Why Corrupt Health Care Leadership May Persist? - Silencing the Whistle-Blower in Rhode Island

We have posted before, most recently here about the leadership problems afflicting our local Roger Williams Medical Center. Its former CEO was just convicted of conspiracy and mail fraud. The hospital is operating under a federal deferred prosecution agreement under the supervision of a federal monitor.

After the CEO was convicted, more details keep coming out about the techniques he used to maintain his power. A new Providence Journal article described what happened to Dr Phillip O'Dowd, former president of the medical staff and board member of the hospital, after he dared to blow the whistle on this case.

After an internal report commissioned by the board of trustees found that then-hospital CEO Robert Urcuioli had billed the hospital for a trip to a medical meeting that was never held, O'Dowd had gone to then-Attorney General Sheldon Whitehouse. Below is the story in the words of the article (somewhat re-ordered).

O’Dowd said he visited Whitehouse three times with folders of evidence.

He said Whitehouse listened politely, but 'hardly said a word.'

Just before he left the last time, O’Dowd recalled saying: 'If you don’t prosecute this in the criminal arena, when you announce your decision, I am going to bark like a dog and squeal like a pig. I am going to try to get every TV camera and every radio person and every print journalist in town and I am going to make the arguments to them that I am making to you. This won’t go away. I’m stubborn. I’m right.'

O’Dowd said his term on the hospital board ended Dec. 31, 1999, and he was fired days later.

He said the cited reason was anger-management problems, but he viewed his dismissal as punishment for pursuing a criminal case against Urciuoli. Asked yesterday whether he had anger issues, he said: 'I did have anger-management problems. I was very angry at the management.'

O’Dowd would not identify his lawyer. But state Democratic Party Chairman William Lynch acknowledged yesterday that he represented the doctor at the time.

[O'Dowd received]... a severance agreement offering him $184,994 on the condition that he not criticize the hospital or then-Attorney General Sheldon Whitehouse’s handling of the case.

The Feb. 17, 2000, agreement ... said:

'Dr. O’Dowd agrees that if the Rhode Island attorney general negotiates or enters into an agreement with Mr. Robert Urciuoli or the Hospital with respect to certain issues … Dr. O’Dowd shall not comment upon or criticize the terms, conditions or circumstances leading to … such an agreement or the conduct of the negotiations.'

Coming to light in the closing days of Democrat Whitehouse’s campaign to unseat Republican [Senator Lincoln] Chafee, the don’t-talk clause was immediately seized upon by Chafee as evidence that Whitehouse had 'cut a deal' to 'muzzle' a whistleblower.

Neither Chafee nor O’Dowd had proof that Whitehouse had a direct role in crafting the agreement. But Chafee said: 'The timeline just supports the allegation that as soon as the whistleblower, the good doctor trying to look out for the nonprofit institution … is muzzled, the attorney general is free to announce his civil settlement.'

After days of ignoring Chafee’s comments about his alleged mishandling of this and other cases – including a judge’s disqualification of the wiretap evidence gathered on Whitehouse’s watch against a former Lincoln town administrator accused of bribery – the Whitehouse campaign issued this statement slamming Chafee for raising what were characterized as false and irrelevant issues in a campaign of national significance:

'We’re at war, seniors are hurting, but Lincoln Chafee refuses to address these issues and instead has chosen to base his campaign on a series of baseless, negative attacks.'

I will not comment on the Iraq war or the plight of senior citizens.

However, it does seem that Dr Phillip O'Dowd joined the ranks of health care whistle-blowers when he tried to get a criminal investigation of the CEO's conduct started. And as has happened before to health care whistle-blowers, his reward was to lose his job, and then to be offered a monetary settlement only in exchange for a pledge of silence. (See the "Cost of Courage" series published by the Pittsburgh Post-Gazette for other examples.)

Clearly, to fight health care corruption, which cases like that of Mr Urcuioli suggest is a systemic problem, we will need to protect the people who have the courage to blow the whistle on the perpetrators.

Why Corrupt Health Care Leadership May Persist? - An Example from Rhode Island

We have previously posted about the travails of Roger Williams Medical Center here in Rhode Island. The Medical Center is currently operating under a federal deferred prosecution agreement (see post here). Its former CEO, Robert Urciuoli, was just convicted of conspiracy and multiple counts of mail fraud in federal court (see post here). The original indictment said that these offenses started as early as 1998. A report today in the Providence Journal suggested why misconduct such as this may be allowed to persist so long in today's health care environment.

