A Famed Hospital Churns Poor Patients Through Weight-Loss Surgery

Supported by Operating Profits A Famed Hospital Churns Poor Patients Through Weight-Loss Surgery New York’s Bellevue Hospital performs thousands of the lucrative surgeries a year, even on Rikers Island prisoners and other inappropriate patients. In the windowless basement of a Manhattan church last month, Bellevue Hospital hosted a fashion show. Dozens of weight-loss surgery patients, some in evening gowns, strutted down a red carpet. While their “before” photos were projected on a screen, an M.C. read testimonials about how the operations had remade their lives. Addressing the cheering crowd, Bellevue’s chief medical officer boasted about a remarkable number. The overwhelmed public hospital, which routinely treats gunshot and stabbing wounds, was on track to perform a record 3,000 weight-loss surgeries this year. “We have a lot to be proud of,” the executive, Dr. Nathan Link, said. Bariatric surgery is a major operation that, for the right patients, can ward off heart disease, diabetes and strokes. Bellevue, which serves a disproportionately poor and obese population, says the operations have saved many lives. But a New York Times investigation found that the bariatric program, led by surgeons with financial incentives to perform more operations, has become a high-speed assembly line that has endangered some patients and compromised urgent care for others. And because most of the hospital’s patients are on Medicaid or uninsured, taxpayers foot the bill. The surgery shrinks patients’ stomachs and requires them to radically change how and what they eat. Even some successful operations can lead to a lifetime of stomach cramps and debilitating acid reflux. For that reason, hospitals often require surgical candidates to try to lose weight on their own and go through months of screening and preparation for the procedure and its aftermath. Bellevue, however, frequently cuts corners as it hustles patients through the process, according to the Times investigation, which is based on interviews with 70 Bellevue employees, patients and executives from New York City’s hospital and correctional systems, as well as internal hospital documents, court filings and medical records. Prospective patients often receive tentative surgery dates after attending a single informational session, filling out a worksheet and speaking briefly with a doctor. Meetings to assess patients’ mental health sometimes last just 10 minutes. Many patients said in interviews that they had agreed to surgeries without fully grasping the risks. In its zeal to increase volume, the hospital has operated on people whose body mass indexes were too low for them to qualify for surgery under standard medical guidelines, according to eight doctors and nurses involved in the operations. It has recruited patients from New York City’s Rikers Island jail complex who have virtually no chance of maintaining the required diets after surgery. Two prisoners told The Times that they had become malnourished and regretted having the operation. Two of Bellevue’s bariatric surgeons often race each other to see how many operations they can perform in a day, at times even relying on unlicensed equipment technicians to assist them, The Times found. Anesthesiologists sometimes reduce doses of pain medication so that patients wake up sooner and operating rooms can be cleared faster. This year, as the volume of operations surged, doctors accidentally operated on a pregnant woman after medical staff neglected to check her test results. The bariatric department has an incentive to move fast. The hospital receives at least $11,000, and sometimes much more, for most weight-loss surgeries. And unlike many doctors at Bellevue, who get paid flat salaries, the bariatric surgeons earn more money when they perform more operations. “It’s all about the numbers,” said Dr. Carmen Kloer, who worked with Bellevue’s bariatric department as a medical resident before quitting in October. “They are just churning through cases.” Since 2008, Bellevue has performed more than 17,000 weight-loss procedures. In the first year of the pandemic, nearly 1,200 patients underwent bariatric surgery, nearly as many as the roughly 1,400 who were hospitalized for Covid — even though the hospital halted elective operations for three months of the year. Weight-loss surgeries now account for one of every five operations at Bellevue. Some bariatric patients have contracted life-threatening infections. One spent a month in a coma after her surgeon accidentally nicked her spleen. Another died. Bellevue publicly reports rates of complications from bariatric surgery that are on a par with the national average. But those figures capture only certain serious problems in the month after surgery. They don’t include longer-term problems like ulcers, hernias and weight gain. Nor does Bellevue’s complication data cover surgeries this year, when volumes soared to what some doctors and other medical staff regarded as dangerously high levels. The booming bariatric practice has also crowded out other services, with the hospital repeatedly delaying urgent surgeries for patients with stab wounds and broken bones, The Times found. Christopher Miller, a spokesman for Bellevue, said the bariatric program was a much-needed service for