Coastal Cardiology — a group of 13 physicians who have a virtual monopoly on local cardiology care — continue to collect money for serving “on call” at Sierra Vista even though they primarily transfer patients to French.

The physicians with Coastal Cardiology and other investors own the land where French Hospital is located. They lease the land to Catholic Healthcare West, which owns French.

On Feb. 11, the husband of a nurse who works at Sierra Vista arrived at that hospital’s emergency room complaining of chest pains.

Tway – who was “on call” at the time – failed to respond to numerous calls to read the stress echo cardiogram that technical staff had performed, even though he was being paid to do so.

After eight days of waiting, another doctor was asked to read the patient’s results in order to give the patient a diagnosis.

Two months ago, along with Coastal Cardiology doctors Mark Bocchicchio and Robert Doria, Tway joined a cardiac section committee focused on improving and supporting cardiology services at Sierra Vista.

However, Tway told CalCoastNews that he believes Sierra Vista should shut down. He believes the community would be better served by only one hospital in the City of San Luis Obispo: French Hospital.

“I am not one of the doctors who owns the land under French,” Tway said. “There is not enough business in the area for two hospitals. I had planned to bring in a partner – that was before Sierra Vista brought in Ken Stevens.”

Stevens is a cardiologist that Sierra Vista recruited to join its staff in 2009.

A handful of local medical professionals, not long after a group of them purchased the land under French Hospital, began airing their goal of shutting down neighboring Sierra Vista.

Meanwhile, cardiac patients transferred to French have had to wait for hours on equipment because of the backlog created by Coastal Cardiology doctors’ shifting of patients — while cardiology labs at Sierra Vista remain vacant. Because of the current shortage of cath lab patients at Sierra Vista, management recently terminated three employees and reduced lab hours from 24 hours seven days a week to nine hours on weekdays. No weekend service is offered.

Critics of the “one central hospital” plan contend that neither French with 135 beds nor Sierra Vista with 165 beds is large enough to adequately compensate for the closure of the other.

After years of “on call” abuses, some hospitals have fought back against doctors who force hospitals to compensate them for services to patients that they do not actually provide.

In 2006, a Virginia hospital took action against a group of cardiologists over hospital transfers and their continued failure to show up when paid to be “on call.” The hospitals filed a suit against the doctors alleging federal anti-trust violations.

The Federal Trade Commission has frequently taken action against physicians who try to illegally negotiate as a group. Withholding contracted services may also violate anti-trust laws, and transferring patients may violate Medicare fraud and abuse regulations if any compensation is tied to the transfers.


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Lilylu

Recently a close friend had an extended stay in the ICU at Twin Cities Community Hospital. They saved his life! I don’t think he could have gotten better care anywhere. His was a pulmonary problem not cardio. It was an incredibly clean well run facility and his care was outstanding in every respect. The RN’s were kind, caring and very knowledgeable. I was amazed, as I had heard negative things about Twin Cities in the past. The North County should have it’s own cardiology facility so patients having a heart attack would not have to be taken over the grade. I think Twin needs to recruit its on cardio surgeon and cardiologists.


slohealth

Again, same problem. TC cannot recruit their own. CC shut down Cardiology Caths at TC for the same reason: to pump up volume at French.


Lilylu

I guess I don’t understand why you say Twin could not recruit their own cardio surgeon and cardiologist. Several posts have asked why Tway did not ask Stevens to be his partner. Wouldn’t that have made Stevens part of the monopoly? Seems like Sierra and Twin needs to find a good cardio surgeons and cardiologists who will partner w/ Stevens to provide care at both hospitals.


SLORN

Lilylu


Easier said than done


slohealth

Because there is not enough community need, and no current general surgeons that would back up the CV surgeon. The General Surgeon Cartel here runs who can and can’t come to town. Dr. Stevens was never meant to be Dr. Tway’s partner, and technically Dr. Tway is not a player in the Cartel but merely one who will lay in bed with them to avoid confrontation.


