Limb amputation is frequently characterized as a failure in the system however there are some instances when limb amputation in patients with chronic arterial disease or nonhealing wounds can be the most direct route to obtaining better function with improved quality of life.
Various modalities exist for limb salvage including angioplasty, stenting and atherectomy. Atherectomy in particular has gathered a great deal of steam over the past 5 years.
All of these modalities have a select group of patients who they are most appropriate for and they all have limitations. For the patient who presents with severe infection with gas gangrene, prompt amputation with staged revision can be life saving. Conversely, I have seen some patients with chronic ulcers of the heel who undergo multiple procedures in an attempt to reconstruct a foot which may never be weight bearing.
The take home message is to consult a practioner who specializes in limb salvage using the state of the art technology and experience to know what treatment is appropriate for each individual patient.
High profile cardiovascular angioplasty and stenting malpractice case appears to be resolving according to a report from Dr Demaio in The Heart. The center of a high profile medical malpractice case involving Dr Demaio is apparently coming to the final stages of resolution
Austin, TX - The Texas interventional cardiologist investigated by his medical board and sued by eight patients over allegations he'd performed a range of unnecessary procedures has emerged from his three-year ordeal with no restrictions to his license and all but one lawsuit behind him.
As previously reported by heartwire, Dr Samuel DeMaio (Star State Heart, El Paso, TX) first made headlines in August 2010 when it came to light that the Texas Medical Board filed a complaint alleging that DeMaio had violated standards-of-care in nine patients dating back to 2008-2009.
According to the board's original complaint, DeMaio placed multiple stents in areas of insignificant or moderate disease; performed multiple angiograms in patients who were asymptomatic and had normal stress tests; unnecessarily implanted an ICD in two patients; failed to adequately inform patients of risks; failed to obtain informed consent for the off-label use of a stent in one patient; and inappropriately administered propofol to one patient, contributing to the patient's demise.
In the mediated agreed order signed earlier this month, however, the board's findings are dramatically curtailed, saying only that the board had found DeMaio to have placed multiple, elongated, overlapping drug-eluting stents in areas of insignificant or only moderate disease, and that his "reading of angiography film as it relates to percentage of arterial occlusion was flawed and disagreed with IVUS imaging performed."
One lawsuit unresolved
Speaking with heartwire, DeMaio said the board, "has dropped most of their original allegations," adding that he's emerged with no restrictions on his license and no formal reprimand. He also settled with the board neither admitting nor denying the allegations against him.
Moreover, of the eight lawsuits brought against him, two have been resolved in his favor, and he's been dismissed from the other five. These five cases were all settled with payments made to the patients from codefendants that DeMaio would not name, but not, he stressed, from him or his insurer on his behalf.
In the case of the final lawsuit, DeMaio emphasized to heartwire: "I don't want to settle the lawsuit because it's a case where I don't think I did anything wrong, and my attorney thinks I can fight it."
This last case, according to the Austin Statesman involves a patient in his 80s who alleges DeMaio implanted 32 stents over a 13-month period. DeMaio has previously discussed this case in some depth with heartwire, acknowledging that 32 stents was "an exceptional number," but noting that the patient had refused bypass surgery.
November 14, 2011 (San Francisco, California) — Surgical malpractice payments are decreasing in number, but payment amounts are increasing, according to an analysis of national malpractice trends reported here at the American College of Surgeons 97th Annual Clinical Congress.
"We found that significant variation in payments between states exists. This heterogeneity of payment sizes suggests that there is a profound impact from the local legal environments," said Ryan K. Orosco, MD, from the University of California at San Diego.
Dr. Orosco and colleagues used the National Practitioner Data Bank (NPDB) to evaluate what is happening today with malpractice claims in the surgical specialty. The NPDB reflects the mandatory reporting system of medical malpractice payments and adverse actions related to limitations on licensure, clinical privileges, professional society membership, and participation in federal programs. It contains data reported by malpractice carriers, hospitals, professional societies, and state licensing boards since 1990. Malpractice payments made directly by practitioners themselves (personal funds) do not need to be reported to the NPDB.
The researchers wanted to indentify the factors affecting surgical malpractice payment size and to evaluate predictors of malpractice claims ending in large payments.
