Prognosis Guarded: Trusting your doctor

By Marvin Ginsburg MD

"Prognosis Guarded" follows the exploits of doctors who owned a small hospital to develop in their own creative way, a method to bill Medicare for patients who were critical throughout their hospitalization. However, these patients had died months to years previously. This is a medical mystery surrounding greed and the dedicated medical professionals who attempt to uncover the mysteries. This book is a page turner that involves the interpersonal relationships that entwine in evil and an outcome that cannot be anticipated though hints are presented repeatedly.

• Language: English
• Publisher: BookBaby
• Release date: Jan 30, 2024
• ISBN: 9798350925265

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Dedication

To the doctors practicing medicine who remain their patients’ advocate and oppose the radicalization of this noble profession.

Acknowledgment

I had no problem writing this book, but I could not have gotten it ready for publication without the help of my son, Mark.

Contents

Acknowledgment

1 A Reason to Leave

2 Making New Friends and Hearing Gossip

3 Marital Bliss Not

4 Sick Father and Sicker Son

5 Financial Frenzy and the Salvation Plan

6 Alex Seeks Medical Help

7 Making the Mask

8 The Art of Alex

9 Complications

10 Dr. Lund Finds a Way

11 Alex Hears the Bad News

12 More Admissions to the Respiratory Care Unit

13 Leaving for Good

14 The Hook

15 The Offer

16 Got Three More

17 Ready for a Fight

18 Preparing for the Audit

19 God’s Gift to Surgery Arrives

20 The Ideal Medicine for Respiratory Failure

21 Another Surgery Gone Bad

22 Good News for Alex

23 CAYMAN ISLANDS

24 Dr. Mark Gaines Reviews Dr. Kovacs Care

25 Alex Comes Home

26 Dr. Gaines Sees His First Case of Myasthenia Gravis

27 Poor Alex

28 US Care Makes Purchase Offer

29 Another QA Problem

30 Erin’s and Bob’s Plans for the Future

31 Erin Revises the Plan

32 It All Comes to Roost

33 New Rules for the Respiratory Care Unit

34 Hiring Tony

35 A Very Rare Chest X-Ray

36 The Mask of the Masked Revealed

37 Kovacs Meets His Maker

38 Marriage, Bora Bora, Fiji, and Turtle Island

39 Dr. Lund Falls Ill

40 The Assets

41 A Visit to the Bank

42 Surprise, Surprise

43 Tony the Knight in Shining Armor

44 Dr. Small Gets His Share

45 The Last Straw

Epilogue

Author’s Note

Copyright Marvin L. Ginsburg, 2023

All rights reserved. This book or any portion thereof may not be reproduced or used in any manner whatsoever without the express written permission of the publisher except for the use of brief quotations in a book review.

This book is a work of fiction. Names, characters, places, events, and incidents are fictitious, and any resemblance to actual persons, living or dead, is purely coincidental.

ISBN: 979-8-35092-525-8 paperback

ISBN: 979-8-35092-526-5 ebook

1

A Reason to Leave

The anxiety he experienced as he drove along desolate Highway 14 was making it difficult to breathe. It was only made worse by his inability to cast from his mind last week’s medical staff surgical committee meeting at Woodland Community Hospital. The sun drenched the opaque mountains splattered with patches of yellow and gold. Immediately, he found himself squinting in an attempt to hide from the sun’s blinding rays. His meeting was scheduled to take place in one hour with the owners of Palmdale Hospital. Dr. Mark Gaines was desperate to move away from the den of iniquity he had blindly entered.

Leaving the University Hospital in June 1995, only a few short months ago, he decided to enter the practice of internal medicine with the subspecialty of pulmonary medicine in the west San Fernando Valley. Never in his wildest dreams had he expected to witness the shocking state of the practice of medicine he had come to know so well.

He had rapidly become disenchanted with the practice of medicine in the Valley. Too often his ideals and moral fibers were tested and caused him to develop defense mechanisms and symptoms of anxiety in order to cope with these problems. What kind of people are these who hold themselves out to be healers and yet they march to the tune of Mammon, God of Money? They have no compassion and do not measure their self-worth by the satisfaction of their performance or the warm feeling that comes from helping the sick.