There was other evidence of Urciuoli's misconduct before the turn of the last century, but even a persistent physician whistle-blower who also was president of the hospital's medical staff and a member of its board of trustees was unable to get law enforcement interested in it.

[It is interesting that one reason this story has come out is that one of its principals, former Rhode Island Attorney General Sheldon Whitehouse, is locked in a close election contest with Senator Lincoln Chafee for the latter's Senate seat. Chafee has made corruption in government and health care a campaign issue.]

To quote from the Pro Jo,

[Medical staff president and board member Dr Philip] O'Dowd had brought allegations regarding Urciuoli to the Roger Williams board.

A subsequent review by Boston law firm Goodwin Proctor & Hoar found that Urciuoli had misspent thousands of dollars on golf trips, family dinners and stays in luxurious hotels such as The Breakers in Palm Beach, Fla.

Urciuoli also may have committed 'a serious fraud upon the hospital, the review concluded, when he billed $5,998 for an eight-day sojourn to the Scottsdale Princess Resort in Arizona for a nonexistent health-care conference.

Urciuoli agreed to repay the hospital $16,000 and kept his job. O'Dowd, who wanted Urciuoli fired, went to the attorney general.

Meanwhile, members of the executive committee were meeting with the attorney general's office. They provided [Sheldon] Whitehouse with documents and information, and brought in the Boston lawyer who had led the internal review. But the hospital refused to provide the lawyer's final report, saying that it was protected by attorney-client privilege.

Dr. Philip O'Dowd said that he met three times with Whitehouse, then the Rhode Island attorney general, in the fall of 1999 and presented him with documents regarding possible crimes by Urciuoli, the hospital's president.

But rather than investigate, O'Dowd said, Whitehouse told him that the matter would best be handled civilly because hospital leaders did not want to press criminal charges.

O'Dowd, who was a Roger Williams board member and president of the medical staff, faults Whitehouse for listening to the hospital's executive committee, whose members he compares to 'the foxes saying everything was fine in the henhouse.'

'When [the executive committee] said that they didn't want to press criminal charges, that became a legal fact in the case,' said Whitehouse. 'Any reasonable prosecutor could have foreseen its effect on disabling a criminal prosecution, by having the purported victim deny that there had been a crime.'

Whitehouse says that his office determined that it would have been difficult to prove criminal intent without the hospital's backing. Another former attorney general, James O'Neil, disagrees.

'The man [Urciuoli] went golfing, then came home and reported he had been at a health-care conference when there was no conference,' said O'Neil, ...'What more do you need? A prosecutor has to infer intent it's not stamped on a document.'

First, to be charitable, this seems to be a case in which a government law enforcement official showed excessive deference to some members of the leadership of a local hospital. Perhaps he still viewed hospital leaders as they were in decades past - dedicated, generally poorly paid "superintendents" or "directors" of thread-bare institutions dedicated to their patient care and academic missions, not the business oriented, lavishly remunterated, sometimes ruthless leaders of today. This view of a hospital as an impeccable, white, shining institution on a hill may cause many in the public, and even in law enforcement, to deny the gritty reality of how hospitals and other health care institutions are too often lead today. And some hospital leaders, like perhaps Mr Urciuoli, might be inclined to hide behind these outdated views of these institutions, until they are caught.

Second, it may be that Attorney General Whitehouse somehow blurred the identity of the hospital with that of its top leaders. Note that because the few members of the hospital's executive board declined to press charges, Whitehouse seemingly gave up on criminal prosecution, even though it was the hospital, not the board members, which may have suffered a loss, and even though at least one other board member, Dr O'Dowd, was urging criminal prosecution. We have noted before how some health care leaders seem to have an almost royal view of their dominion over their organizations - l'hospital ce moi [pardon the bad French] (see previous post here).

Unpleasant as it may be, we need to open health care professionals' and the public's eyes to the sort of leaders who may run some health care organizations today, and to remind hired managers of their role, and that they are neither the owners nor the kings and queens of their institutions.

Another One Bites the Dust: Former Roger Williams Medical Center CEO Convicted

We have previously posted about the woes of a local Rhode Island hospital, Roger Williams Medical Center. The hospital's former CEO, Robert A Urciuoli, and a vice president, Frances P Driscoll, were accused of hiring a former state legislator to promote the hospital's political interests. The hospital agreed to a federal deferred prosecution agreement, admitting that the government had evidence of wrong-doing, and pledging reforms. The hospital's board fired Urciuoli and Driscoll. (See posts here and here.)

