MEDICAL FRAUD IN USA

Aria Sabit, MD, was a newly minted spinal surgeon in Southern California who got very busy following a business proposition in April 2010.

During the prior 8 months, Dr Sabit had performed 64 instrumented spinal fusion surgeries — installing various screws, plates, rods, and other pieces of hardware — at Community Memorial Hospital, in Ventura, according to the US Department of Justice (DOJ). In the 8 months that followed, he doubled his pace, performing 130 of these procedures at the hospital.

What happened in between, the DOJ said, was a lucrative offer from Apex Medical Technologies, which distributes spinal surgery instrumentation. Invest $5000 in the company, use its hardware, and share in the revenue. They'd be fat enough, potential investors were told, "to put their kids through college."

Dr Sabit, a refugee from Afghanistan, performed his end of the bargain, according to the DOJ. He used Apex products in more than 90% of his subsequent spinal fusion surgeries after having used none before the investment offer.

In turn, Apex made good on its profit sharing promise. From May 2010 to December 2010, when Dr Sabit resigned from the hospital staff under a cloud, the company paid him $264,957, the DOJ said. The payments continued through June 2012, while he was practicing in Michigan. In all, Dr Sabit made $438,570 on his $5000 investment.

What some might call profit sharing, however, amounts to illegal kickbacks in the eyes of the DOJ. Last month, the 41-year-old Dr Sabit pleaded guilty in a federal district court in Detroit, Michigan, to conspiring to receive kickbacks from Apex. The payments "incentivized" him to operate when he didn't have to, according to the plea agreement that he signed (and initialled on every page). Dr Sabit also pleaded guilty to billing Medicare, Medicaid, and private insurers for spinal fusion surgeries that omitted the documented hardware and to illegally prescribing a painkiller.

A triumphant DOJ press release said he had stolen $11 million in insurance proceeds.

The husband and father of three children — and a naturalized US citizen — faces a likely prison term of 9 to 11 years when he is sentenced later this year.

To all of this, the federal government could say, "I told you so."

For years, the Department of Health and Human Services (HHS) has warned about the conflict of interest posed by joint partnerships between physicians and companies that depend on them for referrals or new business in general. Such warnings have extended to physician-owned distributorships (PODs) such as Apex, which the HHS Office of Inspector General (OIG) called "inherently suspect" under the government's antikickback laws in a March 2013 study. Later that year, OIG reported that the number of spinal surgeries grows at a faster clip at hospitals that purchase instrumentation from PODs compared with hospitals that do not buy from PODs.

Dr Sabit's story, however, is about more than a shady business deal. From a clinical perspective, his 18-month tenure at Community Memorial in Ventura gave rise to nearly 30 malpractice suits, according to federal court records.

Marc Anderson, an attorney who represented plaintiffs in seven malpractice cases against Dr Sabit, recalls taking his deposition. The surgeon was cordial, polite, and "very self-confident," Anderson told Medscape Medical News.

"He was a surgeon who was proud of his work," Anderson said. "He didn't think he did anything wrong.

"He had an explanation for everything."

In September 2013, the California medical board went after Dr Sabit's license, which he surrendered the following year. The board cited him with gross negligence in patient care and "dishonest and corrupt acts."

His case also shows the medical profession at its honest and moral best, or so it would seem. Two physicians in Ventura took note of Dr Sabit’s frenetic pace in the operating room, his botched surgeries, and his financial ties to Apex and reported it all to the feds. They later filed a qui tam, or whistle-blower suit, in a federal district court in California accusing Dr Sabit and others of Medicare fraud under the False Claims Act. Such suits allow private citizens to take civil action against alleged fraudsters and share in any monetary recovery.

"Reckless Haste"

Dr Sabit came to the United States in 1984 when he was 10 years old. After earning an MD at Virginia Commonwealth University School of Medicine and completing a neurosurgery residency at the University of Medicine and Dentistry of New Jersey, he joined a practice headed by Moustapha Abou-Samra, MD, in Ventura in early 2009. Community Memorial granted him temporary privileges in June 2009 and then provisional privileges 2 months later. However, Dr Sabit never advanced beyond that status, noted Cary Savitch, MD, and Gary Proffett, MD, the two physicians who filed the whistle- blower suit.

"From the initial procedures he performed at [Community Memorial] operating rooms, it was obvious to the operating room and nursing staff that Sabit was either not qualified or not competent to perform these neurosurgical procedures, or he was reckless in his surgical technique," they said in their lawsuit. Dr Savitch is an infectious disease specialist at Community Memorial, and Dr Proffett treated many of Dr Sabit's patients in nursing homes, tertiary care facilities, and rehabilitation centers.

In February 2010, Dr Sabit began talking to Apex Medical Technologies about an investment stake, according to the DOJ. Apex was one of a dozen-odd PODs formed and controlled by the owners of a spinal instrumentation company called Reliance Medical Systems. Dr Sabit started to install Apex screws, rods, and other hardware in spinal fusion patients that April during an evaluation period that let the company monitor his surgical volume and use of its products. In May 2010, Dr Sabit gave Apex $5000 for a 20% share of the company.

Although physicians investing in device companies makes the HHS suspicious, the practice is allowed provided certain "safe harbor" requirements are met. One requirement is that payments to investors must be "directly proportional to the amount of capital investment." In a civil lawsuit filed in California against Reliance, Apex, a sister POD, Dr Sabit, and several others Apex investors, the DOJ said Dr Sabit's relationship with Apex flunked the proportionality test, given a minimal investment with a fantastic return of 8614% in roughly 2 years.

Reliance expected physician-investors such as Dr Sabit to convince the hospitals where they operated to buy spinal implant devices from Apex and other affiliated PODs, said federal prosecutors. Should a hospital balk, physicians were supposed to threaten to take their surgery patients elsewhere. At the same time, their investment stake in PODs was on the hush-hush, said prosecutors. In his guilty plea in the criminal case in the federal district court in Detroit, Dr Sabit admitted to concealing his relationship with Apex from the hospitals where he operated.

Dr Savitch and Dr Proffett said that they found out the truth about the kickbacks, however, as well as Dr Sabit's quality of care, which they characterized over and over again as "poor".