He made his decision to escape from that pit of hell because he could not stand to see the cheating games played out daily. The indignation and holier than thou attitudes, as well as the grandiose declarations and pontification by those doctors of medicine, were more than he could endure. They proclaimed innocence of their incompetence to their colleagues, who were just as inept. If you had a large patient base, then you were king because you controlled their referrals, and no colleague wanted to alienate you for fear of losing that source of patients. It was so bad that there were many physicians who found that the indication for a procedure, surgery, or test was entirely predicated on the type of health insurance. He had had it! Last week he had decided he would leave, although, despite his conviction, he continued to agonize over his decision.

How could he have stood silently by and allowed that young girl to undergo a needless thoracotomy by that so-called surgeon? When Dr. Kovacs had asked him to evaluate her for elective surgery because she had asthma, he never imagined the web of entanglement that would follow.

She could have physically undergone the surgery, but that wasn’t the point; her chest X-ray had revealed a six-centimeter cyst in the left lower lobe. The film, taken ten years previously, had shown the identical cyst. It had not changed in size; the girl was entirely asymptomatic, and her breathing tests were normal. After evaluating all the facts, he had concluded that this was a simple congenital lung cyst that required no surgical intervention. In his written consultation, he so stated this, which was interpreted by Dr. Harvey Kovacs as depriving him from a healthy four-thousand-dollar fee to carve open her chest, leaving a hideous scar.

After all, he told me he was the surgeon and the one who must accept the responsibility for this patient’s care. I have asked you to evaluate her for her ability to undergo the anesthesia and to tolerate the surgery, and I am not interested in hearing what you have to say about the lung lesion. Gaines was shocked that Dr. Kovacs was attempting to coerce him into removing his objection for this patient’s surgery. There was no doubt in this doctor that this caused him some element of financial distress.

Mark was adamant about his position, which he knew was correct, and he was incensed over the fact that Dr. Kovacs was so motivated by money. Then Mark said, What you are planning to do is malpractice, and I will take this to the surgery committee.

Dr. Cohen, the chief of surgery, was notified and was in accordance with Mark’s position. He felt the quickest way to deal with the problem was to select an ad hoc committee to hear the issues and decide on their merit.

The next day, the ad hoc committee for the Department of Surgery was called to order, and Gaines was requested to present his case in detail. When he finished, the floor was turned over to Kovacs for his presentation and rebuttal. If he had only known that what he had started was a holy political war, Mark might have elected to walk away from the confrontation.

Those doctors who derived referral patients from Dr. Kovacs were lined up on his side of the long table. They were showing their support for their colleague. The others were seated with Gaines on his side of the table. Honesty was defined here as not being in the referral pattern of Dr. Kovacs and his friends. The others, of course, looked at the good doctor as a continual source of revenue enhancement.

Dr. Harvey Kovacs was a man about fifty-five years old, five feet ten inches tall, with shocking white hair much more extreme than a man his age deserved. He had a fair complexion and piercing light blue eyes. He was revered by many of his colleagues and loved every minute of it. Harvey spoke with deliberate purpose and a slight New York accent, sounding like a charming politician exemplifying the classic con man. Mark was convinced that Kovacs might have missed his calling. He explained away his rationale for wanting to operate on his patient with total disregard for anything even slightly resembling the truth. His opinions were bathed in untruths, omissions of facts, and innuendos, and like an artist, he produced a picture that only could have been created by his dishonest mind. It was his intention to sway and lead his supporters in his direction. After all, he said, this may be a malignancy; one can never be sure.

Dr. Mark Gaines interrupted, But there are no risk factors, and her entire evaluation is normal. Harvey’s eyes scanned each of his friendly colleagues seated at the conference table. He attempted to transmit the dollar signs that referral patients signify. I have been doing chest surgery for twenty-five years, he said using his soft-spoken convincing voice. I strongly object to you questioning my opinion. Mark asked, Why haven’t you done a lung scan, which would easily answer this question? This is a simple lung cyst requiring no surgical intervention, and, if you are wrong, you will only inflict upon your patient a large, hideous scar forever. I can’t let you do this to her, Mark said. Harry Cohen, chief of surgery, called for order, and after he had asked a few choice questions of his own, he then allowed the discussion to continue. He then called for a vote on the issue. Mark’s position was affirmed by the committee, and the good Dr. Kovacs was ordered to cancel the surgery for the lack of an appropriate indication.