Urciuoli, Driscoll, and a leader of the hospital's assisted living center have been on trial in federal court in Providence. The verdict was just announced. I will quote relevant details from a Providence Journal story.

A federal jury today returned a mixed verdict in the Roger Williams Medical Center corruption trial that centered on whether hospital executives had abused the honest services of a former state senator -- who became the star witness against them.

After entering their seventh day of deliberations in U.S. District Court, jurors convicted former hospital president Robert A. Urciuoli of conspiracy and 35 of 36 counts of mail fraud. They cleared Peter J. Sangermano Jr., a partner in the hospital's assisted-living center, of the same 37 counts against him. The third defendant, Frances P. Driscoll, a former hospital vice president, was cleared of the conspiracy charge, but convicted of the one other count against her, mail fraud. A conviction for conspiracy carries a penalty of up to five years in prison and a $250,000 fine. Mail fraud is punishable by up to 20 years in prison and a $250,000 fine.

The defendants in January were named in a 38-count indictment, charging them with conspiracy and mail fraud. The indictment alleged that Urciuoli, Driscoll and Sangermano hired Celona as a consultant to The Village at Elmhurst, which was partially owned by the hospital, but that Celona's real work was using his public office to influence legislation and perform favors.

The indictment charged that one or more of the defendants directed Celona on various matters, from legislation to persuading municipalities to increase their ambulance runs to Roger Williams to pressuring health insurers with legislation before his Senate committee to increase their reimbursements to the hospital.

In 1998, the indictment charged, Driscoll and Sangermano directed Celona to work against a bill prohibiting health facilities, including the Village at Elmhurst, from offering care for Alzheimer's disease.

As chairman of the Corporations Committee, Celona had the power to advance or kill bills of importance to companies, including Blue Cross and United Healthcare, each of which were embroiled in a dispute with Roger Williams over insurance payments.

Urciuoli and Driscoll are thus new additions to the unhappy roster of health care organization leaders convicted of criminal misconduct in the course of their official duties. (Another relatively recent addition to this roster was the former CEO of Fletcher Allen Health Care, see post here.) Thus, they join the most extreme examples of abuse of power in health care. Yet, as I have said so often, even cases as egregious as these get little attention outside of their local geographic region. So physicians and other health professionals stuck under their demoralizing penumbra often believe that their misery is a local anomaly, not part of a larger pattern.

Hopefully, the litany of cases, big and small, of concentration and abuse of power on Health Care Renewal may persuade some physicians, other health professionals, policy researchers, and policy makers that there are systemic problems that must be addressed.

What Roger Williams Medical Center Must Do To Keep Its License: A Generalizable Framework for Governance of Troubled Hospitals?

The Providence Journal reported major changes in the works for Roger Williams Medical Center.

We have posted several times, most recently here, about the travails of the hospital, which is now operating under a federal deferred prosecution agreement, and whose former CEO has been indicted by a federal prosecutor.

The Rhode Island Health Department convened an extraordinary licensing hearing in which it proposed imposing unprecedented conditions on the hospital for it to maintain its license. These included, "requirements that Roger Williams invite a Health Department representative to all board meetings and file a monthly report. The hospital would also have to give advance notice to both the department and the state attorney general whenever it appoints a new trustee or a new senior administrator, whenever it changes the duties of a senior administrator, and whenever it changes a corporate document."

Of particular interest to me were additional conditions, those

would require Roger Williams Medical Center to hire a forensic auditor to review its finances and an expert in nonprofit corporate governance to recommend changes in the way the hospital is governed. Another condition would have the hospital study the Sarbanes-Oxley Act, an anticorruption law that applies to for-profit businesses, and adopt aspects of the law that are applicable to nonprofits.

Again, these might be part of a more generalizable framework to improve governance of other troubled hospitals and academic medical centers, and even hospitals and academic medical centers that are not troubled, at least outwardly.

Roger Williams Medical Center Consents to Deferred Prosecution Agreement

We have previously posted about the troubles of Roger Williams Medical Center (RWMC) here in Rhode Island. The hospital, its former CEO, and two other former executives were under federal indictment, charged with hiring a former state legislator to promote the hospital's legislative interests.