patients who often struggle to get medical care. “There’s an incredible need and demand for this surgery,” he said. He cited a report this year from the American College of Surgeons that praised Bellevue for running “a very high-volume program without sacrificing quality.” The review, based largely on data provided by Bellevue, was part of a routine accreditation process. Mr. Miller denied that Bellevue operated on unqualified patients or that it rushed them through screening and approval. He said the hospital prided itself on having made its surgical processes more organized and efficient. Mr. Miller accused The Times of cherry-picking negative examples and painting an inaccurate picture of a successful public health program. “We are saving lives in large numbers” and improving patients’ quality of life, he said. “To frame this any other way is wrong and a disservice to our patients, our employees and New Yorkers.” Always Hitting Targets In 2007, Bellevue recruited a young surgeon named Manish Parikh to help the hospital open a new department. Until then, Bellevue’s doctors had referred potential bariatric surgery patients to the city’s private hospitals. Now executives wanted Bellevue to treat those patients. Because of the large amounts that Medicaid pays for bariatric surgeries, the program might even turn a profit for the chronically underfunded hospital. To get the program off the ground, Bellevue enlisted Dr. Parikh, who had recently finished his medical residency at New York University. N.Y.U. already ran a bustling weight-loss surgery program. After surgeries began in 2008, Bellevue agreed to pay Dr. Parikh in part based on volume. Aaron Cohen, the hospital’s chief financial officer from 1995 to 2015, recalled being impressed that Dr. Parikh continuously set and then met higher targets for how many surgeries he could do. “If he committed to doing 100 cases, he hit 100 cases,” Mr. Cohen said. “The whole time I was there, he never missed a target.” In 2020, the team performed 1,192 procedures. The next year there were 2,071. This year Bellevue is on track for 3,000. Dr. Parikh did not respond to requests for comment. Mr. Miller said that paying doctors based on volume was “extremely common” and that Bellevue operated only on medically appropriate patients. Bariatric surgery has been gaining popularity nationwide, increasing by 66 percent from 2011 to 2021, according to the American Society for Metabolic and Bariatric Surgery — though not nearly at the pace of Bellevue. Dr. John Morton, who heads the bariatric surgery program at Yale and was a former president of the society, said Bellevue’s volume was “exceptional.” He was unaware of any other hospital performing so many weight-loss operations. Bellevue doesn’t publicly disclose how much money it brings in from bariatric surgeries. Based on Medicaid reimbursement rates, The Times conservatively estimated that Bellevue stands to earn at least $34 million this year. At this year’s celebration of its bariatric program, Bellevue set up a gala-style backdrop for newly slim patients to take photographs that would later appear on the hospital’s social media pages. Some patients held signs with phrases like “I Feel Bari Good Today.” Alvaro Macias-Rodriguez walked the runway wearing tight black pants and a big smile. He said that before surgery last year, he had weighed 330 pounds, putting him at heightened risk of liver cancer. Since the operation, he said, he has lost nearly 100 pounds. “I don’t know where I would be without it,” Mr. Macias-Rodriguez said as pop music blared. He praised what he said was Bellevue’s swift approval process, saying it was much faster than the yearlong wait he had faced at another Manhattan hospital. A Rushed Process Bariatric surgery is a serious undertaking. Patients must severely restrict their diets for the rest of their lives. Before surgery, many hospitals require that patients spend months trying to lose weight through exercise and diet. The theory is that if they can’t adopt a healthy lifestyle before surgery, their odds of doing so afterward are low. Patients must go through a lengthy approval process, including counseling and visits with nutritionists. At Bellevue, the process is often compressed. More than a dozen patients said it took about three months from their first appointment to their operation. That speed has caused some doctors to worry that the hospital is not doing enough to prepare patients. “Some people benefit from surgery, but the amount that have no idea what they’re getting into is huge,” said Dr. Kloer, the former Bellevue surgeon. Medical guidelines published last year by the professional society for bariatric surgeons recommend the operation only for severely obese patients. They should have a body mass index, which is based on a combination of weight and height, of at least 35 or, if the patients have certain other medical conditions, at least 30. But eight doctors and nurses said they participated in surgeries on patients whose medical charts showed that their B.M.I.s were below 30. And 15 current and former Bellevue employees questioned whether patients were being adequately informed about the risks of bariatric surgery. Some patients said they weren’t even sure what type of surgery they had undergone. Melody Vargas said she didn’t recall being told about any risks