Assignment task:
Gabriela Marco, a former regional manager for the Chipotle restaurant chain. On January 2, 2008 (but it might be 2009 due to an error on the medical records from, understandably, forgetting to use the new year, right after December 31), Gabriela underwent surgery in Eyeowah with Dr. Wright to donate a kidney to her cousin Scott Connolly. The surgery was successful and there were no reported complications. The same day, in a separate surgery, Dr. Maccabee transplanted Gabriela's donated kidney into Scott. In the subsequent days, Scott experienced some complications with the donated kidney. Additional surgical procedures were required. On January 10, Dr. Maccabee performed an exploratory surgery on Scott and apparently mistakenly stitched the renal artery which supplied blood to the donated kidney. On January 12, Dr. Daly performed yet another surgery on Scott. Dr. Daly observed Dr. Maccabee's sutures transgressing the renal artery and determined that the donated kidney could not be saved. Dr. Daly ordered the kidney to be removed. The true cause of the issues with the kidney are never disclosed to Scott or Gabriela.
EMMC is a non-profit hospital and Scott qualifies for their Charity Care Policy, but the hospital has indicated that they will not allow him to avail himself of the Charity Care Policy because transplants are not included under the policy.
At the time, Gabriela was obviously disappointed that her organ donation was unable to help Scott. But it was only a few months ago, when she returned to EMMC for some tests, that she learned this was due to surgical error. She is now not just disappointed but really disgusted that she subjected herself to serious risks from surgery for Scott, and it was all for nothing. Gabriela has some physician friends.
You are a hospital administrator at EMMC and you have this case reviewed by the following experts. Dr. Lucy is a cardiologist at Johns Hopkins in Baltimore. She opined that it was negligent to stitch the renal artery during the exploratory surgery. Dr. Apple is a surgeon at the Mayo Clinic in Rochester, MN. Dr. Apple also opined that it was negligent to stitch the renal artery during the exploratory surgery. Dr. Apple further opined that both Dr. Maccabee and Dr. Daly were negligent for failing to monitor and supervise Scott properly and detect the decreased blood flow to his transplanted kidney after the exploratory surgery. Dr. Apple said that if the decreased flow had been detected, there would have been a "good chance" the kidney could have been saved.
As I mentioned, in September 2013, Gabriela went to EMMC for some tests. She had been experiencing fatigue and urination problems. Dr. Sean diagnosed Gabriela with kidney disease. While medicine cannot reverse chronic kidney disease, it is often used to help treat symptoms and complications and to slow further kidney damage. Since Gabriela only has only one remaining kidney, Dr. Sean prescribed Soobent, a drug that has proven effectiveness for her condition. But apparently because of the $4000 per month cost, Gabriela's health insurer, Medicare, denied coverage. Medicare, explained that Soobent is still a new drug and has only significant proven effectiveness with patients who have kidney disease more serious and more advanced than Gabriela. Therefore, using it with someone like Gabriela is "experimental" and falls within the insurance contract's coverage exclusion for "experimental therapies." Dr. Sean appealed the denial by adding some additional false information into her medical record that makes Gabriela's appear sicker than she is. Her insurance company approves the drug, along with some other additional treatments based on the falsified documents in her medical record.
The CEO at EEMC hears about everything that has happened with both Gabriela and Scott. The CEO asks you as the hospital administrator to evaluate the risks for the organization based on the facts that you currently have. The CEO also asks you to come up with a corrective action plan so something like this doesn't happen again in the future. The CEO would like the risks and associated corrective action plan laid out in a memo so that he can present it to the Board. He would also like your opinion on whether EEMC should self-disclose the fraud by Dr. Sean to Medicare.