It really is that much of a soap opera here.


SavedByGrace

The assertion that Dr. Tway does not respond to on call requests is absurd. Last July 8th I suffered onset of cardiac distress when my left main artery became 95% blocked. I went to Ken Stevens who insisted that I go immediately to Sierra Vista. When I argued that French had a better cardiac care unit, I was rebuffed that my assertion was just “marketing hype.” Well I went to Sierra Vista, went through a cauterization and had to be shipped by ambulance to French for immediate intervention. Why-because as the nurse told me while I was being prepared for transport, Sierra Vista is not licensed to do interventions, only diagnostics.


Dr. Tway met me in the cath lab at French and became immediately alarmed. I sensed something was wrong and ask what it was. He told me to put my head down and keep it down. He worked quickly and efficiently. Within a short time I had the blockage removed and a stent placed. The ICU staff was incredible, providing superior care to me. The next morning Dr. Tway was at my bedside at 6:30 AM telling me how fortunate I was since the first symptom of my problem is usually sudden death. He discussed in detail my continued care and medication options.


Fast forward 3 months. I was enrolled in an arthritis study for several years prior to the cardiac incident. The study doctor obtained the minute by minute surgical reports from both Sierra Vista and French hospital. Something the patient never sees. Guess what? The reason Dr. Tway was so concerned that evening was because the sheath and catheter used at Sierra Vista was the wrong size and apparently during the diagnostic procedure they “bumped” the clot thereby making it unstable.


Upshot: I got to pay for a botched diagnostic procedure and an ambulance ride that I didn’t need to if I had just gone to French in the first place. Take my advice – If you’re having a coronary event, GO TO FRENCH immediately. I didn’t wait, got fabulous care, you won’t have to pay lots extra for double procedures and endanger your life with an ambulance ride in an unstable condition.


As for Dr. Tway not being a great cardiologist, go blow. I’ve seen him 3 times since, yesterday being the most recent and he is exceptional at cardiac care.


Finally about Dr. Tway and the others not taking Blue Cross – well I don’t blame them. I have Blue Cross (sadly) and the insurance sucks. The doctors are paid a poor rate for their services. It’s not the doctor’s fault – it’s the greedy insurance companies fault. Doctor’s have to pay for expensive equipment, staff, malpractice insurance, rent, electricity and other bills just like the rest of us. Why should they get short changed by greedy insurance companies? As my wife said when I got the bill from Dr. Tway, “Don’t complain – Your alive, he saved you. Pay it and shut up about it.” As usual, she was right.


MaggyMay

SavedByGrace,


Sadly the Dr. Tway on-call is fact. Now whether or not you chose to believe it or not is up to you. You saw Dr. Stevens because of what reason? Were you referred ? The reason Dr. Stevens asked you to go to Sierra is that CC will not allow him at French (again proven fact). Also the reason that there are nointerventions are performed there is because the second mafia group in town (The Associated Surgeons) pulled out of Sierra thus leaving them with the option to NOT be able to perform an intervention with your Cath there. Also Alan Iftuniuk has yet to produce a transfer agreement in over a year, allowing you to have a intervention with your heart cath due to the lack of CV surgeon back up at Sierra. Is it possible that Dr. Stevens asked you to go to Sierra for a better evaluation before knowing that you in fact you needed an intervention?

Also French is trying to shut Sierra Vista down so when you arrived at French why would they say that the heart cath was great? They are trying to manipulate the community to think that Sierra Vista and Dr. Stevens are not worthy.

I would also like to know what is it about Dr. Stevens that has a cardiology group of 13 and the CV Surgeons so worried? I wouldn’t think one man could be so intimidating but I guess when you have been giving the community substandard health care and the “new guy” comes in to town and is honest and puts the patients needs in front of profit, I can see how that would ruffle the peacocks feathers.


hoopitup

SavedByGrace,


Your closing comments are interesting, you wrote. “Take my advice – If you’re having a coronary event, GO TO FRENCH immediately.” You must have missed the central point of the article…French is now the only place in SLO to get a heart cath due to a coronary event deemed emergent by medical professionals, with surgical support.