"There are reports in the literature suggesting that an estimated 2% to 3% of patients suffer medical harm due to negligence, and about half these patients will recover damages. I think many of us would agree that the current malpractice system is flawed.... Anything that adds data to the discussion is a good thing, and that is our goal here," Dr. Orosco explained.
Review of the NPDB
The researchers performed a retrospective analysis of the NPDB from 1990 to 2006 to identify malpractice payments involving surgeons and surgical residents. Large payments were defined as those exceeding $1 million. Using multivariate regression analysis, they evaluated predictors of large payments, which were adjusted to 2006 dollars.
Defending Medical Malpractice Lawsuits Trying the “Gray Area” Cases1
By Robert C. Seibel and J. Thaddeus Eckenrode
Undertaking the representation of a medical professional or institution being sued for medical negligence presents the defense attorney with a variety of interesting challenges. Almost all malpractice cases involve a serious, if not devastating or crippling injury, complication, or death. Juror sympathy for the plaintiff is highly probable. The defense attorney’s first job, in conjunction with the healthcare provider’s professional liability insurance carrier, is to try to accurately assess the case at the earliest possible stage. A predictable small percentage of cases will present as such clear liability matters that defense counsel and the insurance company may try to promptly settle these cases, where possible, to avoid needless additional litigation expense to the carrier or disruption of time to the physician. Many of those cases cannot be resolved quickly, however, because damages (and therefore the potential value of the case) cannot be accurately ascertained in the early stages without some formal or informal discovery. Even so, very few “clear liability” cases ultimately make it to trial.
Another small percentage of cases are so clearly merit less and defensible, of course, that they should be vigorously defended through trial, if not otherwise dismissed earlier, either voluntarily or by motion. Several years ago, we saw a greater number of these “frivolous” cases, at a time when some plaintiff’s attorneys believed (sometimes correctly) that professional liability insurance carriers would, at some point in the case, make a nominal or “cost of defense” settlement offer. Over the past decade or so, with the introduction in 1986 of both Missouri’s medical malpractice statute2 (discussed infra), and the development of the National Practitioner Data Bank, 3 professional liability insurance companies and their claims departments are likely to force a plaintiff to file a “healthcare affidavit”4 before ever considering settlement, and physicians with “consent” policies may object to any payment that would require their name to be listed with the Data Bank.
Defending a non-meritorious case, or settling a clear liability case, are easy decisions to make. Medicine itself, of course, is rarely black and white, and the majority of medical malpractice cases, therefore, will fall into a vast “gray area.” In these “gray area” cases, we know that the plaintiff will be able to find an expert to testify that there was malpractice, and we know that we can find an expert to say that there was not. Some of these cases get settled, and some must be tried. Statistics suggest, of course, that even the great majority of these cases will ultimately be settled, although the wisdom of settling “gray area” cases should be debated. The factors that go into the decision to settle such a case vary from insurance company to insurance company, and physician to physician. Sometimes the amount for which a case can be settled, measured against the downside verdict potential, plays a role. Sometimes it does not. Sometimes the trial venue or the appearance of the parties themselves plays a role. Sometimes they do not. Despite their belief to the contrary, the identity of the plaintiff’s attorney himself rarely factors into the decision. Professional liability carriers today require defense counsel who are committed to the proposition that the “gray area” cases can, and need to be tried. Ultimately, the most interesting and important challenge to the defense attorney is in preparing to try the “gray area” case.
Service of Suit The first key to successfully defending any case, in our opinion, is to prepare the case from the outset with the assumption that the case will go to trial. Despite statistics to the contrary, we do not believe in assuming that a case will settle or be dismissed. Preparation for trial, therefore, begins the moment that we receive the petition from the insurance company. The initial inquiry is whether there are any immediate defenses to be raised by motion5 (i.e., improper venue,6 statute of limitations violations,7 etc.). Then we turn to the allegations themselves. Although Missouri is a “fact pleading” state,8 most judges in the various eastern Missouri counties in which we have appeared seem to take a dim view of motions for more definite statement, motions to strike, etc. Many insurance companies now encourage defense counsel to avoid needless motion practice, so unless the petition is so unreasonably defective as to make it nonsensical, we prefer to simply file an answer and to commence meaningful discovery. A review of the allegations of negligence should provide a general overview of the claims being made against the defendant, but frequently we see completely different allegations or criticisms of the defendant by the time plaintiff’s expert is deposed. Obviously, therefore, the limited claims made in the petition should not restrict defense counsel’s evaluation of the care provided by the defendant in the case.