Dr. Kovacs, upon hearing this decision, ejected himself from his seat by throwing his chair back against the wall and began a barrage of self-serving statements. He shouted, I have never been so humiliated before my colleagues! I have been a surgeon for more than twenty-five years, and you have prevented me from performing a needed surgery on my patient.

Dr. Gaines got up and left the room. In seconds he was confronted by Dr. Kovacs. You will never see another patient in this valley, I’ll see to that, he snarled while positioning himself between the hospital entrance and Gaines. You’ll regret this, you son of a bitch! he shouted, shaking his long, delicate surgical finger in Mark’s face. I’ll get you one day, you bastard. You’ll be blackballed in this town. I know everybody, and you will pay for this. Kovac told him much more than his verbiage.

For but a fleeting moment, Mark again felt the fear of losing a practice that he had only just begun to build. You money-grubbing incompetent. Go screw yourself. Dr. Gaines stormed out of the hospital.

The freeway sign read Avenue S Exit. Mark entered the right lane without signaling, feeling that it was unimportant since he had only seen three other cars on the freeway the entire time. As he approached the stop sign, he saw strange plants along the adjacent hillside. They were five to seven feet tall, were very straight, and their leaves were long and stiffly pointed. He dimly recalled that a small town in the desert was named after the plant: Yucca Valley, he thought. The sign pointed to the right for the hospital. He turned right and traveled the road about a mile to the stop sign. Carefully looking both ways, he scooted across the intersection and drove another mile, where he noted an American flag waving from a flagpole. The flagpole was situated in front of a low-profiled building that was sprawling on two sides. As he turned right to approach the building, he drove through a barren desert for a quarter of a mile. This hospital seemed out of place, situated right in the middle of the desert surrounded by junipers, yuccas, and jackrabbits. To the right of the hospital was another single-story rambling building that extended along the street to the main road he had just turned from. He walked into the small entrance and approached the telephone switchboard operator who was sitting behind an enclosure.

May I help you? she asked.

Why, yes. I am Dr. Gaines, and I have an appointment with Dr. Small.

Very well. If you’ll have a seat, I will let him know you are here, she announced in a loud voice.

Thank you, replied Gaines, slightly annoyed at the operator. Her loud voice was brash to him, and it made him feel ill at ease.

He looked around at the tiny area that was obviously reserved for patients’ families. The wall lacked color coordination, and the hanging pictures were desert scenes, some of which were ghastly and certainly didn’t belong in a hospital. This was especially true of the one picture depicting a circling vulture about to descend upon a dying cow. He thought the other pictures were just as harsh. The yellow-green walls were not pleasing to the eye, and the carpet was a hideous blue with green designs that resembled a Rorschach inkblot test. Dr. Gaines studied the design and was sure he could see a dragon’s head.

Hi, glad you could come and visit with us. My name is Dr. Rick Small, he said in a manner that indicated perhaps he wasn’t sure of his own name.

What a weirdo, Mark thought. They walked down the hill and entered the rear door of the other building that he had passed on the way to the front of the hospital. After a few feet, Mark was led through a door that opened on the left side of the hallway. They were in a large dining hall furnished with many oak tables. On the left side was a serving line where white-hatted servers spooned food onto large plates. The line ended at a cashier strategically positioned to collect money from the diners. He was motioned by Dr. Small to enter the line, upon which he did so with gusto since it was already one o’clock and he hadn’t eaten anything since 6:00 a.m. As he passed through this line, he became aware of a silence that blanketed the room; the initial voices and conservations were now gone. He barely noticed the questioning glance that the cashier directed at Dr. Small. Dr. Small grunted something unintelligible and led the way to a far corner of the room where a large, round table was situated. It seemed to be purposely placed so as not to be too close to any other table. In the center of the table was a black telephone. They sat at the table, and Dr. Small introduced him to Dr. Bob Lund.

