Suit: IU Health and HealthNet cheated feds, risked pregnant women's care

A federal whistleblower lawsuit claims IU Health and the state's largest midwifery practice bilked the government of millions of dollars and compromised patient safety by letting nurse midwives care for hundreds of high-risk, low-income pregnant women who should have been seen by doctors.

The suit, filed by a doctor who served as director of women's services at HealthNet as well as medical director of ob-gyn services at IU Health Methodist Hospital, says that HealthNet and IU Health shunted Medicaid high-risk patients to less-expensive nurse midwives. Then, the suit says, the providers submitted bills as though doctors had treated the women.

If the suit is successful, plaintiffs say, potential damages could reach around $100 million for IU Health, the state's largest health system, and HealthNet, an IU Health affiliate that serves poor patients through eight inner-city clinics. MDwise, a local managed care insurer, is also named in the suit.

HealthNet, MDwise and IU Health spokespeople declined to comment on the suit, citing an ongoing investigation and litigation. The U.S. Attorney's Office also refused to comment, citing an ongoing investigation.

Dr. Judith Robinson, the former employee who filed the suit, claims she was terminated in 2013 after raising questions about patient safety at HealthNet. Her suit claims doctors often never saw HealthNet patients with high-risk pregnancies or were called in only on an emergency basis, sometimes when it was too late.

The suit alleges a lack of doctor involvement may have contributed to one mother's death, and brain damage in children.

"I went to everybody and anybody I could because I was concerned about these patients," Robinson said in a recent interview. "Why is it that it seems to be OK to have this population of indigent patients … get less care? It is just not right."

The lawsuit cited an email Robinson sent her employers in spring 2013, shortly before she was fired. In it, Robinson identified 14 clients with near misses and two "terrible outcomes" within a six- to eight-month span and said she wanted to fix "a broken system."

HealthNet Chief Medical Officer Donald Trainor responded, saying her request was "premature," the suit says.

Robinson is not the first to question a hospital's obstetrical billing practices. In 2002, Columbia University paid a $5.1 million fine for billing New York Medicaid for services provided by midwives, doctors-in-training and other non-Medicaid providers. Two years later, New York University Downtown Hospital paid $2.1 million in a similar case.

Using midwives to cut costs

Robinson's suit says HealthNet, MDwise and IU Health all benefited financially by using nurse midwives, who command a lower salary than doctors.

HealthNet, a not-for-profit corporation, was set up to provide primary care to the medically underserved. More than half of the about 4,000 women who visit a HealthNet clinic for prenatal care each year deliver at Methodist. MDwise processed many of the claims.

In a February 2011 email included in the suit, Trainor explained the reasons why HealthNet employed more nurse midwives than obstetrician-gynecologists.

"The first is largely financial," the suit quotes the email as saying. The email went on to say that midwives are paid one-third to one-half as much as obstetrician-gynecologists but that HealthNet is "paid the same amount by Medicaid (our primary payor) regardless of who provides the care."

The suit says that in 2010, midwives were paid $108,632 on average while obstetrician-gynecologists received an average salary of $349,976.

Currently, HealthNet has 24 nurse midwives on staff and nine obstetrician-gynecologists, according to its website. The section on midwifery on HealthNet's website tells visitors, "Most women do not see a physician during their pregnancy or birth."

According to state policy, nurse midwives may not provide services to Medicaid members with medically high-risk pregnancies, said Marni Lemons, a spokeswoman for the Family and Social Services Administration, which oversees Indiana's Medicaid program.

Since 2010 a woman who has two or more risk factors, such as obesity, tobacco use, asthma, a history of cesarean section and diabetes, is considered high risk, according to state Medicaid rules, the suit says.

While 70 to 90 percent of HealthNet patients were high risk, HealthNet intake staff did not code them that way, paving the path for certified nurse midwives to oversee their care without input from doctors, the suit says.

"There was this big abyss," Robinson told The Indianapolis Star. "We were sitting on the sidelines, waiting for the disaster to happen."

When Robinson asked why doctors weren't consulted more often on high-risk patients, the manager of HealthNet's nonphysician provider group, Mary Blackburn, a certified nurse midwife, told her not to micromanage, Robinson told The Star.

"This is a midwife practice, so we decide what patients you docs will see and who you won't see and we will decide what you need to know about them and what you don't need to know," Blackburn told Robinson on Feb. 20, 2013, according to the suit.