The Affidavit of Merit Pursuant to statute,9 a plaintiff must file an affidavit attesting that plaintiff’s attorney has obtained the written opinion of a physician who finds plaintiff’s claim to have merit. It is a statute with bark, but little bite, and probably is the neutered result of legislative compromise. The statute does not require the plaintiff to actually produce the “written opinion” or to even disclose the identity of the reviewing expert, allowing for the possibility for an attorney of questionable ethics to file such an affidavit without actually having had the case reviewed. The statute requires that a separate affidavit be filed as to each defendant within 90 days of suit or the case is subject to dismissal. We frequently see motions filed on behalf of some defendants because a “separate” affidavit has not been filed as to each defendant, but we believe that to be a waste of our client’s money to pursue if the plaintiff’s affidavit mentions our client somewhere. We will vigorously pursue dismissal if no affidavit has been filed, although most judges seem willing to give a plaintiff up to 60 days additional time upon request when told that someone is currently “reviewing” the case. Most plaintiffs’ attorneys who handle malpractice cases with any frequency at all, however, will usually voluntarily dismiss a case if they have not already found an expert within 90 days. Sometimes it takes the filing of the motion to prompt that action, and we recommend that defense counsel make an effort to promptly seek dismissal of those suits where plaintiff’s counsel has failed to timely file the required statutory affidavit.
Early Case Investigation An early meeting with the defendant healthcare provider is important. Defense counsel has the opportunity to assess him as a witness, determine what problems he sees (or is willing to admit) with the case, and to get him focused on the seriousness of the matter and the need to stay in touch with us. We try to collect the relevant medical records as quickly as possible. This process is often easier if there are codefendants in the case, since we can exchange our clients’ respective records. When we are on our own, collecting records means waiting for signed authorizations from the plaintiff, unless we want to spend the time and money to depose a records custodian.
Once the records are obtained, we evaluate and compare the allegations of the plaintiff’s petition against the records. This frequently allows us some insight into whether the plaintiff’s attorney has had the case reviewed, or whether he is so off base that the petition must have been based solely upon his client’s story. We also try to get the records into the hands of a good reviewing expert as promptly as possible. This helps us with the ever-critical early assessment of the case, and in determining if the story our client tells us really holds water.
We find the use of nurse-paralegals of great importance in preparing the defense of malpractice cases and to be the most significant paraprofessional support that is available to defense counsel. A well-organized and complete medical chronology, bound and indexed medical records, and preliminary medical literature research prepared by a good nurse-paralegal is almost essential in allowing defense counsel to understand and locate the key medical information, and to thereafter focus ongoing discovery efforts.
Elements of the Medical Malpractice Claim: Negligence and Causation Like any personal injury tort claim, a medical malpractice case requires that the plaintiff establish the defendant’s negligence, and a causal relationship between the negligence and plaintiff’s injury. Negligence in a medical malpractice case is defined specifically in the Missouri Approved Jury Instructions as the “failure to use that degree of skill and learning ordinarily used in the same or similar circumstances by members of defendant’s profession.”1O Until trial itself, most attorneys simply refer to this as the “standard of care,” which is a phrase used throughout the pendency of a case during expert depositions, etc. Establishing a deviation from the standard of care by the defendant (usually through the testimony of plaintiff’s expert) is a required element of plaintiff’s proof, without which, plaintiff does not make a submissible case.’11 Plaintiff must also prove that “but for” the defendant’s negligence, plaintiff would not have suffered the injury alleged.12
Written Discovery The recent trend of using “pattern” discovery in St. Louis City civil courts’3 has taken some of the creativity and “heat” out of interrogatories, objections to which once seemed to keep the courts’ motion dockets going for hours. Although that is a good thing, we still believe that it is important to review and note the answers to some of the pertinent pattern questions, i.e., identity of treating physicians, experts, and witnesses, damages claimed, employment history, etc. A diligent defense attorney will not leave a question unanswered, partially answered or with an objection unresolved without approaching the court for relief. Otherwise, he might find himself facing a surprise witness at trial who he cannot keep from the witness stand simply because the witness was not identified, if plaintiff’s vague answer or objection to the interrogatory was never taken up and ruled upon.14
Although written discovery tends to simply be an exchange of the aforementioned “pattern” discovery these days, nothing prevents counsel from preparing or utilizing supplemental requests or additional interrogatories,15 and well crafted and case-specific written discovery can help isolate issues, and weed out irrelevancies at trial.