The latest news (per the Providence Journal, here and here) is that the hospital has consented to a federal deferred prosecution agreement. RWMC admitted "that the government has sufficient evidence to prove that [former CEO Robert A.] Urciuoli and [former Vice President Frances P.] Driscoll committed the offenses charged in the indictment." The hospital agreed to "significant reforms" to make it "a leader in corporate ethical conduct."

The hospital's operations will now be overseen by a federal monitor. Furthermore, "Roger Williams will hire an executive ethics officer, reporting directly to the board of directors, and strengthen its corporate compliance program, including employee training . The ethics officer will maintain a hot-line for employee complaints."

This was apparently the first deferred prosecution agreement in RI for a not-for-profit, and the US Attorney said that RWMC was "the first nonprofit in Rhode Island to face federal corruption charges."

Health Care Renewal has been commenting on the somewhat parallel case of the University of Medicine and Dentistry of New Jersey (UMDNJ), which also is operating under a federal deferred prosecution agreement, and is under the supervision of a federal monitor.

The acting CEO of the hospital, Kenneth H. Belcher, said, "We need to take responsibility for our actions. We need to say we're sorry to our community, to our physicians, to our employees, the patients we serve, the government agencies that brought this action. And work to earn back the trust."

Responding to Belcher, Dr Paul Y Liu, chair of the hospital's surgery department said, "It's a breath of fresh air."

My gosh, it is a breath of fresh air. It's amazing to hear a hospital CEO apologize for managerial misconduct(even though he was not responsible for the actions of the previous administration).

Furthermore, the actions that RWMC will be undertaking may be a model for more ethical governance of health care non-profit organizations. In particular, in my humble opinion, the notion of an ethics officer with independent responsibilities to the board of directors is a great idea. Of course, having such an officer may then require the hospital to promulgate an explicit code of ethics for its management, which might be another first. As we mentioned in a previous post, academic medical centers have not up to now subscribed to explicit codes of ethics. [Chervenak and McCullough found "there has been to date no ethical framework offered that academic leaders can use to identify, prevent, and responsibly manage the ethical conflicts that are inherent, but sometimes hidden, in being an academic leader." Also, "ethics is an essential but largely neglected tool in the AHC (i.e., AMC) leader's 'toolbox'...." {Chervenak FA, McCullough LB. An ethical framework for identifying, preventing, and managing conflicts confronting leaders of academic medical centers. Acad Med 2004; 79: 1056-1061.}]

Will wonders never cease?

Busted, Now Fired: CEO of Roger Williams Medical Center Gets Pink Slip

We have previously posted about the federal indictment of the Roger Williams Medical Center (RWMC) here in Rhode Island, and of its current Chief Executive Officer (CEO), Robert A. Urciuoli, and two former executives.

The Providence Journal just reported that the CEO was just fired.

During a 5 1/2-hour meeting Monday night, the trustees of Roger Williams voted to fire Urciuoli "for cause" -- meaning that he not only stops collecting a paycheck from his $400,000 post, but he also won't receive any severance pay and the hospital stops paying his legal bills in his criminal case, according to his lawyer.
The Roger Williams board also voted to stop paying the legal fees of its former vice president, Frances P. Driscoll, who was also indicted earlier this month.
The termination letter said that Urciuoli was being fired as a result of 'willful criminal acts,' said his lawyer, Robert G. Flanders.
'After taking the position for months that Mr. Urciuoli and the hospital had done nothing criminal in hiring John Celona, now they're doing a 180 [degree turn] that is the product of extreme duress arising out of their negotiations with the government,' said Flanders. 'The board has acted as judge and jury and convicted him.'
If the hospital, in firing Urciuoli, is 'accusing him of criminal wrongdoing, then he acted in his capacity as the president of the hospital,' said Flanders. 'He acted with the knowledge of and benefit of the hospital. So if the hospital is accusing him of wrongdoing, they're pointing the finger at themselves.'

The Governor of Rhode Island had a different take on it,

Removing Robert Urciuoli as president of Roger Williams is an appropriate step in the wake of the recent federal indictments . . .,
But I also recognize that much more needs to be done to ensure the future of Roger Williams Hospital and to restore the trust of its employees, patients and the community at large.

