The Maintenance Man: Fata-nomics the cancer plaguing healthcare

Editorial Note: This post is from Johanna Ryan

“You murdered my dad. You poisoned him. You tortured and murdered my dad.”

The sentencing hearing for Farid T. Fata, M.D. at the federal courthouse in Detroit last week did not lack for drama – and Piero Zanotti’s daughter was not the only victim to accuse him of murder. The U.S. government might well have done so, if he had not pleaded guilty to lesser charges of healthcare fraud. Dr. Fata admitted to misdiagnosing and mistreating cancer patients, giving them expensive and highly toxic chemotherapy treatments for no other reason than profit. Or, as the U.S. Attorney put it, he had ordered his patients poisoned for money. This wasn’t a case of bad judgment or a bias towards “aggressive” treatment. “I knew that it was medically unnecessary,” Fata affirmed in court in response to each separate charge.

The results were horrific, as was the testimony of patients who lined up to give victim-impact statements. Several had learned, after Fata’s arrest, that they never had cancer at all. Others endured four, five or ten times the number of toxic injections that were medically necessary. Patients were treated with risky biological agents for an unheard-of five to seven years, permanently crippling their immune systems. People with Stage IV terminal cancer were not allowed to die in peace or comfort; instead, they were sold false hopes and pumped full of toxic chemicals to the end.

On July 10, Fata was sentenced to 45 years in prison. His victims felt he should have gotten the 175-year maximum.

An even bigger question that hung in the air was: How had he gotten away with this for so long?

To consent to chemotherapy involves a leap of faith. Patients often know full well that they will vomit, feel godawful pain, lose their hair or teeth or fertility. These drugs can scar your liver, ruin your kidneys, eat away at your bones, fry your nervous system. They can even raise your risk for new cancers. Patients who take them must place extraordinary trust in the oncologist who tells them chemotherapy is their best shot at beating an otherwise fatal cancer. Fata blatantly violated that trust, over and over. He told people with benign conditions that they had life-threatening cancers. He told people with hopeless cases that he could cure them.

The inventor of maintenance chemotherapy

But his signature scam may have been the idea of “maintenance chemotherapy.” Over and over, patients testified that Fata told them their cancer would come back unless they submitted to long-term chemo – often, for the rest of their lives. That’s what Fata told Michelle Mannarino’s mother – while administering a colon cancer drug to a woman with advanced breast cancer. “We have since learned there’s no such thing as maintenance chemo,” she said bitterly. Ervin Jones doesn’t know whether to laugh or cry when he remembers his four years of chemo, supposedly for myelodysplastic syndrome (MDS). Month after month, his blood counts were normal. “I’d ask Fata, ‘Can we stop now?’ Jones recalls. “He’d just chuckle and say, ‘Oh, no, we can’t do that. It’ll go into leukemia if we do that.’ ”

It was that “lifelong maintenance” bit that got my attention. What was this guy doing – studying for his psychiatry boards? In thirty years of treatment for depression, I have seen the concept of “chemical imbalances” requiring lifelong medication expand to cover every form of mental distress or dysfunction psychiatrists can treat. The results may have done wonders for the health of drug companies, but I’m convinced they’ve done patients like me more harm than good.

Lately, every field of medicine seems to be succumbing to the Maintenance Machine.

Heartburn has become GERD, which requires lifelong proton-pump inhibitors rather than a swig of Di-Gel or Maalox as needed. Hypertension and high cholesterol must be permanently “controlled” with medication, even after our readings come down. Even the new weight-loss drugs, most of which promise to take off as little as ten pounds, are coming on the market as lifelong treatments for the Disease of Obesity. The science behind all this Maintenance has often been weak, but the economic rewards have been powerful.

Was Farid Fata just trying to do what all the other doctors on the block were doing? His business plan was predatory and heartless in the extreme, of course, but isn’t there a little bit of “Fata-nomics” in most of the healthcare system? If not, why had none of the major players in the healthcare market put a stop to him long ago?

Where were the doctors?

“The best in the region – a real doctor’s doctor,” one victim recalled being told about Dr. Fata. Trained at the elite Memorial Sloan-Kettering Cancer Center, he owned a chain of six prosperous suburban clinics and had co-authored articles in top medical journals. He made Hour Detroit Magazine’s list of “Top Docs” from 2006 – 2009. In 2011 he was named one of the area’s Health Care Heroes by Crain’s Detroit Business for his role as founder of the Swan for Life Foundation. Fata’s foundation paid for acupuncture, counseling and other “holistic” care for cancer patients, and its well-publicized fundraisers further raised his profile. (It may also have served as a front for kickbacks to the good doctor.)

Certainly dozens of doctors must have worked alongside him, referred patients to him or seen patients who were under his “care.” You would have to be practicing under a rock to avoid knowing his name. The stories patients could tell about Fata – how he held back medical records to keep them from getting second opinions, ordered them in for chemotherapy when sick with the flu, and often took their charts home with him each night – must have raised red flags galore. In the end, however, only one blew the whistle – a young Burmese doctor named Soe Maunglay who was Dr. Fata’s latest associate.