Plaintiff’s Deposition The deposition of the plaintiff is necessary, but infrequently of overwhelming benefit, since plaintiffs themselves often have minimal recall or understanding of the truly important medical issues. The deposition is important, however, to allow defense counsel to tie down the story to be told factually at trial, and to determine how the noneconomic”damage claim will be described. To that end, of course, the deposition of the plaintiff should almost always be secured, unless there is some reason to believe the plaintiff might die before his/her testimony is otherwise memorialized.
Defendant’s Deposition The defendant doctor’s deposition, on the other hand, is, in many respects, the most important part of preparing the defense case. Substantial pre-deposition preparation of the defendant is sometimes the critical difference in a malpractice case. A defendant who does not listen carefully or whose answers ramble on may inadvertently say something that exposes him to a verdict without ever meaning to do so. The line between conduct which meets the “standard of care” and that which is outside the standard of care is often thin, blurred and potentially still evolving. A question posed to the defendant that leaves out certain important facts may lead to a deposition answer that is not truly relevant to the case itself, and if taken out of context at trial, may seem to the jury to be an admission against the defendant’s interest. To that end, defense counsel must listen carefully to the questions put to the defendant, and be prepared to lodge the appropriate objections.
There are a variety of questioning tactics or styles for which the defendant should be prepared. Some plaintiff’s attorneys bore into the defendant aggressively and accusatorily. Others are slow and detail oriented. Some are almost apologetic in tone and try to “buddy up” to the defendant. Many attorneys use one or more of these methods purposefully, while for others, it may simply be their general style. No matter what, however, the defendant should be alerted to concern himself more with what is being asked, not how it is being asked. Despite the oft-repeated mantra of “just answer the question,” the most difficult thing in preparing a physician for his deposition is frequently trying to convince him that he will not talk plaintiff’s counsel out of the suit by going on endlessly, trying to oversell his medical knowledge.
Although the plaintiff’s expert has likely come to some preliminary opinions based upon his initial review of the medical records, his review of the defendant’s deposition will be his first opportunity to learn about why the defendant did some of the things he did, and it will (depending on the extent of plaintiff’s counsel’s examination) illuminate details that may not appear in the medical records and accompanying office notes. If well prepared, and by answering carefully and articulately, the defendant physician can force a reasonable plaintiff’s expert to either limit his criticisms or to concede important elements of the defense case.
It is rarely good strategy for defense counsel to ask any questions of the defendant on crossexamination, since that may just remind the plaintiff’s counsel of additional questions to cover, and is not likely, in most cases, to flush out an answer that will cause the plaintiff’s expert to completely change his opinions. The general rule almost always applies to defending the defendant doctor’s deposition: keep the answers honest, short, and responsive to the question asked. Despite extensive pre-deposition preparation, even the most intelligent and savvy doctors still remain unpredictable once the deposition begins, and may yield to the temptation to say too much.
Expert Witnesses and Discovery Medical malpractice cases are unique in that expert testimony is generally requiredl6 of the plaintiff in order for the plaintiff to make a prima facie and submissible case. Although the defendant is not required to offer expert testimony, a defense expert is usually offered in order to counter the fact that the plaintiff offered “expert” testimony. Despite the recent attacks on “junk science” and the Daubertl7 case, it still requires very little to qualify as an “expert” witness in medical negligence
WASHINGTON -- A federal jury has convicted a Maryland cardiologist on six counts of insurance fraud for implanting coronary stents that weren't needed, ordering unneeded tests, and making false entries in patient records.
John McLean, 59, a retired interventional cardiologist in Salisbury, Md., implanted unnecessary cardiac stents in at least 100 patients from 2003 to 2007 at Peninsula Regional Medical Center, where he had hospital privileges, according to a press release from the Justice Department.