Incidentally, the Providence Journal article suggested the previous influence of conflicts of interest on the hospital's board might have contributed to Urciuoli's longevity in the face of various allegations of unethical behavior,

The meeting, at the downtown Providence law offices of Holland & Knight, which represents the hospital, was stormy at times. Board member Richard A. Licht, a former Rhode Island lieutenant governor, argued against firing Urciuoli, according to someone familiar with the situation.
Flanders, Urciuoli's lawyer, said that Licht had helped convince the board not to accept a deal with prosecutors on the eve of the hospital's indictment on Jan. 5.
Licht, who is a friend of Urciuoli's and has represented Urciuoli's wife's family real-estate business, did not return calls yesterday seeking comment.
As a member of the board's executive committee in 1998, Licht had argued against firing Urciuoli after an internal review concluded that the hospital president had spent thousands of dollars of hospital funds on personal expenses -- lavish family dinners, golf trips and stays in luxurious hotels.

The federal indictment of not only the CEO of Roger Williams Medical Center but also the medical center itself is a new low in our annals of bad management of health care organizations.

I would not expect his lawyer to agree with me, but I believe that firing the CEO was an important first step in the cleaning up of this 128 year old health care institution.

Of course, the current board did fire him before his day in court. But, again in my humble opinion, hospital (and other health care) leaders need to aspire to higher ethical standards than simply not yet having been convicted of a crime.

ADDENDUM (2 January, 2011) - Mr Licht was appointed head of the Department of Administration in the incoming administration of Governor Lincoln Chafee, see this Providence Journal article.

Busted: Roger Williams Medical Center, Its CEO, Two Former Executives Indicted

Things just got much worse for Roger Williams Medical Center here in Rhode Island, its current (but suspended Chief Executive Officer [CEO] Robert A Urciuoli, and two of its former executives.

The Providence Journal reported:

Roger Williams Medical Center yesterday became the first nonprofit institution in Rhode Island ever to face federal corruption charges when a grand jury issued a 38-count indictment against the hospital, its president Robert A. Urciuoli and two others.The indictment, charging conspiracy and mail fraud, alleges that Roger Williams and its representatives stole the "honest services" of a Rhode Island senator, John A. Celona, by putting him on the payroll to do their bidding at the State House.
Also charged were Peter J. Sangermano Jr., the former president of The Village at Elmhurst assisted-living center; and Frances P. Driscoll, a former Roger Williams vice president.
The indictment alleges that Roger Williams Medical Center and the others hired Celona as a consultant to The Village at Elmhurst, which is partially owned by the hospital, but that Celona's real work was using his public office to influence legislation and perform favors.
The hospital, Urciuoli and Sangermano were each charged with 37 counts -- 1 of conspiracy and 36 of honest services mail fraud. Driscoll was charged with two counts -- one of conspiracy and one of honest services mail fraud.

The indictement charged "that the defendants conspired to hire Celona as a consultant in 1998, and that the senator was paid more than $260,000 over the next six years 'to cause him to use his influence, power and authority as a state senator to benefit the political and financial interests' of Roger Williams." Furthermore, " As part of the alleged conspiracy, the indictment says, the hospital disguised the true nature of Celona's work and deceived the state Ethics Commission when it sought an advisory opinion regarding the senator."

"The indictment chronicles a litany of actions that Celona allegedly performed at the direction of Urciuoli, Sangermano or Driscoll, from seeking to influence legislation to using his political muscle and powers of persuasion." These included:

• " At Urciuoli's direction, the indictment charges, Celona pressured Blue Cross and UnitedHealthcare to increase their insurance reimbursements to Roger Williams. "
• "The indictment alleges that when Roger Williams was seeking a merger with a for-profit corporation, Urciuoli and Driscoll informed Celona that they opposed a Senate bill prohibiting hospital officials from serving on the board of a converted hospital."
• "The indictment also accuses Urciuoli and Driscoll of telling Celona to oppose a 1999 bill creating a Rhode Island Cancer Council, to coordinate research and treatment, because it could hurt hospital finances and because they expected it would be led by a former Roger Williams doctor for whom they 'felt animosity.' Driscoll subsequently directed Celona to threaten an unidentified state representative, the indictment says, 'and advise her that she would suffer negative political ramifications if she supported the Cancer Council.'"
• " Urciuoli and Driscoll were also accused of directing Celona to attempt to influence municipalities to increase ambulance runs to Roger Williams. "
• "Driscoll was charged with directing Celona to amend legislation to reimburse Roger Williams for a bone-marrow donation program."
• "She was also accused of directing Celona to work to kill a bill to require nonprofit corporations in Providence to make payments in lieu of taxes."
• "In 2000, the indictment says, Driscoll directed Celona to oppose a proposed merger between Lifespan and Care New England, 'because the merger could have an adverse financial impact' on Roger Williams."
• "In 1998, Driscoll and Sangermano allegedly directed Celona to work against a bill prohibiting health facilities, including The Village at Elmhurst, from offering care for Alzheimer's disease. "
• "Sangermano was also accused of asking Celona to work behind the scenes to extend a moratorium on new nursing-home beds in Rhode Island, to help The Village at Elmhurst's finances."