The cath lab at SV, as indicated in this article, has been reduced to a staff of two where generally in most communities it’s a minimum of four support staff (not including doctor) or more. This makes performing an emergency heart cath a risky business for SV, I would assume. So until SV gets their staffing in the cath lab up to community standard AND cardiovascular surgical back-up services in place either via transfer agreement with French or on call cardiovascular surgeons, there’s little reason anyone would receive an emergency level heart cath at SV.


And as for this comment you wrote: “Upshot: I got to pay for a botched diagnostic procedure and an ambulance ride that I didn’t need to if I had just …” Sorry to hear you suffered a complication of your procedure. I’m assuming you’re referring to a diagnostic heart cath performed at SV? And it was ‘botched’? As deemed by Dr Tway? Next time you go see Dr Tway ask him has he ever ‘botched’ a heart cath JUST LIKE yours was botched? My point? I thought you’d never ask…Your botch is seen periodically among cardiologists who perform these procedures and it’s not just Dr Tway either.


As I’m certain you’re aware, complications in heart caths are always a possibility and many factors contribute to the chance it will happen. Lots of things like obesity, being on blood thinners, excess patient movement with a sheath in place/in artery, and the unknown things like existing heart disease in the left main artery /any coronary artery that previously was not diagnosed.


I don’t know if I agree with the article that claims Dr Tway doesn’t respond to “call”. I beg to differ on that one. I think he does answer them, crusty or otherwise in his demeanor.


I would agree that you should stick with Dr Tway until you are no longer in need of his services. If it works for you then do it, right?


Finally, the main theme of these articles point less to Dr Tway and more to the group he’s NOT an official part. If you read the other articles they seem to hint more at the unethical perhaps even unlawful medical practices of Coastal Cardiology.


I don’t blame you for standing up for Dr Tway but don’t mistake the forrest for the trees.


Greedy insurance companies? YES


I’m glad you had a positive outcome in your heart health care. Stay active, take your meds as directed by Dr Tway and stay the heck of any hospital! Best of luck!


slohealth

Sir, as a member of the team on your case and without violating HIPPA, I can state that your care was directed and performed to the best of the circumstances it could be. Dr. Stevens had to undergo diagnostic cath on you because without it, he would not know if you had a level of stenosis that would require intervention. I remember your case accuratley, and Dr. Stevens made arrangements prior with Dr. Tway for your transfer correctly and swiftly. You do have a right to all of your medical records, and if you choose to request them you would note that neither your procedure nor your transfer was botched, but performed under the correct guidelines. Should there have been any misappropriation of your case, I assure you a peer review would have been conducted by the Administration at both SVH and FH which it was not. You were treated as a pawn, and in something not uncommon anymore harrassed and made to feel fear about your service with Dr. Stevens.


Part of the issue exists that the CV Surgeons left SVH for 2 low volume programs, leaving the cath lab compromised, and unfortunately, the Doctors from CC who are appointed to revitalize and support that department do not do so and continue to slander the hospital to their own benefit. Imagine being Dr. Stevens without any power up against 13 people hell bent on closing an entire department. Through the past weeks and comments you will see that this is not untrue and quite well known.


Another point, Mr. Iftuniuk is holding out on the community and while he preaches about his hospital’s community service, has refused a transfer agreement to exist between FH and SVH, which would have meant that if in place, Dr. Stevens would have been able fully complete your intervention without transfer. The transfer agreement is being held as a pawn to not allow SV trauma designation. Sad isn’t it? With a transfer agreement inplace, and only with a transfer agreement as per EMSA, SV would be deemed the local trauma center due to it’s NICU and Neurology center.


Thompson Rueters is as true of a consumer reporting agency as JD Powers, did you know that? JD Powers is a stamp of approval for pay. Look at the local health grades site and look at the OSHPOD site which is available to the public and note the not only is FH an average rated hospital, but the CV Surgeons have a higher rate of mortality than most areas of the state, add that into the fact that they do not perform up to date procedures including TMR, and minimally invasive bypass.


