Preventive Medicine and the Seven Deadly Sins: Avoiding Discipline Against your Medical License

Greed n. Inordinate or reprehensible acquisitiveness: avarice

"The point is, ladies and gentlemen," Gordon Gekko pontificated in the movie "Wall Street," "that greed - for lack of a better word - is good. Greed is right. Greed works. Greed clarifies, cuts through, and captures the essence of the evolutionary spirit. Greed, in all of its forms - greed for life, for money, for love, knowledge - has marked the upward surge of mankind."

We are a conflicted society. Reprehensible acquisitiveness versus the upward surge of mankind. What a dichotomy.

The sad truth is, the sin of greed is so pervasive that it will be a challenge to find ways to surprise you with its more shameful manifestations. The more classic incarnations of greed - Medicare fraud, Medi-Cal fraud, insurance fraud, income tax evasion, mail fraud - they have become so prolific they are mundane to most investigators. During F/Y 2005-2006, the Medical Board received 294 complaints alleging fraud. Obviously, the temptation for many to make a quick and easy buck is not surmountable, but here I must warn you. Should this errant fantasy befall you, I hope you will consider that physicians who have been convicted of fraud often aren't invited to attend physician conferences in a district office. They don't come to us. We go to them. In prison, that is, since often this is the locale where we must conduct the interview to hear our subject's story about what prompted him or her to stray. Or how about having a new title to disclose on a job application, something that looks like ... felon? I would hope that most of these doctors would no longer agree that "Greed is right."

According to the United States General Accounting Office and health insurance industry sources, between 3% and 10% of any state's Medicaid budget is lost due to fraud and abuse. The federal Office of the Inspector General's Medicaid Fraud Control Unit convicted 1,226 individuals in Fiscal Year 2006 and recovered more than $1.1 billion in court-ordered restitution, fines, civil settlements and penalties. Additionally, due to health insurance fraud, 3,425 practitioners were excluded from participation in the Medicare, Medicaid and other federal healthcare programs.

California's Medi-Cal losses reach billions of dollars annually. In Fiscal Year 2005-2006, the Bureau of Medi-Cal Fraud filed 94 criminal cases for fraud. During that same period, 65 individuals were convicted. To avoid encouraging a risk/benefit analysis, it should be noted that this disparity is due to the pendency of the remaining criminal cases. Zero individuals were acquitted during this time period. Over six million dollars was paid in criminal restitution and defendants paid $267,854,037 in civil monetary recoveries. I would hope that these folks would no longer agree that "Greed works."

For those who still might abide by Gordon Gekko's words, consider the myriad of agencies in addition to, or in conjunction with, the Medical Board, that investigate allegations of fraud: the state Department of Justice (Bureau of Medi-Cal Fraud and Elder Abuse), the Federal Bureau of Investigation, the Office of the Inspector General, the Department of Health Services, the Department of Insurance, to name but a few. Additionally, most large insurance companies have in-house investigation units dedicated to the problem of fraud. Greed may "Capture the essence of the evolutionary spirit," but it also inspires the tenacity of the just spirit, because greed impacts all of us personally. Our tax rates increase, our insurance premiums increase, our deductibles increase because of the huge losses a few greedy people impose on all of us.

Fraud cases often come to our attention after a physician has been convicted. That investigation process was described in detail for the "sin of anger" article (Medical Board Newsletter, April 2007). Sometimes the Medical Board receives a complaint from an insurance company, or a tip from an anonymous employee, and we work up the fraud case ourselves. For example, the Glendale police department once called a district office to report they had responded to a call and found an office filled with hundreds of medical charts, in varying phases of construction, being prepared for submission to Medi-Cal for false billings. Bad people sell patient identifying information and from that, data is derived to submit false claims.

