Grady-Emory Reports This Week May Have Opened The Floodgates

(See related story here)

By Dick Pettys
InsiderAdvantage Georgia

(8/31/07) Revelations about a Grady Hospital audit that until Thursday had been kept secret for two years -- along with implications that Emory Medical School, which provides most of Grady’s doctors, may be cherry-picking patients from the financially-troubled public hospital for its own private hospitals -- seem to have stirred a flood of new reports from the public questioning the relationship between the two hospitals.

Since that story broke here and elsewhere this week, lawmakers have heard from a number of new sources about the issue, according to a lawmaker involved in the General Assembly’s efforts to find a solution to Grady’s problems.

And from sources within the medical community, InsiderAdvantage has received new reports, as well. A physician who practiced extensively at Grady provided Insider with a look at how things are supposed to work at the hospital compared to how the doctor experienced them while working there. More on that in just a bit. First, a reminder of how the story got to this point.

Grady has been a public flash point for most of this summer, with predictions that it could end the year some $120 million in the red, and a warning from a task force of the Metro Atlanta Chamber of Commerce that it must overhaul its governance system and line up new sources of funding or risk closing its doors.

House Speaker Glenn Richardson and Lt. Gov. Casey Cagle both are paying close attention to the issue.

Cagle has warned Fulton and DeKalb authorities, who control the hospital, they must overhaul the way the hospital is run. He has endorsed legislation proposed by Sen. David Shafer, R-Duluth, that would require the hospital to be run by a nonprofit hospital management board.

Richardson has appointed a special House study committee and told those interested in Grady’s fate, “I’m serious about getting something done.”

Early this week, a letter written by former Grady Trustee William Loughrey was circulated among state legislators suggesting that Emory has been skimping on services at Grady which might turn a profit but could compete with services offered at hospitals which Emory owns.

The letter also said Grady staff members have expressed concern about a systematic steering of paying patients from publicly-owned Grady to Emory-owned hospitals, leaving Grady with “an unsustainable patient mix dominated by indigent and other nonpaying patients

In addition, it suggested that an audit exists but has been kept secret for two years which faults Emory’s system of documenting the services for which it is being paid under the Grady contract. Two whistleblowers who were fired got large financial settlements but under non-disclosure terms, the letter stated.

(Late Thursday, Grady Hospital turned the audit over to Shafer following his Open Records Act request for the document. Emory University immediately put out a press release asserting the report vindicated its position. Shafer saw it a little differently. See that story here.)

Loughrey's letter was available to members of the special House study committee on Grady when they held their first meeting on Tuesday, and they asked Dr. Thomas J. Lawley, dean of the Emory School of Medicine, about it.

Insider has previously reported his comments (they can be found here), but in summary he said Emory hasn’t been under funding potentially profitable services at Grady or steering paying patients to Grady. “Why would we systematically transfer paying patients out of a hospital that owes us $45 million? We would like to be paid,” he said.

He confirmed there is an audit but said he’s never seen a final report, and said he believes it points the finger at Grady - not at Emory.

Now, back to today’s story. The doctor with whom Insider spoke and exchanged e-mails believes there have been “ghost” billings to Grady for work that probably was not performed. The doctor spent a number of years working closely at Grady but has been less involved in the last several years and acknowledges things may have changed.

However, the e-mail offers a sense of how things work for those of us who aren’t familiar with the complexities of medical care, and the doctor begins with some helpful background:

“Grady is a teaching hospital. In such a hospital, doctors in training, interns and residents, as well as medical students, are the first doctors to see and evaluate patients. Attending physicians, doctors who have completed all their training and have a license to practice medicine, oversee their work. For Emory, the attending physicians may be based at Grady, or may be based at Crawford W. Long or Emory, but they are medical school faculty and as such also have other responsibilities—teaching elsewhere, research or seeing private patients. In a healthy teaching environment, the attending physicians strike a balance between oversight and direct intervention. To make this happen, and to comply with state and federal law, the attending physicians must see and examine the patient themselves, and document this oversight in the medical record. Grady pays Emory and Morehouse for these attending physician services.

“Both the quality and quantity of these services was surely an area of concern in the audit. Each medical school, and each department (e.g., internal medicine, orthopedics, radiology) within each school, has discretion regarding how this oversight is achieved.

“One of the areas of serious concern has been the amount of oversight on the Internal Medicine inpatient service. Interns and residents will admit patients to the hospital during a 24 hour period, and then the attending physician is responsible for seeing those patients within 24 hours, and at least every 2-3 days thereafter (if not more frequently), and documenting their exam in the medical record.

“However, most physicians trained at Grady (and that probably means 85% of the MDs in Atlanta!) will tell you that they “never saw” their attending physician. In other words, the interns and residents took care of their patients without appropriate supervision, meaning Grady paid Emory and Morehouse for “ghost” attendings.

“How much? However many physician salaries plus fringe should staff an 800 bed hospital—millions, if not tens of millions, of dollars a year. What were those attendings doing if they weren’t at Grady? See the paragraph above—“they are medical school faculty and as such also have other responsibilities—teaching elsewhere, research or seeing private patients.

“I was ... appalled by the lack of oversight.

“The dean will undoubtedly say: ‘Oh, it is just that our hardworking attendings don’t document their oversight’ but what the question really should be is, “Were those doctors that Grady paid for actually at Grady seeing and examining patients?’ Or were they elsewhere?”

"We're hearing the same things from others who have worked at Grady," one lawmaker said.

Meanwhile, a paper circulating among legislators and written by Dr. Samuel Newcom - chief of the Hematology Clinic at Grady from 1984 to 1994 - points out that Emory’s billing practices were called into question in the late 1990s. That resulted in Emory repaying the state $4.5 million in Medicaid overcharges, The Atlanta Journal-Constitution reported at the time.

Among other things, state investigators found that Emory had charged Medicaid for a high level of patient services in gynecology and obstetrics that its records didn’t support, the newspaper reported.

Also, according to the newspaper, inspectors found incomplete records to support bills filed for the equivalent of 22 full-time, teaching physicians in Grady’s ob-gyn department.