So, Dr. Gaines, are you interested in practicing here with us? Lund began. Somewhat stunned at the direct salvo, Dr. Gaines gazed about the table. He was aware that all the diners in the cafeteria were now staring at him as though he were a Martian. Perhaps he had food on his mustache. His wife was forever alerting him whenever he had tried to feed his mustache. His hand slipped quickly to his lap, and with a single motion, he drew the napkin to his lips, sneaking a brush over the mustache. Feeling certain that nothing was there, he lowered the napkin and looked directly at Dr. Lund. Dr. Small was a man of fifty years of age, medium build with sparse white hair and a large bald area in the center. He had a ruddy complexion and was clean-shaven. His eyes were dark brown so that the pupils were not easily visible, and he wore a white doctor’s jacket that was badly stained. It looked as if it hadn’t seen starch in many a year. Mark was suddenly acutely aware that he hadn’t answered the question.

Oh, ah yes, I am.

Mark, I’d like you to meet our hospital administrator, Bill Hendrickson, said Dr. Lund.

Mark stood up and leaned forward slightly while extending his hand across the table. Bill was at least six foot two, trim, with curly sandy hair. His eyes darted between Drs. Lund and Small and had that wily and insecure appearance. It was obvious that Hendrickson was a pawn. Mark concluded that his function was to validate everything said by the doctors. This became immediately apparent as Hendrickson bobbed his large head in agreement with Lund, who had just made an insignificant remark. Mark’s antennae were immediately tuned in.

Mark told them Dr. Reed, the radiologist at Santa Clarita Hospital, informed him that a well-trained internist was badly needed in Palmdale. He told them he was interested in relocating to another area and in exploring the opportunities that their group had to offer.

Well, began Dr. Lund, we have only one internist here, and that’s me. I am a general practitioner though. Our hospital must transfer many patients down below for their acute hospital care because I can’t handle the high workload in the hospital as well as the office. Also, Palmdale has an overwhelming number of seniors who are seriously ill and really require someone in Internal Medicine.

Where’s this down below you mentioned? Mark interrupted.

That’s the San Fernando Valley, he replied.

How often does that happen? Mark inquired.

What would you guess? Dr. Small asked abruptly, directing his statement to Dr. Lund.

Oh, five to six times a week, said Lund shaking his head up and down.

What are the usual medical problems involved? asked Mark.

Half trauma and half acute medical problems, said Bob Lund.

Where are the closest internists? asked Mark.

In Lancaster, about fifteen miles away, replied Bob Lund.

Won’t those docs come here? Mark asked, wrinkling his brow with disbelief.

Nope. They are at war with us, interjected Bill Hendrickson.

Why is that? asked Mark.

Well, it’s a long story, but in a nutshell, they have their own hospital and want to hurt us.

I still don’t get it, answered Mark looking confused.

It’s like the Hatfields and the McCoys, piped up Dr. Small for the first time.

Who owns this hospital? he asked. All three of his lunch companions started to answer at once.

Dr. Lund replied, Dr. Small and I are the owners.

I see. It’s a battle of economics then, and, if they won’t help, they think you will eventually fold.

That’s right, Lund said in despair.

Do you think that I can build a practice quickly? asked Mark eagerly.

No problem there, Hendrickson volunteered. We will refer to you all the medical patients seen in the emergency room as well as the patients from the managed care plans, not to mention the patients we would refer to you for consultation.

What about your pulmonary services, and who reads your EKGs? Mark asked.

Well, said Dr. Lund, we could contract those services to you." Small and Hendrickson both eagerly nodded their heads in confirmation. Mark liked what he heard. He then felt very excited, for this was an opportunity just waiting to be seized.

He mulled the possibilities over in his mind as he left the hospital after saying his goodbyes and told Dr. Lund that he would call him in a day or so. All the way back to the San Fernando Valley, he replayed the recent conversation with Dr. Lund over in his mind. Mark wondered if these doctors could really be trusted to fulfill their part of the bargain. More specifically, he was concerned whether there was really an opportunity as good as the picture just presented to him. He knew this area of LA County had recently seen a population explosion in both the working-age groups, as well as the Medicare ages. In his specialty he was certain that he would see more patients in the Medicare age group. The doubt he had was related to the fact that the people who were over the age of sixty-five were, for the most part, signed up with managed care groups who administered the medical care for the large health maintenance organizations (HMOs). It was funny, he thought, that no mention of any HMO patients or group practice who had an HMO contract was ever mentioned at the meeting. He’d give them a call tomorrow to explore those issues. If most of the patients were already signed into a medical group for their care, how would he get referrals from private Medicare patients? He already knew he had to be a member of the referral doctor’s group or of the independent practice association in order to provide medical care to a patient. Gone now were the days when a patient chose his own doctor and was not controlled by a gatekeeper who directed all his medical care. Today, patients were referred to doctors who had agreed to accept a marked reduction in their fees in order to gain patient referrals. Some doctors had even been capitated for their specialty services and would thus receive a fixed dollar amount per patient assigned to them per month. In one way, this was a good thing. If the patients were not ill, the doctor would not have to see the patient, thus allowing the doctor more time for other paying patients. The only problem with the scenario was that there were not many other patients. All the patients were assigned to group medical practices, and those groups were trying to stay alive by accepting large numbers of patients into their group in order to increase their capitation and enhance their profitability.