Then there is the kind of greed involving physicians who receive kickbacks from laboratories or entities selling medical devices. Or there is the physician who performs one level of service but bills for a much higher level. There is "unbundling," where the physician bills for a number of services, individually, when the services are customarily billed as one global service. There are physicians who perform unnecessary procedures. A particularly egregious recent case involved an interventional cardiologist whose fraudulent test interpretations caused patients to undergo coronary bypass procedures. There are physicians who employ staff to travel around large cities to pick up indigent "patients." These folks are driven to a doctor's office where numerous unnecessary tests are run and unneeded medical services are provided and billed to Medicare or Medi-Cal. The patient is provided a meal, or a fruit basket, or $20. Hopefully they're returned to the same place from where they were extracted, but sometimes we receive complaints that they were abandoned and had to find their way back home.

There are drug cases that straddle greed - the physician who charges a fee for a prescription. Never mind the appropriate prior examination or medical indication: if you've got $50, you can have a prescription for #30 Vicodin. The Internet has become a popular medium for greed. Apparently cyberspace does not discriminate between men and women because most of us have been inundated with electronic mail from entities proffering erectile dysfunction medications. And I know most of you never look at the back of this publication to see who's been disciplined, but if you go back a year, you'll note an increasing number of doctors finding themselves in trouble for Internet prescribing.

Mix greed with vanity and you might have an explanation for the cosmetic and Lasik surgery booms. Physicians who were trained in other specialties see the quick money in Lasik surgery or an untapped market in bariatrics. Many cosmetic surgeons and hair transplant physicians hire "counselors" or "assistants" to screen prospective patients with strong-armed sales techniques reminiscent of the stereotypical used car salesman.

Mix greed with sloth and a dash of insanity, and you might understand the motivation for the three doctors who were successfully prosecuted because they substituted saline for flu vaccinations. Or the ones disciplined for using non-pharmaceutical grade Botox to save a buck or two. Or the ones disciplined for disposing of hazardous waste in conventional trash bins; or of throwing away patients' records because proper disposal costs too much money. Physicians have fabricated clinical study records in pharmaceutical trials. In these circumstances, I would be less inclined to agree that "Greed clarifies."

Mix greed with dishonesty, and you might discover someone like this physician — the one engaged as an expert witness who will say whatever the hiring attorney wants if the price is right. Within the last year, at least one physician was disciplined for dishonesty in testifying as an expert. I suspect we'll be seeing a lot more of these cases since greed also seems to beget litigiousness.

Mix greed with naivete or financial desperation and you might happen upon a disturbing trend we've been seeing the past five years or so. A large number of newly licensed physicians and elderly physicians are being hired to "front" clinics that are actually owned and operated by lay people. Some of this involves sophisticated organized crime rings, and physicians become unwitting victims when they align with a shrewd lay person who promises a steady and generous paycheck, an office, and a source of patients. These lay people masquerade as business managers, but physicians constructively become the layperson's employee, or should I say puppet, which translates into the unlicensed practice of corporate medicine. The layperson utilizes the physician's license to commit fraud. Often, once the physician realizes what's happening, and tries to exert control, they are locked out of the practice, or left fearing for their safety when they realize the gravity of what is happening with their license and want to get out of the situation. It seems newly licensed physicians are especially vulnerable to this scheme because of oppressive student loans and business naivete. Elderly physicians who really should have retired from the practice, but have not properly planned for retirement, are also easy marks for this form of fraud. (More information about the prohibition against the unlicensed corporate practice of medicine can be found in the April 2004 issue of the Action Report, page 4. You can review it on the board's Web site at www.mbc.ca.gov/Publications/Newsletters/action_report_2004_04.pdf.

And finally, I cannot omit corporate greed as it epitomizes this sin: you know, the physician who is penalized for not seeing enough patients in a given time period so billings can be maximized? Or the paradox of this situation - the physician who purposely over schedules him or herself to the point that laboratory results are missed and not acted upon, or other lapses in good medicine occur.

Maybe it is true that greed has marked the "upward surge of mankind," but at whose expense? In these egregiously greedy times, it's hard not to jump on the Avarice Express, but hopefully the aforementioned scenarios, not to mention the fate of Gordon Gekko, will lead you to conclude that "Greed, for lack of a better word," is dangerous.

Coming up next: Pride.