A federal jury in Baltimore found McLean guilty of falsely recording the existence of coronary artery blockage in the patients' medical records in order to justify submitting a claim to insurers, including Medicare and Medicaid.
He also ordered that his patients "undergo a battery of medically unnecessary follow-up tests such as stress tests, echocardiograms, and EKGs," and submitted insurance claims for those tests as well, according to the Justice Department.
"The evidence shows that Dr. McLean egregiously violated the trust of his patients and made false entries in their medical records to justify implanting unneeded cardiac stents and billing for the surgery and follow-up care," said U.S. Attorney for the District of Maryland Rod J. Rosenstein.
McLean faces a maximum sentence of 10 years in prison for healthcare fraud, and five years in prison on each of five counts of making false statements related to healthcare matters that he is charged with.
The federal government is also seeking $711,585 -- the amount McLean is believed to have defrauded the government of -- but a federal judge will determine the exact amount of damages when McLean is sentenced on Nov. 10.
"Placing unnecessary stents in the hearts of patients is a crime of unthinkable proportions," said Nicholas DiGiulio, a special agent with Department of Health and Human Services' Office of Inspector General.
"We will continue working to bring to justice those who practice greed rather than good medicine," DiGuilio said in the press release from the Justice Department.
The conviction comes on the heels of the Maryland Medical Board's decision to revoke the medical license of cardiologist Mark Midei, MD, for implanting unnecessary stents in four patients. Midei is not facing any criminal charges.
Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.
Primary care trusts are required to monitor the occurrence of Never Events within the services they commission and publicly report them on an annual basis.
The Never Events Annual Report 2009/10provides an overview of the Never Events reported to the NPSA by NHS organisations in England from 1 April 2009 to 31 March 2010.
An engagement exercise on the future of Never Events for 2011 and beyond for the NHS is being led by the Department of Health. Further information is available on the Department of Health website http://neverevents.dh.gov.uk
Baltimore, MD - Embattled interventionalist Dr Mark Midei is back in the news this morning after the release of a Senate Finance Committee report investigating ties between Midei and Abbott Laboratories [1].
The report, published on the Finance Committee website, calls the Midei imbroglio "a clear example of potential fraud, waste, and abuse."
"This report sets forth alarming evidence that patients at St Joseph Medical Center received unnecessary and potentially harmful stent implants time and again—a pattern that is shocking, disturbing, and shameful," Senate Finance Committee chair Max Baucus (D-Mont) said in a press statement. "Doctors should not be performing invasive medical procedures patients don't need, and taxpayers certainly shouldn't be paying for these wasteful and improper implantations."
According to the Senate Finance investigation, St Joseph billed government and private insurers more than $6.6 million for the procedures performed by Midei; more than half of this amount was paid by Medicare.
As previously reported by heartwire, Midei is alleged to have implanted hundreds of unneeded stents when he worked at St Joseph Medical Center in Towson, MD. The Maryland Medical Board is also investigating Midei, saying he repeatedly overestimated the severity of stenosis and used stents that weren't needed; the medical board proceedings have not yet concluded.
Midei has told heartwire that he stands by his work, although it's "possible" that faced with the same case today, he might "approach it potentially differently." After losing his privileges at St Joseph, Midei worked at the Prince Salman Heart Center, in Saudi Arabia, the report notes.
Other physicians who have reviewed the cases for St Joseph's or Midei's legal team have reached different conclusions as to whether the stents were medically necessary.
"A clear example of potential fraud"
According to the Finance Committee senators, who obtained thousands of internal documents, letters, and emails from both Abbott and St Joseph, Abbott had long been in the practice of rewarding Midei for being a high-volume user of its stents—a practice that continued "despite the ethical and legal questions surrounding Dr Midei."
A 2007 Abbott report titled "Project Victory," obtained by the committee, notes that Midei was one of the highest users of Abbott's stent in the US Northeast. Back in August 2008, just two days after Midei implanted 30 Abbott stents in a single day, Abbott paid for an "appreciation" pig roast for St Joseph's cardiac staff held in Midei's backyard; at least $1925 total was spent by Abbott on more than one occasion for "crab and barbecue dinners" at Midei's house. "Abbott employees attended the events during the period that Dr Midei implanted stents without clinical indication and consequently may have been medically unnecessary," the report notes.
