UA docs' skin clinic dismissals cut service

The move has set off angry protests throughout Tucson medical circles, already battling a severe shortage of skin cancer specialists.

Now struggling to function with only one surgeon, few patients and a near-defunct clinic, the UA's dermatology service also is in danger of losing its ability to train medical students in this specialty, those who have worked there say.

The loss is occurring amid an ongoing shortage of dermatologists in Tucson — a Sun Belt city sometimes dubbed "the skin cancer capital of the world," where patients often wait months to see a skin specialist.

"The supply of dermatologists to Tucson basically depends on the UA having an active program to train dermatology residents, and right now that program is sketchy. It's endangered," said Dr. Alan Levin, a Tucson dermatologist who has worked at the UA Dermatology Clinic. "This has been a tremendous loss to Tucson."

University officials have declined to comment, except to say this is a personnel issue that has been inaccurately described by some of those involved. They stress they are working to rebuild the dermatology service as soon as possible, perhaps within the year.

At the crux of this mess is a 10-year-old federal regulation passed to crack down on Medicare billing fraud at teaching hospitals. Violations of the rule — cited as the reason the UA dermatologists were dismissed — have triggered multimillion-dollar fines at other medical school in recent years.

Especially hard-hit by this situation are indigent patients formerly treated at the UA clinic. Many are scrambling to find care because most private dermatologists don't accept them.

"These are patients with nowhere else to go," said Dr. Xuan Nguyen, who finished her training in dermatology at the UA in June, and witnessed the demise of the program.

"Already, we are seeing some of them coming up to Phoenix to be seen, and they are having trouble getting what they need," said Nguyen, now at Phoenix Children's Hospital.

"All I can say is that before this happened, the UA was a wonderful place to train. The doctors who taught me were brilliant. They loved caring for their patients and teaching their students. Those doctors are gone now, and it's a very chaotic situation."

The two fired physicians — Dr. Norman Levine, who served as the UA's chief of dermatology from 1986 until 2003, and Dr. Jerry Bangert, a dermatology pathologist who had been with the program since 1984 — were found in violation of the Medicare regulation by University Physicians Healthcare after an internal investigation that ended in February, according to physicians who worked at the clinic.

UPH is the doctors group that provides services to the UA College of Medicine and operates the UA Dermatology Clinic.

UPH also demoted Dr. Ronald Wheeland from his position as chief of dermatology. Wheeland, a past president of the American Academy of Dermatology, is a dermatology surgeon who joined the UA in 2003.

The regulation states that doctors at a teaching hospital, such as the UA College of Medicine, cannot bill Medicare for treatment of patients unless they are directly involved in and present for the patients' care. Passed in 1996, the rule ended the long-standing medical school tradition of allowing the doctors in training — the residents — to care for many patients, under supervision, and then bill for those services.

But because Medicare subsidizes a good chunk of the salaries of doctors in training, the agency considers it double-billing if a teaching hospital bills for treatment given by a resident — unless the supervising doctor is directly involved in the treatment.

Physician colleagues of Levine and Bangert are protesting what they call UPH's drastic actions against the doctors. They also fault the company for failing to properly train UA physicians in how to comply with this rule.

"UPH has acted in a capricious, outrageous and malicious manner, and without due process, in firing two ethical and highly respected professors — the pillars of the dermatology training program — who had served the university for over 20 years," Dr. Richard Miller, a Tucson dermatologist who had worked part-time at the UA Dermatology Clinic, wrote in a letter to the Arizona Daily Star.

"Termination suggests a crime of great magnitude. … If, indeed, the physicians were not present when a competent resident examined the patient, was a crime of great magnitude really committed, and was not the same offense doubtlessly committed by other physicians throughout the medical center?

"The result (is) destruction of dermatology at the University of Arizona, with dire consequences for medical students, dermatology trainees, and patients in Tucson and throughout the state of Arizona."

Miller and other dermatologists think UPH panicked because other medical schools have been hit with huge fines for violating the regulation. They say UPH clamped down on the dermatology section to prove to Medicare the hospital is correcting the problem, to avoid a hospitalwide audit.

In two extreme cases, the University of Pennsylvania was fined $30 million in the late '90s for similar violations, and the University of Washington was fined $35 million in 2004. As several UA doctors pointed out, fines like that can bankrupt a medical school.

"The university is scared to death of these kinds of fines and they want to call off the federal dogs," said Dr. Gerald Goldberg, a longtime Tucson dermatologist and past president of the Tucson Dermatology Society. He has volunteered to help train UA residents at his private practice until the UA gears back up.

"They're trying to tell Medicare, 'Don't come here, we're purging the problem.' There's just total outrage how this has been handled."

Declining to discuss the discipline and dismissal of the dermatologists, Norm Botsford, chief executive officer of UPH, said: "This is a personnel issue, and we are not going to comment on it. I will just say we disagree with some of the facts others are putting out there about what happened."

UPH has notified Medicare of the violations and is waiting to see what the agency does. Some kind of fine, even a massive one, is a possibility, Botsford said. "We suspect we have done everything possible to disclose the problem," he said.

Federal Medicare officials in the regional office in San Francisco declined to say if the UA or UPH is under investigation.

Botsford denied there has been inadequate compliance training for UA physicians, as Miller charged.

"We've had active compliance training in all federal regulations," he said. "There are issues in billing all the time, and we do all we can to educate and advise our people how to properly follow the rules."

Although Botsford would not say what other issues may be involved, several other medical schools fined by Medicare also were found guilty of what's known as "upcoding" in billing. That means billing Medi-care for more costly treatments or procedures than patients received.

That may have been a factor at the UA as well, Miller said.

"Often, the residents would code the cases early in the treatment, and I think that led to a lot of errors in coding," he said. "After the inquiry, they changed the system and got a coding expert."

Levine declined to talk about what happened. "This has been very traumatic. It's been a nightmare, and I just want it to go away. I'm trying very hard to get on with my life," he said. Levine formally opened his new private practice in Tucson last week.

Bangert did not return phone calls last week for comment. Wheeland declined to comment.

The UA's dermatology section is operating now with only one full-time physician, Wheeland, a surgeon. As a result, the clinic patient volume has declined dramatically. In its heyday, a year ago, some 1,440 patients were seen there in June. This June, only 420 patients were treated, according to UPH records.

"It's running at a much lower capacity now," Botsford said. "It's very difficult to get a dermatology appointment anywhere in town. There's been a dermatologist shortage in Tucson for years, and yes, this has made it worse."

UA officials hope to rebuild their program to full strength within the next year, sooner if possible.

"Dermatology is a critically important specialty in any health-care institution, but it is stating the obvious that it's more important in Arizona than anywhere else in the country," said Dr. Keith A. Joiner, dean of the UA College of Medicine.