by Nelson Griswold
When Maureen Pacheco of Palm Beach, FL, needed spinal fusion surgery in 2016, general surgeon Ramon Vazquez was assigned to cut her open so the two spine surgeons could perform the fusion procedures.
A Board-certified surgeon, Dr. Vazquez is a Harvard University graduate with a medical degree from New York's prestigious Albert Einstein College of Medicine, with top ratings on Google, Vitals, and U.S. News & World Report. All the evidence points to Dr. Vazquez being a great doctor.
After cutting open Ms. Pacheco, Dr. Vazquez noticed a mass on her pelvis. Believing it to be a cancerous tumor, he removed the mass in its entirety, without a biopsy or the patient's permission, then allowed the spinal procedure to continue.
Following a successful spinal surgery, Ms. Pacheco woke up in recovery to an unexpected—and horrifying—outcome. She now had two fused vertebrae...and one kidney.
What Dr. Vazquez presumed to be a malignant tumor was, in fact, Ms. Pacheco's healthy left kidney, a "pelvic kidney'' that had never moved up to its normal position in the upper abdomen. Dr.Vazquez later acknowledged that he never reviewed his patient's medical records before the surgery, which would have revealed the pelvic kidney.
Yet, even after removing a patient's healthy kidney, settling the resulting malpractice suit, getting dismissed by the hospital where the surgery occurred, fighting off the state's efforts to revoke his medical license, and agreeing to pay a $3,000 fine, Dr. Vazquez remains a doctor in good standing in the Florida Blue (BlueCrossBlueShield of Florida) provider network. His listing in the FloridaBlue online physician directory offers no warning or any indication to the member that this is a doctor with poor patient outcomes and a recent case of gross negligence.
Of course, a reasonable and generous person could view what happened to Ms. Pacheco simply as a terrible but well-intentioned mistake on the part of Dr. Vazquez. After all, until then he had a clean disciplinary file with the state Board of Medicine.
If one were to check his surgical outcomes quality scores, however, one might discover scores that confirm Dr. Vazquez to be a bad surgeon.
What is most concerning isn't that there are bad doctors like Ramon Vazquez. There always will be bad doctors and unsafe hospitals, of course, but shouldn't we expect our health insurance company to protect us from them, and to guide us to the best providers?
Low-volume, high-risk hospitals
In hospitals, a high volume of any particular surgical procedure almost always equates to high quality. Most patients are unaware that the opposite is equally true, that low volume of a surgical procedure in a hospital equates to high risk for patients having the procedure at that hospital.
Patients undergoing high-risk surgeries are more likely to suffer complications, harm, or even death when the surgeon and/or hospital are inexperienced at that procedure. In one low-volume hospital, an analysis by U.S. News & World Report showed that patients were 24 times more likely to die from a knee replacement surgery than in the highest-volume facilities.
This problem is extremely widespread. Fully 87.8 percent of hospitals perform open heart procedures too infrequently to ensure patient safety and high-quality medical outcomes. And 90.9 percent of hospitals similarly perform rectal cancer surgery too infrequently. The BUCAH (Blue Cross, UnitedHealthcare, Cigna, Aetna, Humana) insurance companies know which hospitals perform a sufficiently high volume of any given surgical procedure to be safe and high-quality...and which do not and pose a danger to patients needing that procedure. Due to their network contracts, however, the BUCAHs refuse to inform and guide their members to the safe, high-volume hospitals.
Health-care Russian Roulette
Bottom line, the BUCAH insurance companies will not and cannot keep you safe from bad and even dangerous providers. By denying you provider quality scores, the BUCAHs force you to play Russian Roulette with your health and your life when choosing a doctor or hospital from their networks. You might get a world-class doctor—CLICK; you might get another Ramon Vazquez—BANG.
According to the New England journal of Medicine, just two percent of physicians are responsible for 39% of medical malpractice claims paid in the U.S. Let's assume-wrongly-for our purposes here that only two percent of doctors are dangerous. Two percent seems like a small risk, doesn't it? But if offered a jar of 100 aspirin tablets for your bad headache, would you take a couple of tablets if you knew that two—just two—of the 100 were cyanide tablets?
Life and death decisions in the C-Suite
Business owners and company executives, of course, would find absurd the idea of providing even a single employee an aspirin with 98 aspirin tablets and two cyanide tablets. That miniscule risk is totally unacceptable.
Yet every year, owners and executives in America's C-Suites makes the decision to put their employees in BUCAH-managed health plans that intentionally conceal provider outcomes data from their plan members.
Most employer-sponsored healthcare plans are BUCAH fully insured health plans or self-insured plans managed by a BUCAH carrier under an "administrative services only" (ASO) agreement where the employer funds the health plan. Since both BUCAH fully insured plans and BUCAH ASO arrangements require use of the carrier's provider network, all BUCAH-managed health plans hide provider quality scores from the plan members.
That means that any plan run by a BUCAH carrier will force the members to choose their doctors and hospitals without the benefit of provider outcomes quality scores.
So, at every annual plan renewal, the C-Suite makes a decision regarding the company's healthcare plan that can have life and death implications for their employees. When owners and executives decide to put or keep employees in a BUCAH-managed plan, they unwittingly are putting the health and lives of their employees at risk. In other words, every year when choosing their employees' healthcare plan, employers are making life and death decisions in the C-Suite.
When you see someone being forced to play Russian Roulette, don't you take away the gun? Once you realize that your current BUCAH health plan forces you and your employees to play health care Russian Roulette, unnecessarily putting you and your employees at risk, don't you want to remove the BUCAH plan and look for an alternative?
This post includes an excerpt from Chapter 1 from the book Life and Death Decision in the C-Suite. To purchase the full book, click here.