In all, Abbott paid more than $30 000 to Midei to help market its drug-eluting stent, including paying for a trip to Asia geared toward "getting the word out in China/Japan." When Midei lost his privileges to practice at St Joseph over the unnecessary-stenting allegations, Abbott swooped in to help, offering him consulting work. "It's the right thing to do because he helped us so many times over the years," an email obtained by the Finance Committee notes.
Other emails are also telling. Following some of the initial stories about Midei in the Baltimore Sun, an Abbott executive said in an email: "Someone needs to take this writer out and kick his ass! Do I need to send in the Philly mob?"
Guilt, innocence, and opinion
The Midei case is a high-profile example of what may become a more common phenomenon: state and federal checks on individual physician and hospital use of stents and other devices. As reported by heartwire, another "unnecessary-stenting" case is currently playing out in Texas, where the medical board there alleges that Dr Samuel J DeMaio failed to meet the standard of care in his treatment of nine patients, placing multiple stents in areas of insignificant or moderate disease, among other charges. In one case, DeMaio placed more than 30 stents in a single patient, albeit over a number of years.
Quoted in a New York Times article about the Senate investigation [3], Dr Steven Nissen (Cleveland Clinic, OH) observed, "What was going on in Baltimore is going on right now in every city in America," Nissen says. "We're spending a fortune as a country on procedures that people don't need."
But Dr William O'Neill (University of Miami Miller School of Medicine, FL), one of the physicians who reviewed patient records and scans for Midei's legal team, told heartwire that Midei is being treated as "guilty until proven innocent."
"Where does Dr Midei go to get his reputation back when he is exonerated? I have seen nothing in my review of records that suggests that he was negligent or dishonest or fraudulent in treating his patients. . . . It is irresponsible of Dr Nissen to comment on this case without ever having seen charts or cines or been involved with medical supervision of this cardiologist."
In response, Nissen told heartwire: "I wasn't commenting on the specifics of the Midei case, although it seems astonishing that a single cardiologist could place 1200 stents in a single year. The excessive use of stents in stable-angina patients in America is readily apparent to most observers. I frequently see patients with multiple stents that were initially placed for atypical symptoms in the absence of severe stenoses and without evidence of documented reversible ischemia. Our payment system incentivizes aggressive use of invasive procedures, and that's often what we get, quantity rather than quality."
Abbott spokesperson Jonathon Hamilton told heartwire that the consulting arrangements between Midei and Abbott had concluded earlier this year, although he could not provide a reason. He called Midei a "highly regarded physician in this field."
Last Modified: Wednesday, June 29, 2011 at 9:59 p.m.
BARTOW | A Polk County man has filed a lawsuit against Winter Haven Hospital, saying a fire broke out during a procedure to give him an implantable cardioverter-defibrillator and that the fire caused him to lose two fingers on his right hand.
The fire caused second- and third-degree burns to his thigh and right hand, resulting in skin grafts on his thigh and amputation of his fourth and fifth fingers, Ormond Dees said in the lawsuit filed in Circuit Court in Bartow.
His medical malpractice lawsuit also names as defendants Dr. David K. Evans, cardiovascular and thoracic surgeon, and Florida Heart and Vascular Surgeons P.A., the professional association with which Evans is affiliated.
WHH has filed a motion to dismiss the complaint, saying it doesn't specify people for whom the hospital is liable.
Florida Heart and Vascular Surgeons, in its response, alleges that Dees contributed to the injuries and that third persons other than the surgeon were responsible for the injuries Dees sustained.
Dees' lawsuit contends the hospital, including the surgical nurses attending Dees, was negligent by not having proper sterilization solution available, by applying excessive alcohol preparation solution and by failing to allow the alcohol-based solution used "to dry so as to avoid causing a fire." The surgery took place June 7, 2010.
It said having excessive solution caused the solution to pool on the bed sheets, resulting in a fire breaking out during the surgery.
Justice Douglas E. McKeon, center, meeting with lawyers as part of an effort to resolve malpractice suits before they move to trial.