CEO Urciuoli was unavailable for comment. "When the indictment came down yesterday, he was with his family in Florida. Last summer, his wife bought a house on a golf course, the Country Club at Mirasol, in Palm Beach Gardens, for $939,000, according to Florida land records."
The indictment of an entire not-for-profit hospital may be another first in the annals of health care mismanagement. In an accompanying article in the Providence Journal, Rick Wade, Senior Vice President of the American Hospital Association is quoted, "I have no inkling of how you would indict and try an entire institution." Furthermore, "It could be that indicting the hospital is sending a message to every hospital, that it's just not one person acting -- there is institutional responsibility for these kinds of things," he said. "For boards of trustees everywhere, it's a reminder of how serious the responsibility of hospital trusteeship is."
The hospital's Board issued a statement that they were "shocked and deeply disturbed," furthermore,

This decision has threatened a respected 128-year-old institution that employs more than 1,400 people and provides millions of dollars of free care annually to Rhode Islanders who can't afford to pay for care. Hundreds of nurses, doctors and other dedicated caregivers devote themselves to caring for patients on a daily basis at Roger Williams. Their livelihood is now at risk

True enough, but the question is: who was ultimately responsible for the threat, the grand jury who indicted the hospital, or the leaders of the hospital who allegedly took the actions that lead to the indictment?

The membership of the Medical Center's Board has changed since the 13-3 vote to keep Urciuoli on despite evidence of his financial improprieties, since Urciuoli hired Celona, and since the events allleged in the indictment. If the new Board wants to protect this 128-year old institution, it clearly needs to clean up the Medical Center's administrative act.

As each new case of mismanagement of health care organizations makes headlines, awareness that such organizations' leadership is all too often ill-informed, inept, conflicted, and even corrupt should grow.

That awareness should motivate making such leadership more representative, transparent, accountable, and ethical.

A Mulligan for Roger Williams Medical Center CEO

A local story for all you golf fans, about Roger Williams Medical Center here in Rhode Island:

We posted a while back about the messy story of former RI State Senator and Committee Chair, John Celona, who admitted selling the services of his office to three major health care organizations, the CVS drug company chain, Rhode Island Blue Cross and Blue Shield, and Roger Williams Medical Center in Providence. (See previous post here.)

A federal grand jury is continuing the investigation of this case. Late last year, the Providence Journal reported that federal prosecutors had offered the Medical Center a deferred prosecution agreement, "which would require the hospital to admit to wrongdoing in the hiring of John A. Celona," and "to pay a fine, cooperate with the investigation, and agree to to internal reforms." So far, the Medical Center has not agreed.

One bone of contention was an internal report the hospital commissioned in 1998 to investigate the financial dealings of the Medical Center's Chief Executive Officer (CEO) Robert A Urciuoli. The report incidentally refuted charges that Celona was hired by the hospital for a "no-show" job, but did seem to demonstrate that Celona was using his position as a State Senator to benefit the hospital.

In December, 2005, the Providence Journal reported that CEO Urciuoli had been put on leave by the hospital, but was continuing to collect more than $300,000 in salary.

On New Year's Day, the Providence Journal reported, eight years on, about the contents on the 1998 internal investigation. In 1998, Dr Philip O'Dowd became a member of the Medical Center's Board of Trustees when he was elected President of the Medical Center's Medical Staff. O'Dowd began hearing complaints from hospital staff that "Urciuoli had charged personal expenses to the hospital, steered hospital contracts to friends, and improperly borrowed more than $40,000 from the hospital against unused vacation time."