before her 2016 operation. She was 28 and weighed more than 400 pounds when her mother encouraged her to look into the surgery. She described the preparation process as “crowded and rushed,” starting with the first time she talked to a doctor, at an information session packed with at least 60 people. “It was like you’re at a McDonald’s, and you choose what food you want,” Ms. Vargas said. “They make it seem like the operation is really nothing serious.” Days after her operation, she said, she was in the intensive care unit with a life-threatening infection that required emergency surgery. For six months, she relied on feeding tubes for nutrition. Mr. Miller said patients signed forms acknowledging the risks of bariatric surgery. “The information is discussed at several points,” he said, during a screening process that typically lasts three to six months. He said that the time frame was consistent with other hospitals’ and that all patients meet eligibility guidelines set by the American Society for Metabolic and Bariatric Surgery. Yet employees sometimes ignore signs that a patient might not be ready for surgery. When Bernadette arrived for surgery in 2020, she was asked if she had followed doctors’ orders to stick to a two-week liquid diet. No, she recalled replying. In fact, she had eaten Chinese food the night before. The operation went forward anyway, said Bernadette, who asked that her last name be withheld for privacy reasons. Mr. Miller said he could not comment on specific patients. An Egregious Error The overriding principle of the bariatric department, according to more than two dozen Bellevue employees, is to operate on as many patients as possible as quickly as possible. “Two female bariatric surgeons involve their residents in a well-known daily ‘race,’” a manager wrote in 2021 to Bellevue leadership, outlining a variety of concerns about the hospital’s operating rooms. Six other employees said they knew about the race. Mr. Miller said Bellevue’s bariatric surgeries were only slightly faster — about 10 minutes quicker on a roughly hourlong procedure — than the national average. Doctors, nurses and other hospital staff described a hurried process to get patients into surgery and swiftly turn over rooms. That allows surgeons to squeeze up to six or seven patients into a single day. When they have been short on assistants, bariatric surgeons at times have asked equipment technicians, who were not hospital employees or licensed to treat patients, to scrub in and participate in surgeries, two Bellevue doctors said. Mr. Miller did not dispute the doctors’ accounts. Earlier this year, Bellevue’s staff forgot to check a patient’s pregnancy test before surgery, four employees said. It was positive. After the procedure, doctors counseled her about potentially terminating the pregnancy because her body might not be able to absorb enough nutrients to support the growing fetus. Dr. Anthony Petrick, who leads a committee that accredits Bellevue’s bariatric program, said operating on a pregnant patient was an egregious error. “This should never happen,” he said. Mr. Miller declined to comment on the patient’s case. In another case this fall, bariatric surgeons realized before surgery that they had the wrong patient in the operating room, according to four Bellevue employees. Three anesthesiologists said surgeons chastised them when patients took too long to wake up. So they lowered the doses of pain medication, giving just enough to carry patients through the surgery. Some patients woke up in intense pain. Mr. Miller denied that surgeons pressured anesthesiologists. On other occasions, five doctors said, they saw Dr. Julia Park, a weight-loss surgeon, pinch and slap patients’ bellies to rouse them from anesthesia. “We have no knowledge of this,” Mr. Miller said. Dr. Park did not respond to requests for comment. In 2015 Bellevue promoted Dr. Parikh, giving him control over all of the hospital’s operating rooms. While life-threatening emergencies always got priority, patients with minor stab wounds, broken bones and detached fingers regularly waited hours for surgery because bariatric surgeons were occupying so many operating rooms, according to more than a dozen doctors and other employees. One day in October, for example, a patient arrived at Bellevue with shattered ribs but could not be operated on because bariatric surgeons were occupying multiple rooms, according to an employee who was there. (That day, bariatric surgeons performed 16 weight-loss surgeries, according to surgical schedules reviewed by The Times.) The rib surgery was pushed to the next day, the employee said. Mr. Miller said the hospital had dedicated operating rooms for emergencies. “The bariatric surgery program never blocks an emergency surgery from proceeding,” he said. Operating on Prisoners Early one morning in February, a guard clanged on the door of David Mustiga’s jail cell on Rikers Island. Soon, the 43-year-old was shackled and put on a bus to Bellevue. Rikers detainees often struggle to get even rudimentary medical care. But Mr. Mustiga and 10 other prisoners have undergone elective bariatric surgery at Bellevue, often spending weeks in the hospital. Even in the best conditions, recovering from bariatric surgery is tough. Trying to recuperate in jail, where detainees have little control over