Finally, SVH worked to bring another CV Surgeon in town who was actually the first in the country to perform heart surgery by robotics, it would be a health care coup for this entire region, and would help so many. Due to the monopoly and sunday bbq buddy crowd, he was sadly blackballed.


Dr. Stevens is a highly credentialed and the most educated and experianced in our area. I have worked side by side with all of the Cardiologists in this area at SVH, and sir there is not one finer. Please do not be fooled by the smoke and the mirrors.


And yes, having worked in this arena it is not uncommon for Dr. Tway to have been paged and contacted mulitple occasions to no response. You had to take a ride across town, could you imagine waiting 8 days to know whether you had a cardiac issue?


The majority of health care in this area is dirty. It’s greedy, it’s filled with good doctors who became obsessed with making more money, acheiving status and fighting against the worst reimbursement in the country to afford their home in the slo country club. We need more eyes looking a this system, breaking up these monopolies, improving medicine, taking care of the patients, and keeping those who are traveling outside of the area for care home. I have been on that side of care, and there are absolute flagrant abuses of medicare being conducted by CC and it has been reported. Nobody wants to shut them down, we still need cardiologists. But what we need are Doctors (from every specialty) remembering their oath, and dammit Lois Capps getting back out there and fighting for our reimbursement level.


rogerfreberg

Well, not to worry, affordable “Health Care” is on the way! It won’t be much, but it will be ‘affordable.’


In the meantime, allow me to offer a few suggestions to help you in the future: 1) lose weight… losing weight cures almost anything… high blood pressure? Loose weight! Got Type 2 diabetes? Loose weight! Too ugly? Sorry, no cure there.


So drop your excuses and don’t wait for the government to save you, because, they can’t even save themselves right now.


Goyo

Dr. Tway is reported to have observed that this burg does not have enough ‘business’ to support two hospitals. Business? It would be good for the health care and hospital ‘business’ if more people had health problems? That by reducing the supply of health care it can be made more profitable? I want everyone to understand that Dr. Tway’s take on the role of physicians and health care provision is not so different from the model upon which all of organized medicine is based, and all licensing laws have been instituted.


Booty JuJu

Doctors acting in their own financial best interest and contrary to their patients best health interest?


What is it about this that you think is new?


Twelve years ago I waited over 30 days for a kidney stone procedure because the mobile unit was in the parking lot at French and my urologist was “affiliated” with SV.


Me: “So doc, instead of waiting 30 minutes for treatment I’m waiting over 30 days simply because it is in your best interest?”

Doc: “Correct”


There is nothing new about this, and nobody has ever really cared enough to do anything about it, nor will they. Public outrage and Government intervention? Come now. The American zombie public just wants their comfy suburban existence and the “liberty” to eat at Micky D’s and shop at Wally World. As more and more of them lose jobs and incomes, will they resent their government-issued extended unemployment benefits? I doubt that you’ll see them burning their own checks in big public demonstrations the way the Vietnam War protesters burned their draft cards. And of course this also goes for the retiree Tea-baggers who show up at their Tea Parties to inveigh against the government — except the agency that prints their social security checks, or the other one that pays for their liver transplants (while 40-million unretired, un-insured Americans under sixty-five get slammed with extortionate hospital bills that end up bankrupting them).


