Hospital Profits as MD Maimed and Killed Patients

August 1, 2011

EDITOR’S NOTE: In September 2010, the Minnesota Board of Medical Practice publicly reprimanded former St. Luke’s neurosurgeon Stefan Konasiewicz (right) for “unethical and unprofessional conduct,” citing four cases that resulted in injury, quadriplegia or death.

Based on that action, the News Tribune launched an investigation into the history of Konasiewicz’s practice in Duluth.  A News Tribune series May 29-31 described Konasiewicz’s rise to become St. Luke’s hospital’s highest-paid physician even as he was sued nine times for malpractice.  Allegations of harm by former patients or their families were confirmed through searches of databases, public records and patient-volunteered medical files.

Today’s report focuses on the efforts of Konasiewicz’s former colleagues to warn the St. Luke’s administration about his practice, and the hospital’s response. 

by Brandon Stahl
Duluth News Tribune

As St. Luke’s kept a surgeon connected to numerous complaints, his practice helped the hospital turn a profit.  Despite numerous malpractice suits and warnings from their own doctors and staff that Stefan Konasiewicz posed a risk to patients, St. Luke’s hospital continued to allow the neurosurgeon to practice.

One possible reason: Konasiewicz, who worked at St. Luke’s from 1997 to 2008, produced significant revenues for the hospital by performing more neurosurgeries than his peers in Duluth.

And during Konasiewicz’s time at St. Luke’s, the hospital went from the red to the black, financial records obtained by the News Tribune show.

“The assumption from many people was that St. Luke’s didn’t deal with him because he was bringing in so much revenue,” said Suzanne Canfield, a retired surgical technician who worked in St. Luke’s neurosurgery department. “Many physicians and anesthesiologists had concerns about him right from the beginning.

“But what bothered me was that administration didn’t address them,” she said. “At least, nothing ever changed.”

Peter Goldschmidt, an orthopedic surgeon who shared patients with Konasiewicz as part of St. Luke’s trauma team, said he saw so many complications and adverse outcomes from his colleague that in the early 2000s he brought his concerns directly to St. Luke’s senior administration. People he addressed, he said, included CEO and President John Strange, Vice President of Clinics Sandra Barkley and Chief Nursing Officer JoAnn Hoag. He said he also spoke about Konasiewicz with the then-chair of St. Luke’s board, Wells McGiffert.

“I thought something had to be done because of the unacceptably high complication rate,” said Goldschmidt, who has worked in Duluth since 1994 with Orthopedic Associates, an independent practice that works with St. Luke’s. “Nothing seemed to change in (Konasiewicz’s practice). And I never received any follow-up.”

In an interview on Friday, Strange, who has been CEO of St. Luke’s since 1996, said the responsibility for taking any action against Konasiewicz lay with St. Luke’s doctors.

Strange said concerns that are brought to him or other administrators about any doctor are taken to the hospital’s medical executive committee, which is composed mostly of physicians and has the ability to discipline doctors or restrict their privileges. Strange said he is on the committee but does not have a vote.

“I’m not a physician,” Strange said. “Some of that stuff is so technical. I’m not in a position to make a judgment on whether or not something was good care.”

But doctors on the medical committee said that Strange had the ultimate authority over their decisions.

“As far as I was concerned, all employment decisions were made at the direction of the administration,” said Joel Zamzow, an orthopedic surgeon who has practiced in Duluth since 1994 and was on St. Luke’s medical executive committee from 2004 to 2010.

“We were aware of Dr. K., and the administration was fully aware of the problems that Dr. K. made,” Zamzow said. “The way it was dealt with was to allow the physician to continue to practice. What the administration tried to do was to see if he could be monitored or get more education. Personally, I don’t think that’s very effective, and it turned out not to be.”

Zamzow, who works at Orthopedic Associates, said he resigned from the committee and as section chief of St. Luke’s orthopedics department “over concerns I had and my frustration with administration regarding concerns over quality.”

Number of surgeries questioned

By the time Konasiewicz left St. Luke’s in 2008, the hospital had recorded three straight years in the black, with $4.3 million in profits. That’s a far cry from 1997, the year Konasiewicz was hired and when the hospital was in financial trouble. It was going through at least its second year in the red and on its way to a third, with combined losses of $7.7 million by the end of 1998.

To make matters worse, the hospital lost one of its biggest money-making departments: neurosurgery. An agreement to share those services with its rival, SMDC, had dissolved in the mid-1990s. All of the neurosurgeons went to SMDC.

But one doctor, William Himango, told the News Tribune that he returned to St. Luke’s to set up a neurosurgery department. Shortly after, the hospital hired Konasiewicz to work with Himango.

Konasiewicz was paid based on the number of procedures he performed, and he quickly became the busiest neurosurgeon in the city, several current and former Duluth surgeons told the News Tribune.

Numerous patients of Konasiewicz’s described him as diagnosing a problem in five minutes or less and then recommending major spinal surgery — sometimes the day after his diagnosis. Many patients said they were never warned about potential complications from the surgeries. If true, that would be highly unusual, said Dr. Robert Donley, a neurosurgeon who worked at St. Luke’s while employed at SMDC.