By WILLIAM GLABERSON
Published: June 12, 2011
In Justice Douglas E. McKeon’s fluorescent-lighted chambers in the Bronx, a new way of handling medical malpractice suits was on full, and sometimes gruesome, display. Around a polished wood table, lawyers haggled over the price for a lost nose ($300,000) and the missing tip of a finger ($50,000).
The discussion was like some kind of malpractice bazaar, with lawyers blurting out terrible facts and big numbers.
“Our offer of $500,000 is more than we’ve ever had on a dead baby case,” said Margaret Sherman, a lawyer for the New York City Health and Hospitals Corporation, which runs 11 public hospitals.
The patients were not there, but the lawyers and Justice McKeon — who has better-than-average medical knowledge — were. Cajoling, flattering and arguing, Justice McKeon, of State Supreme Court, worked to bring about settlements long before the cases moved toward trials.
The approach, known as judge-directed negotiation, is seen by the Obama administration as offering states a way to curb liability expenses that have sharply increased health care costs nationally. Getting judges involved earlier, more often and much more actively in pushing for settlements, is its crucial ingredient — evident in the recent session watched by this reporter, one of many that are usually not attended by the public.
New York officials say the program bypasses years of court battles, limiting legal costs while providing injured patients with compensation that is likely to be less than a jury would award but can be paid out years earlier, without lengthy appeals.
Under a $3 million federal grant, the city courts are now expanding the program beyond the Bronx, where it started in cases against city hospitals, to courts in Brooklyn and Manhattan, as well as to cases against private hospitals. It is to begin in Buffalo courts in the fall.
“We would hope that other states across the country would look at this as a model they might want to replicate,” said James B. Battles, the official overseeing the grant at the federal Agency for Healthcare Research and Quality. By some estimates, the program could save more than $1 billion annually if state courts adopted it nationally, Dr. Battles said. The city’s public hospitals say the program, along with other changes, like sharply increased attention to safety, has helped save $66 million in malpractice costs a year. During the recent session in Justice McKeon’s chambers, the lawyers seemed more relaxed than they would be with patients watching. After he agreed to take $1.5 million for a child with cerebral palsy, a plaintiffs’ lawyer, Louis G. Solimano, seemed disappointed. “I didn’t get a grand slam,” he said.
Malpractice costs have been at the center of the debate about health care expenses for decades, with some states enacting legislation to limit awards. But the lawsuits have been difficult for judges to control, partly because the cases can go on with little judicial involvement for years, pushing up legal expenses and solidifying positions.
Michelle M. Mello, a Harvard professor of law and public health who is evaluating the New York experiment, said the program represented a major cultural change in malpractice cases. “Ordinarily when the parties come to a settlement conference, it’s late in the game,” she said. “It’s often a pro forma exercise rather than an attempt to grapple with the tricky issues in the case.”
It is estimated that over the next twent years, the number of diabetics will double worldwide. Diabetics are at risk for a number of systemic complication of disease including stroke, heart attack, blindness, renal failure and limb amputation. Limb amputation is usually preceeded by the development of a foot ulcer or wound which will occur in over 15-24% of diabetics of the course of their time suffering from diabetes. Of those diabetics who develop ulcers, studies suggest that over one half will require some degree of amputation. Frequently the delay in identification and treatment is because diabetics frequently suffer from neuropathy and thus lack feeling. Therefore they may not know when a wound is present. Additionally, because of poor eyesight, they may not see the wound.
Early identification and referral to specialists familiar with the workup and evaluation of the wound etiology is critical. These specialists may include podiatrists, vascular surgeons, plastic surgeons and cardiologists.
End Stage Renal Disease is a life changing process for patients requiring either kidney transplantation or hemodialysis. Hemodialysis through dialysis shunts, fistulas, peritoneal catheters or dialysis catheters is an effective means of cleansing the blood of toxic metabolites. The minor procedures to construct these sites are not without periodic complications like infection, bleeding, thromboses, steal syndrome however early recognition of such complications permits treatment and avoidance of many long term consequences
Treatment of End Stage Renal Disease by a multidisciplinary team of vascular access professional facilitates this early recognition of problems and not unlike other disciplines of medicine leads to improved outcomes.