what they eat or how fast they eat it, is especially difficult. Mr. Miller said patients from Rikers were “screened and assessed like all others” and were kept at Bellevue until they were ready to eat the types of food that were available at the jail. Mr. Mustiga, who was later convicted of drug trafficking, weighed more than 300 pounds and had high blood pressure. He had been excited months earlier when a staff member at the Rikers medical clinic first told him about the benefits of bariatric surgery. He said no one had warned him about the challenges of recovering while incarcerated. When Mr. Mustiga boarded the bus to Bellevue, he thought it was for a brief visit to get bloodwork in preparation for surgery. Instead, he was admitted to the hospital’s locked prison ward and placed on a liquid diet. There, he met another patient waiting for bariatric surgery, Luis Perez. The men bonded over their dieting ordeals and teamed up to steal scraps from their neighbors’ hospital trays. Mr. Perez, who was awaiting sentencing for drug possession, had surgery first. Afterward, he told Mr. Mustiga that the pain was worse than when he had been hit by a car and lost his arm above the elbow. Mr. Mustiga panicked. He said he had tried to back out of the surgery, but a doctor told him that this was his only shot at getting the procedure and that if he didn’t follow through, he would be sent back to the jail immediately. Mr. Mustiga said he often used the same pressure tactics on his drug customers. “Tell someone it’s their last shot, and they find their wallet pretty quickly,” Mr. Mustiga said. He decided to have the operation. After surgery, patients are supposed to consume small, protein-rich meals. Back at Rikers, Mr. Mustiga bartered cigarettes for protein powder. He reviewed a Bellevue pamphlet outlining dos and don’ts after surgery. It suggested that he eat nonfat Greek yogurt or drink eight cups of Crystal Light. Exercise tips included trying a Zumba dance class. Mr. Mustiga wasn’t getting proper nutrition. He said he lost more than 100 pounds in less than six months — a rate of weight loss that can be dangerous. His hair fell out in clumps, and his medical records show he was receiving iron supplements for anemia. This summer, Mr. Perez was transferred to Franklin Correctional, a prison near the Canadian border, to serve a four-year sentence. During a visit in August with two Times reporters, Mr. Perez’s skin was sallow. He said he was not getting enough protein and could not eat without vomiting. He worried the surgery had made him a target in prison, where size matters for protection. Two months later, Mr. Perez was badly beaten. He said his attackers stole the protein powder he had been saving up. The Blood-Filled Stomach In 2022, Bellevue reported that 3 percent of bariatric patients were readmitted to the hospital within a month of their operation. Experts said that rate appeared to be consistent with other high-quality programs, although it didn’t account for longer-term problems associated with the surgery. After her operation in 2015, Jasmine Nieves was in agony. The 30-year-old repeatedly called Bellevue’s bariatric clinic to report her pain, but she said nobody answered. A few months later, her sister discovered Ms. Nieves passed out on a couch. At a hospital in Brooklyn, a CT scan revealed that the operation had caused fluid to pool in her abdomen, requiring emergency surgery, according to her medical records. She spent the next year in and out of hospitals, at one point needing a feeding tube because she could no longer eat solids. Ms. Nieves filed a malpractice lawsuit against Bellevue, which was dismissed after she missed multiple court dates. Her claims were never adjudicated. Mr. Miller declined to comment, citing privacy restrictions. In 2021, Magaly Rojas, then 43, ended up in a monthlong medically induced coma after her bariatric surgeon, Dr. Park, punctured her spleen, according to a malpractice lawsuit she later filed. She was in the hospital for 75 days. By the time she returned home, her 1-year-old daughter didn’t recognize her. She was about 109 pounds, down from 236, according to her brother. Ms. Rojas couldn’t go back to work because she could not control her bowels. She and her three young children are at risk of losing their apartment. Ms. Rojas’s lawsuit is pending. Bellevue disputes her claims. Soraya de Oliveira, 53, underwent bariatric surgery in 2018. Shortly afterward, staff discovered her stomach was filling with blood. Doctors performed two emergency surgeries, but she died days later. Her family filed a wrongful-death lawsuit. Bellevue settled. Mr. Miller said the hospital’s number of deaths associated with bariatric surgery was below the national average. Only two patients had died, he said. Susan Beachy contributed research, and Robert Gebeloff contributed reporting. Jessica Silver-Greenberg is an investigative reporter writing about big business with a focus on health care. She has been a reporter for more than a decade. More about Jessica Silver-Greenberg Sarah Kliff is an investigative health care reporter for The Times. More about Sarah Kliff Aimee Ortiz is a reporter on the Investigations desk. She was previously a general assignment reporter on the Express Desk. More about Aimee Ortiz

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