He said most candidates for neurosurgical care are counseled for at least an hour, and surgery is rarely scheduled immediately unless a problem reaches critical stages.

“In five minutes, you can’t tell what’s going on,” he said. “And if I see a patient on an elective basis, it’s very unusual to get them into surgery right away, unless they’re in dire straits.”

Canfield said she and other staff and physicians became concerned that Konasiewicz was operating on almost every patient who came in for a consultation and performing unnecessary surgeries.

“These are elective surgeries,” said Canfield, who worked at St. Luke’s from 1975 to 2006. “It would seem like almost everyone who saw him had a surgery of some kind.”

Dr. David McKee, a neurologist with Northland Neurology and Myology, said he believed that Konasiewicz was performing unnecessary surgeries.

McKee often shared patients with Konasiewicz, and he said he looked at their records before and after a surgery.

“I saw many cases where there were no objective findings on imaging studies or physical exams that would justify surgical treatment,” McKee said. “When there’s nothing significant going on neurologically, you can’t justify doing spinal surgery. These patients would get to me months and years later, and I would be scratching my head wondering how surgery could have been justified.”

Konasiewicz did not return repeated calls seeking comment.

St. Luke’s issued a statement about Konasiewicz in May when the News Tribune wrote a series of stories about his troubled history in Duluth. Neurosurgery, the hospital’s statement said, “is a specialty fraught with unavoidable risk of complications. Adverse outcomes do happen on occasion and they are not necessarily the result of negligence or recklessness by the physician.”

‘Alarming’ rate of errors

Donley told the News Tribune that Konasiewicz’s problems were known to St. Luke’s because, on several occasions, complications from Konasiewicz’s surgeries had to be dealt with by neurosurgeons at SMDC.

“The history of malpractice litigation against Dr. Konasiewicz, as reported in the newspaper articles, is very disturbing,” Donley said. “It suggests, contrary to St. Luke’s statements, an alarming and totally unacceptable rate of neurosurgical errors.”

For Konasiewicz, more lawsuits would follow. By 2005, he and St. Luke’s would be sued four times, including for two cases in which his work was alleged to have led to the death of his patients.

Around that time, SMDC began questioning Konasiewicz’s patient care, said Jim Callahan, the former chief of neurosurgery at SMDC.

Konasiewicz had privileges to operate at St. Mary’s Medical Center, Callahan said. But due to concerns about malpractice claims against Konasiewicz, Callahan said his hospital needed the St. Luke’s neurosurgeon to answer questions about the claims before his privileges would be continued.

Instead of answering those questions, Konasiewicz chose to withdraw his privileges at St. Mary’s, said Callahan, who is now practicing with a brain and spine clinic in Indianapolis.

Neurosurgery proved profitable

By the beginning of 2005, St. Luke’s had turned the corner financially. The hospital had experienced five straight years in the black, netting a combined $32 million. At the same time, the number of surgeries the hospital performed increased 164 percent — despite having about the same number of physicians on staff and no increase in the number of hospital beds.

Neurology admissions accounted for almost 25 percent of the hospital’s 5,780 surgical admissions in 2004.

For a neurosurgery department to bring big dollars to a hospital isn’t unusual. Merritt Hawkins, the largest physician search and recruiting firm in the country, surveyed 3,000 hospital chief executive and financial officers and in 2009 found that an average neurosurgeon generated an average of $2.8 million in direct net revenue for a hospital — higher than surgeons in any other field.

Federal Medicare billing data shows that St. Luke’s, like nearly all hospitals, bills specialty surgeries and procedures at far higher rates than for general surgeries. In 2010, for example, St. Luke’s billed an average of $37,757 for a spinal fusion, while a procedure to repair a hernia saw an average bill of $6,050.

“It comes down to how our current medical system is designed,” said Travis Singleton, senior vice president of Merritt Hawkins, which counts St. Luke’s as a client. “We value procedures and specialty surgeries over general medicine, because that brings more revenue to a hospital.”

The money that neurosurgeons generate for other departments in a hospital — X-rays, nursing, physical therapy and prescription drug reimbursements — can be staggering, Singleton said.

“If a hospital loses a general medicine physician, that’s not a big deal,” Singleton said. “But if they were to lose a neurosurgeon, that’d be, holy cow, stop the presses.”

Several current and former staff members at St. Luke’s told the News Tribune that Konasiewicz would brag about how much revenue he generated for the hospital.

And St. Luke’s generously compensated Konasiewicz.

The national average salary for neurosurgeons of $571,000 is higher than for any other medical specialty, according to the Merritt Hawkins survey. But the money Konasiewicz made was even higher. In 2005, eight years after he started working there, Konasiewicz was St. Luke’s hospital’s highest-paid physician, earning $1.3 million.

“That would be tied to his production and what he did for patients,” St. Luke’s CEO Strange said about Konasiewicz’s salary.

