Hospital challenges physicians’ right to jump ship with program, patients

At issue are reimbursements and federal grant money

When renowned pediatric AIDS specialist Andrew Wiznia, MD, and two of his colleagues in the pediatric AIDS clinic at New York’s Bronx-Lebanon Hospital Center decided to resign and move to a new program at another hospital, Bronx-Lebanon administrators didn’t take it lying down. They took them to court.

Alleging that Wiznia coerced both staff and patients into leaving the hospital’s clinic and improperly attempted to move a $1.5 million National Institutes of Health (NIH) grant that largely supported the program, Bronx-Lebanon filed suit in New York asking for $50 million in damages. The lawsuit also sought to bar the defendants from treating patients anywhere else for six months.

The physicians received a judgment permitting them to resign from Bronx-Lebanon and see patients at the other hospital, Jacobi Medical Center. The physicians claim they were ethically obligated to inform their patients about the move and that the research grant would routinely follow them to a new location under NIH guidelines.

Each side claims the other is using these patients as pawns in a larger dispute over much-needed Medicaid reimbursements and federal grant money for AIDS research.

The case has raised other complex questions in the medical community, as well. When physicians leave one practice or hospital for another, how should they inform their patients? What obligations do physicians have to hospitals that have depended on them to support major programs? Should physicians employed by hospitals who treat mostly poor patients covered by federally funded programs be held to a different standard than physicians in private practice who treat privately insured patients?

What happens when physicians leave?

Wiznia came to Bronx-Lebanon and started its pediatric AIDS clinic program 10 years ago. Since that time, he’s watched several of his patients — who initially were not supposed to survive childhood — grow from sickly infants to adolescents who must learn to live long-term with a deadly infection.

Dissatisfied with management changes at Bronx-Lebanon and the hospital’s approach to treating the children, he decided to leave. (For more on dissolutions between physicians and hospitals, see story, p. 64.)

’The whole impetus for moving is that there are services at Jacobi that are not at Bronx-Lebanon that are needed for kids,” he explains. ’There is no intensive care at Bronx-Lebanon, there are no adolescent services or subspecialties. That was the primary impetus. The other was a change in the administration. Things started happening. The environment became one of a productivity model. It became about dollars and cents. You never heard about quality of care or anything like that.”

It is commonly held, and in some states legally required, that physicians should inform their patients of a decision to leave a facility or practice and then either oversee the patients’ transition to a new physician or continue to treat them, says Wiznia.

’Particularly with chronically ill kids, I have been treating some of them most of their lives. That is all we tried to do,” he explains.

According to court papers, Wiznia and the two physicians mailed letters to their patients’ parents informing them that they would be moving to Jacobi and stating that they hoped the patients had been happy with the care provided and the physicians would like to continue treating them.

Most of the parents of the clinic’s children wanted to continue with him because they know he is familiar with their children’s cases and that he cares about them, Wiznia says.

Other physicians and staff who had been treating the children for a long period of time also decided to move to Jacobi, he adds.

The dispute is not about the rights of physicians to offer their services at other facilities or about the patients’ rights to see who they choose, says Ram Kairam, MD, director of pediatrics at Bronx-Lebanon. Instead, Kairam claims, it’s about protecting the clinical integrity of the AIDS program in which the hospital has invested over time from being dismantled by one physician.

’Bronx-Lebanon Hospital has the only community hospital-based pediatric AIDS clinical trials unit in the country, and it has flourished for 10 years, and it has flourished not just because we had one charismatic, committed, knowledgeable, and smart doctor,” argues Kairam. ’He is a very good doctor, but this is not a doctor-patient issue. He is not a private doctor, and these are not his private patients. He was a clinic doctor, a salaried doctor. He did not have a practice by himself. It is not the same as someone who does breast reconstructive surgery or who reattaches earlobes. He was one part of a gigantic operation.”

The entire pediatric AIDS treatment program at the hospital is based on a ’one-stop model” in which HIV-infected pregnant women and infected children are treated in the same place as their other family members who may or may not be infected, Kairam continues.

’We are one of the largest outpatient pediatric AIDS centers in New York,” he says. ’Part of that large operation is the NIH-funded pediatric AIDS clinical trials unit. Residing in that unit are staff and protocols that take care of pregnant women. We have one of the largest concentrations of pregnant women delivering HIV-exposed babies in any New York state hospital. By improperly moving some of these women — he attempted to move some of the adults, the pregnant women, and nearly all of the children — he basically attempted to destroy the backbone of this entire operation.”

One bone of contention is which party gets to keep the NIH grant to fund the clinical trials. Both Jacobi Medical Center, which is a public hospital, and Bronx-Lebanon treat a predominantly poor population. Forty percent of the Bronx-Lebanon clinic’s patients are in foster care, and most are covered only by Medicaid. Consequently, both hospitals are very dependent on grant funding to continue to offer services to patients.

Wiznia, the principal researcher on the NIH-funded study, set up the research protocols and study design at Bronx-Lebanon, and it is common for a grant to follow the principal researcher, he says. However, Kairam contends that the hospital’s ability to guarantee a large number of patients for enrollment in the protocol and its ability to provide the infrastructure, support staff, and physical space for the study were the keys to securing funding.

’It takes a significant amount of resources to be able to maintain a 90% to 95% follow-up rate on these children for two and a half years,” he says. The hospital fought to prevent NIH from moving the study, and it is still at Bronx-Lebanon, although the hospital had to stop enrolling patients due to the dispute, he says.

Kairam says he has replaced all of the staff who left the clinic and expects the NIH to accept his ’transition plan” and permit him to reopen enrollment to new patients in a few days.

However, Wiznia says officials from the NIH have plans to visit Jacobi and decide whether the study can be moved there.

The fallout isn’t over

While both the lawsuit and the NIH funding question are being resolved, the physicians, hospitals, and patients are in limbo. ’There are still people who have been caring for the kids for years over at Bronx-Lebanon, who I believe would like to come here,” says Wiznia. ’A lot of the patients have not been able to come; some of the personnel haven’t been able to come. They don’t want to take risks, and the hospital is not going to hire study nurses until the study is here.”

The physicians won a court order to get the patients’ records sent from Bronx-Lebanon to Jacobi, Wiznia says, but they will have to return to court because the hospital is not complying, he claims.

There is confusion among the children’s caregivers over how to obtain care now, says Kairam. ’Foster care agencies are confused because the drugs are here and the doctors are there.”

The hospital hopes the lawsuit will set a pre cedent in terms of how physicians employed by hospitals must deal with patients treated there, he says. ’If this were simply about his private practice, it would be idiotic to fight him. We would have lost already. We just want something to say that you cannot take a hospital’s patients like that.”

1. Bronx-Lebanon Hospital Center in New York City alleges that Andrew Wiznia, MD, and his colleagues:
A. Coerced staff into leaving the hospital.
B. Persuaded patients to go with them to the new hospital.
C. Improperly attempted to move a National Institutes of Health grant.
D. All of the above.