Robinson filed her suit under seal in December 2013 under the False Claims Act, which allows individuals with knowledge of fraudulent claims submitted to the U.S. government to sue on behalf of the government. The law requires that such suits must remain under seal for at least 60 days. This suit was unsealed in March, making it public.

The False Claims Act allows the government to collect three times the amount of damages as well as a penalty of up to $11,000 for each false claim. Robinson's suit also asks for compensation for Robinson, including two times her back pay plus interest and other damages, such as lawyer's fees.

Near misses, and bad outcomes

In the lawsuit, Robinson details a number of cases that allegedly went awry because certified nurse midwives did not consult doctors.

One patient was admitted to the hospital at 40-plus weeks of pregnancy to have labor induced as she had high blood pressure. The nurse midwife overseeing her care sent her home after two days because she saw no changes in her cervix. Two days later, the patient returned in early labor and an abnormal fetal heart rate was seen, at which point a doctor performed an emergency C-section. The baby was born with permanent brain damage and a review of the first hospitalization showed an abnormal heart rate then, too, suggesting the woman should never have been sent home.

In another case, a nurse contacted Robinson about a patient who had diabetes, high blood pressure and other risk factors that could lead to a problematic delivery. The nurse midwife sent the patient home without having her see a doctor. Robinson took over her care and sent her to the hospital to deliver immediately.

Even after she left, Robinson continued to hear tragic stories, the suit says, including that of Tana' Tyler.

The 26-year-old woman used HealthNet for her first pregnancy. In 2008, she had surgery at Methodist to implant rods and plates to correct a neurological condition. Pleased with both her birth and surgery experiences, Tyler was committed to giving birth at Methodist again, her mother LaDonna Mills told The Star.

A sudden weight gain of 15 pounds sent Tyler to Methodist in July, when she was 37 weeks pregnant. A nurse midwife determined she had pre-eclampsia, a complication of pregnancy that occurs when a woman develops high blood pressure and protein in her urine, and induced her labor.

Nurse midwives cared for her throughout the day, giving her dinner. Mills, who was with her, recalled that her daughter later went to the bathroom, felt ill, and when she returned there was no fetal heartbeat.

She was rushed into an emergency C-section and "because of the pizza in her stomach, she aspirated while under anesthesia and died," the suit says. Tyler died and her son, Chace, now 9 months old, suffered permanent neurological damage.

Mills is left caring for her two grandchildren and missing her daughter, who was studying to become a psychologist.

"These babies, their lives have changed forever. My heart breaks for them," said Mills who has formed the L.A.C.E. Foundation to provide support to children whose mothers die in childbirth. "I think only physicians should see high-risk pregnancies. ... All she came in to do was to have a baby. I want them to be more aware of what's going on and give these patients the proper care they deserve."

In many instances, patients may not even realize that the person overseeing their pregnancy does not hold a medical degree, Robinson said.

Midwives fine for low-risk pregnancies

That does not mean that there's no role for midwives in the hospital, she said.

"As far as midwifery and low-risk pregnancies, they do a wonderful job," she said. "The whole issue here has to do with training — they don't have the experience."

Midwives do bring certain skills to the table even for high-risk patients, said Stephanie VanderHorst, president of the Indiana affiliate of the American College of Nurse Midwives. The three midwives in her Auburn practice work closely with a physician. A patient may see a nurse midwife for a visit or two and then see a doctor.

When it comes to deliveries, in some cases both providers attend the birth, the doctor ready to help if needed.

"The key to safe quality outcomes is to have that established in advance," VanderHorst said. "There are components of the high-risk pregnancy that the physician needs to be present for."

Midwives can help with handling high-risk factors, she added. Doctors will spend only about four minutes with a patient compared with the midwife's average of 18. That gives midwives more time to talk to patients about maintaining normal weight gain and, if necessary, stopping smoking.

And what constitutes a high-risk patient can be subject to definition. The state of Indiana has one list that includes some factors considered on a national level to be within a nurse midwife's scope of practice, VanderHorst said.

Still, Robinson said she has no doubt the HealthNet practices compromised patient care in the interest of the bottom line.

"It's tragic…. All they had to do was allow us to see obstetrics patients," she said. "I felt that I was needed by those patients. It keeps you humble. It reminds you what to be grateful for. I felt like I was maybe making a difference."

Call Star reporter Shari Rudavsky at (317) 444-6354. Follow her on Twitter: @srudavsky.