More harm alleged

Allegations that Konasiewicz was harming patients continued, costing St. Luke’s money and increasing the hospital’s spending on malpractice claims. In 2000, the hospital paid only $200,000 on those claims. But in 2008, when Konasiewicz left the hospital, St. Luke’s spent $1.5 million on malpractice expenses.

A sizeable portion of that is likely due to Konasiewicz, who, by the time he left, had more malpractice cases filed against him than any other doctor at St. Luke’s. Between 2005 and 2008, the hospital settled malpractice cases filed against Konasiewicz for at least

$3.2 million, records show.

By 2005, no private insurance company would cover Konasiewicz, records show. He and St. Luke’s were forced to take out a special insurance policy with the state of Minnesota worth up to $3 million. That policy paid out at least $1 million to Duluth’s Lorena LeBeau after she sued Konasiewicz and St. Luke’s following a surgery in July 2007 in which her spine was so severely damaged that she became a quadriplegic.

Donley said taking out that special insurance policy with the state is uncommon for physicians, even specialty surgeons, where surgeries carry greater risks for patients. Prior to the News Tribune’s reporting, he said, he had never heard of a physician taking out an insurance policy with the state.

“Granted, even very competent physicians can make mistakes, but those mistakes are few and very far apart,” he said. “While neurosurgery inherently poses serious risks to patients, it should never be viewed as having the extraordinary risks suggested in the articles. The risks suggested by Dr. Konasiewicz’s record are completely unacceptable within any medical setting.

“A conventional insurer’s refusal to insure Dr. Konasiewicz is a very clear indication that hospital and surgical privileges should have been immediately terminated,” Donley added.

Konasiewicz and St. Luke’s still have three open malpractice claims that are pending in court, including one scheduled to go to trial on Tuesday.

Seven doctors who have worked at or with St. Luke’s told the News Tribune that they were seriously concerned about Konasiewicz’s ability and competence. Some said they brought their concerns to hospital administrators, including to CEO Strange, but were rebuffed.

“In health care, the peer review process is extremely confidential and subject to law, so there may be things going on … that people won’t know about,” Strange said.

McKee, the neurologist with Northland Neurology and Myology who often shared patients with Konasiewicz, said that he first brought his concerns about Konasiewicz’ competence to the St. Luke’s administration about a decade ago.

“The scope of the problem was evident from an early date,” McKee said. “Information provided to the administration by physicians and nurses was not well-received.”

With Konasiewicz allowed to practice, Canfield said the atmosphere in the hospital surrounding him “was alarming.”

“We all wondered what he was going to do,” she said.

No peer review

Hospitals can become too concerned about profits and as a result might keep doctors who harm patients on staff when they shouldn’t, said Dr. Gordon Schiff, associate director for the Boston-based Center for Patient Safety and Research. Schiff is also an associate professor of medicine at Harvard University.

“Money is driving decisions in health care,” Schiff said.

Rather than punishing problem doctors, he said, hospitals often work with them by setting up peer review committees to examine medical mistakes and see what actions to take to prevent future injuries.

“Getting rid of a doctor may not be the safe thing to do,” Schiff said. “A hospital can get rid of a bad doctor, but they’ll go somewhere else and would continue to harm patients. That’s not dealing with what’s causing the bad outcomes.”

But Canfield said St. Luke’s didn’t have a formal peer review program for its neurosurgeries.

Himango said a peer review program for all neurosurgeons in the city was ended in 2000 by SMDC.

“I was in support of a peer review among all neurosurgeons in our community,” Himango said. “But it wasn’t happening because SMDC wasn’t taking part in that.”

SMDC spokeswoman Kim Kaiser said that when the neurosurgeons went their separate ways, SMDC made the decision to do its own internal peer review.

Administration responsible?

To Diane Pinakiewicz, vice president of the National Patient Safety Foundation, formal peer review programs are crucial in helping to reduce doctor errors.

“There is no excuse, under any circumstance, for the leadership of any organization to accept performance by a clinician that is endangering patients,” she said. “Both the hospital board and administration are responsible for the health and safety of their patients, and they are accountable for it.”

Former SMDC neurosurgeon Donley said he believed the St. Luke’s administration should be held responsible for any harm Konasiewicz caused.

“Administrators have a critical role to play. Ultimately, they set the standards of practice and control the conditions under which medical care is rendered,” he said. “When it surfaces that there has been prolonged substandard care by a physician, they have to be accountable. They should respond to public inquiries because the public has a right to know what occurred, why and what will be done to prevent it.”

In its statement in May, St. Luke’s said: “We reject the premise that Dr. Konasiewicz did not provide excellent neurosurgical care during his time at St. Luke’s. To the contrary: Dr. Konasiewicz performed thousands of difficult and life-saving surgeries on thousands of patients throughout our region. Many people are alive and walking today because of the outstanding care and skill of Dr. Konasiewicz.”

When asked if the hospital still stands behind that statement, Strange replied, “You know I can’t back off of that.”

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