He had an unrestful sleep that night, and upon awakening the next morning, he placed a call to Dr. Bob Lund.

Hi, Dr. Lund, this is Mark Gaines, he said cheerfully.

Good morning, Mark. Have you thought over our proposal?

Uh, yes, I have, he said, somewhat unsure of himself. Tell me, who has the major share of the HMO patients in the Antelope Valley?

Why, we do, right here in our group. Didn’t I tell you that yesterday? questioned Lund.

As a matter of fact, you didn’t, answered Mark.

Mark, we have fifteen thousand capitated lives assigned to us by US Care. You know who they are, don’t you? asked Bob in a positive way, as if to ensure an affirmative answer.

Oh, sure I do, replied Mark with authority. He really didn’t have a clue who US Care was. Tell me, how many are Medicare enrollees?

I’d guess about ten thousand or so, Bob replied.

Mark performed a mental calculation based on what he had read about group capitation and estimated that each patient was capitated to the group at $120 per month. He then quickly computed that the group received one million two hundred thousand dollars a month, or about fourteen million dollars a year. And that was not counting the five thousand non-Medicare or commercial insurance patients.

If that’s so, then I would guess that I would be paid on a discounted fee for service? asked Mark.

We would rather pay you a yearly salary and have you work directly for our group, replied Bob.

Over the next fifteen minutes, Mark haggled out a yearly salary of one hundred fifty thousand dollars, four weeks’ vacation, one week sick pay, one week paid medical education seminars, and a one hundred thousand dollar a year disability policy. He agreed to start the following week.

2

Making New Friends and

Hearing Gossip

Upon arriving at the clinic, Mark rapidly acquired information through the grapevine common to all medical groups. He made friends with some of the nurses and clerical help. At lunch one of the secretaries told him the group was losing a lot of money because they had to refer so many of the very sick patients to hospitals in the San Fernando Valley for hospital care. This turned out to be costly since the group had no contracted rates with any of the larger hospitals. These hospitals knew that groups located away from the Los Angeles basin were at their mercy. Medicine was now a cut-throat business, and for hospitals to survive, they charged what the market would bear. They had to pay all the doctors who provided care as well, and since they had no contracts with these doctors, they were being raped. Since they never knew what doctor would be assigned to their patient, it would be impossible to contract with all doctors. This was coupled with the fact that this area of the desert had seen a massive influx of retired elderly patients who had migrated because real estate in Palmdale was cheap. Many had sold their expensive properties at the apex of California’s real estate boom seven years earlier and had relocated to preserve their wealth. There were now living in the Antelope Valley this large group of seniors who had moved there with their illnesses. They had not always resided in the area, so the statistics for predicting disease in this given population were skewed. They had all moved from urban areas elsewhere in the state with their illness in tow. Now they were part of a large, senior managed care plan sold extensively in the Antelope Valley. The Palmdale Medical Group had flourished at the beginning when the senior enrollment had been three thousand, and it was said they had profited extensively. The Medical Group had spun off a profit of one and one half million dollars during the second and third year of existence. The first year was a wash for the group because they were in the growth stage. Until the group’s enrollment exceeded fifteen hundred enrollees, the profit was minimal, if any. When the enrollees’ numbers were low, there were high costs, and it seemed that everyone was sick. There were no healthy patients who did not require care. The over age sixty-five gang also utilized at least five times the group’s resources. This meant that they used more office visits than their working counterparts. As a matter of fact,