Maunglay’s growing disenchantment with his boss turned to horror at the end of his first year, when one of Fata’s patients, Monica Flagg, was hospitalized at Crittenton with a broken leg. Thumbing through her chart, it dawned on him: This woman did not have cancer. She never had. Yet Fata had subjected her to three bone-marrow biopsies, a year of immuno-globulin injections, and chemotherapy for multiple myeloma. Maunglay told her to get another doctor immediately, and shared his suspicions with office manager George Karadsheh. After several weeks of furtively examining patient charts, they took their story to the FBI. In August 2013, when Fata was led away in handcuffs and the FBI raided his Oakland Township mansion, the entire medical community declared itself shocked.

Where were the bean-counters?

Dr. Fata was a major revenue generator for Crittenton and the four other hospitals where he practiced. His Rochester clinic was part of the Crittenton branch of Detroit’s Karamanos Cancer Center. He participated in hospital-based clinical trials, and was a fixture at grand rounds and annual symposia. A top performer like Dr. Fata usually gets lots of attention from hospital managers and CEOs. They must have had inklings that something strange was behind those marvelous numbers—and they had the power to investigate any member of their medical staffs. If just one hospital had yanked his privileges, it might have been the end. But none even came close.

His purely financial victims included not just Medicare and Medicaid, but Blue Cross/Blue Shield and other large private insurers. In a system built on private profit, they are supposed to be the watchdogs whose interests lie in putting a stop to unnecessary and inappropriate care. Dr. Fata’s patients cost them millions of extra dollars, for treatment protocols one of the government’s cancer experts called “bizarre.” How did all the wizards of Utilization Review fail to notice what he was up to?

Who would have known Farid Fata better than anyone else?

For several Fortune 500 pharmaceutical firms, Dr. Fata was a massive prescriber of their most expensive and profitable products. Medicare records list him as among the top twenty prescribers of Erbitux, Alimta and Gemzar. All three are made by Eli Lilly, who would have known far more than Medicare about his prescribing habits. Fata regularly lectured to other doctors at area hospitals – and between 2009 and 2013, Eli Lilly paid him just under $40,000 in speaker’s fees.

Yet Lilly was just the tip of the iceberg. The real pity is that the disclosure requirements of the Sunshine Act took effect in August 2013, just as the feds were clapping the cuffs on Dr. Fata. The Sunshine Act is far from perfect; funneling payments through medical-education providers is just one of several ways pharma money can still hide from the sun. However, it has identified Genentech as the top spender, and Rituxan (rituximab) as its most-promoted product. That’s the immune-suppressing biological treatment that Dr. Fata gave to so many patients in “stunning” quantities for years on end, according to government experts.

Fata was likely the top Rituxan prescriber in the entire Medicare program. The one doctor who edged him out swears that his numbers actually account for all five doctors at his California clinic. The 4,256 doses prescribed by Fata in 2012 were his alone – and only three doctors in the entire country topped 3,000 prescriptions. Do you think Genentech was aware of Farid Fata? Oh … no more than a mother is aware of her newborn child.

It’s hard not to agree with a reporter for Medical Daily who concluded that Fata was simply “too profitable to tattle on.” And that’s before you even consider Medicare Part B.

“Buy and bill” … and beware of part B bandits

Drugs given in a doctor’s office by injection or IV drip are different from the prescription pills most Americans buy at the pharmacy. Your doctor gets paid the same whether he writes a script for generic Prozac (about $15 retail) or brand-name Abilify (about $900). Doctors giving chemotherapy agents, however, work on the “buy and bill” system. Medicare pays them according to the average price charged to clinics and hospitals by the drug company – as reported by the drug company – plus a 6% markup. (This is covered under Medicare Part B, not Part D which pays for oral meds. Most private insurance companies use the same method.)

Thus, your doctor might earn $60 for injecting a $1,000 drug, but $360 for injecting $6,000 worth of Rituxan – and that’s just if he is paying the average price. Larger clinics like Fata’s routinely get a discount off the “average price,” and are free to pocket the difference. A 10% discount could boost the doctor’s income from that Rituxan injection from $360 to $960. How many doctors in private practice might be tempted to give you a few more injections than you actually need? A lot, unfortunately. Six months before Fata’s arrest, a lymphoma patients’ blog reported a macabre joke making the rounds among oncologists: the “Rituxan retirement plan” some doctors were said to be funding by buying and selling the drug.

Christopher Friese is a longtime oncology nurse who teaches at the University of Michigan. Friese told the Detroit Free Press that private clinics, which handle 80% of chemotherapy treatments, have been allowed to operate in a “Wild West atmosphere” of minimal regulation. Too many take advantage of the same “perversely structured financial incentives” that made Farid Fata rich, and reward doctors for using more and pricier drugs. Reforms were urgently needed, he said, to protect patients from the next Dr. Fata.

Of the new cancer drugs that have come on the market in the past decade, about three-fourths were approved without evidence that they extended patients’ lives. Often severe side effects canceled out modest improvements in antitumor action, according to a Milwaukee Journal-Sentinel report. All, however, were hugely expensive: A month’s worth of Eli Lilly’s Erbitux, a colon-cancer treatment and a favorite of Dr. Fata’s, costs $11,643, while GSK’s Arranon for lymphoblastic leukemia costs $23,112.

To Soe Maunglay, the young oncologist who blew the whistle, putting Dr. Fata behind bars was only one small step. “We need to uncover and correct the fundamental reasons behind the collective failure of our medical system at all levels which enabled this despicable fraud [to continue] for such a long time,” he said.

Until then, we enter the gates of Healthcare, Inc., at our own risk.