As for the Gubbermint, it is established fact that the GDP figure benefits from increases in medical services, meaning that the more obese, diabetic, two-pack-a-day cigarette smoking mongs this country produces, the better off our economy is assumed to be. Bring on the Little Debbie Snack Cakes and let’s turn up the dial on hospital admissions.


rukidding

Dr. Tway is a real character but also a good doctor. He did perform a procedure on me at Sierra Vista Hospital that took about 45 minutes to the tune of around $7000+. The only time I saw him after that is when I was released afrom the hospital; 3 days later. Upon my release he explained all about the stent that he ahd placed in me. Unfortunately my wife and I had to break the news to him that he hadn’t placed a stent in me. Other doctors, on behalf of Dr. Tway, came by to to say hi and/or look at my file while I was in the hospital, they were billed separately and paid by the insurance company. I always questioned why Dr. Tway didn’t come by and then I discovered that he didn’t accept Blue Cross Insurance. Of all the procedures and care that I recieved, which was excellent at Sierra Vista and TCH, the only bill that I received was from Dr. Tway. I find this very disturbing that when addmitted to an emergency room that the law and/or the hospital doesn’t require the attending physician to accept the insurance that the patient has, During an emergency the patient is in no condition to be asking if the doctor will accept his insurance.


standup

So, if the doc being paid to be on call isn’t around, another doc has to be paid to cover. This appears to be a perfect example of why health care costs continue to rise. If the docs don’t like the pay around here, move to LA, there will be someone to fill your place. Go cry your sob story somewhere else. We need both hospitals.


slohealth

Actually, in cases like the one above when Dr. Tway did not respond to multiple pages, the Doctor that covers DOES NOT receive compensation. Also, the poor man that came to the ER with Chest Pains and his Physician had to wait over a week for results……………Yet, Dr. Tway still got his $$. Yeah for SVH for allowing this to happen for months upon months now.


Does anyone wonder what Tenet Corporate must think?


slohealth

Ahhhh Dr. Tway……WOW. I bet CC is cringing right now.


TexasHoldum

This article has 2 main issues.

1. The CC group and Tway are being paid for “on-call” without doing the work? This again seems mind boggling. Why is Sierra Vista (Tenet) paying these doctors without fulfilling their obligations and seeing patients? Also why should they get paid by Tenet if they are transferring all the patients to French (as stated in the previous article). I do not know which is more ridiculous, the fact that Tenet is doing nothing about this or that our community is doing nothing about all this. How is that Tway, Bocchicchio and Doria are even on the board is again they are shipping everyone over to French? Is Ken Stevens on the board? Apparently he is doing the others call for them.


2. Some of the CC doctors own the land that the hospital is on? That seems as though that has to be a conflict of interest. By some of the CC doctors owning the land couldn’t they dictate who is allowed or not allowed to work at French Hospital? Is this also why CC left Sierra Vista to be at French exclusively?

I do not know who this Tway person is but he sounds like he is in bed with CC too. To blatantly state that he wants to shut Sierra Vista down is outrageous. So instead of giving the community a choice of which hospital they can go to Tway and CC want to dictate?

Tway sounds bitter about Sierra Vista bringing in Ken Stevens. If he wanted a partner did he not approach Ken Stevens ?


Again this whole thing is disgusting. To put patients lives on the line for $$$ it BS!

We as a community need to be the ones standing up to all the corrupt greedy business. Especially when it comes to our healthcare.


SLORN

TexasHoldum,


You couldn’t be more correct. It is ridiculous that SVH lets these money grubbing doctors even sit on a board and take call!! Does Candy actually think they will make cardiology decisions with the best interests of Sierra? The MD’s on a committee should be dedicated to the hospital success. Dr Tway drank the koolaid and went to the CC side even though they do not like eachother. He gets bumped cases because he is 2nd to CC, who gets priority in the cath lab. Let’s not forget the Interventional Radiology MD’s who also share the cath labs at French, they are 3rd class there when they could be 1st at Sierra. French does not have 135 beds, they have 50+ licensed beds and when the census gets to full capacity they freak out because they have no room but will never refuse an admit or transfer… God forbid the saftey of a patient may take precedence. Sierra has 2 ICU’s which is about 16 beds but yet these MD’s go to French with an old, run down 8 bed ICU!! Unreal to sit and watch. I hope all the effort that Karen has made ends in something good for our community. Dr Tway stuck his foot in his mouth by saying Sierra should close…is he nuts? where would all these non-cardiac patients go?