The Executive Committee of the Board, (Chairman Herbert Cummings, former President of Citizens Bank, Robert A Licht, former state Lieutenant Governor, Raymond Mancini, owner of Rhode Island Distributing, a liquor distributing firm, Edward C Arditte, a Textron executive, Bradford Gorham, a lawyer and state Republican party chairman, and Raymond Murphy, an accountant with Sullivan & Co), authorized an investigation by Dennis Saylor, a lawyer and former federal prosecutor, and now a judge. This showed:

• Urciuoli charged the hospital for extended trips with family members to lavish golf resorts. For example, in 1997 he and his fiance went to The Breakers in Palm Beach, Florida for a four day conference. But they stayed at the Breakers for 10 days. All 10 days of the trip were charged to the hospital, for a total cost over $7000. Urciuoli later explained that the extra days were needed to "settle in" after the "long flight." The couple also stayed at the Scottsdale Princess Resort in Arizona for eight days, for almost $6,000, for a conference on "Health Care Issues in the 90's." However, "no such conference took place." By requesting reimbursement for this trip, Saylor thought that "Mr. Urciuoli may have committed a serious fraud upon the hospital." Urciuoli's excuse was that he did not want to disappoint his family by canceling the trip when he found there was no conference.
• Urciuoli charged "at least $4,300 in personal meal and entertainment expenses, including $2,850 for family dinners" to the hospital. For example, "in a span of about two weeks in July, 1997, Urciuoli charged two birthday dinners for his two future stepdaughters at the Clarke Cooke House in Newport. The total: $1,599." Urciuoli's excuse was that these charges were a "mistake."
• More than $29,000 other charges on Urciuoli's corporate American Express card were "highly questionable."
• Urciuoli drew several interest-free loans from the hospital, totaling more than $90,000, which he never repaid. In one case, he claimed to have paid back a $5000 loan, but "hospital records recorded the $5,000 payroll deduction as a charitable donation to the United Way." Saylor said that this payment "may raise an inference of tax fraud...."
• Urciuoli "also appeared to exhibit an unusual degree of favoritism" toward hospital vendors. In one case, he dealt with Thomas F. Fay, a consultant to copier company IKON, but also a former Chief Justice of the RI Supreme Court who had been convicted of corruption. Fay introduced Urciuoli to IKON manager Robert Ferland, and the two subsequently traveled to Nantucket in another trip financed by the hospital. Saylor found evidence that Urciuoli shared information on competing bids for copying services with Ferland.

Saylor delivered his report to the hospital Board's Executive Committee. The Committee presented an oral summary, but refused to share the full report with the Board of Trustees. The Committee recommended that Urcuioli should keep his job, but pay the hospital $16,000, a figure which was clearly less than the questionable expenses and loans that Urciuoli charged to the hospital. Committee member Gorham recently said a reason to keep Urciuoli in his position was worry "about the hospital's reputation." In golf terms, the Board granted Urciuoli a "mulligan."
Dr O'Dowd was unhappy with their presentation, "In my opinion virtually all of the employee allegations against Mr. Urciuoli were understated or misrepresented by the EC of the board in an attempt to represent it as clearing Mr. Urciuoli of any serious charges." Other Board members recalled that Saylor had found evidence that Urcioli committed fraud. Nuala Pell, wife of former Senator Claiborne Pell, said she was "surprised that we weren't allowed to see the full report. I thought it was very odd." Gorham said, "they were worried about confidentiality. They were worried that the hospital's reputation would be damaged."
The Medical Center Board voted 13-3 to accept the Executive Committee's recommendations. Nuala Pell later said, "Urciuoli obviously used his position for personal advantage. I felt he should have been fired." Board member Russell W Field Jr later said, "The reason I voted against it was that it didn't smell right. When a person does something wrong, particularly an executive, I lose faith in that person."
Based on Dr O'Dowd's complaints, the RI Attorney General's office launched a criminal investigation. But, the hospital refused to share Saylor's report, citing attorney-client privilege, and Board Chairman Cummings said the hospital did not want to pursue criminal charges against Urcioli. The only result of this investigation was a civil agreement that Urciuoli would pay the hospital $85,000 for the cost of Saylor's investigation.
After the Board voted to retain Urciuoli, several hospital executives left in protest. Dr O'Dowd is no longer at Roger Williams Medical Center.
Reactions to these late revelations of long-ago events has been swift.

Today the Providence Journal reported that efforts are underway in the state legislature to find ways to "hold executives and directors of Rhode Island hospitals to higher standards of 'accountability and transparency.'" The current Lieutenant Governor of Rhode Island, Charles J Fogarty, said that it is "discouraging" that hospital leaders "were not working for the good of the public and the patients they are there to serve." Furthermore, "as we have seen with Blue Cross in Rhode Island and Enron and WorldComm nationally, some of these higher-ups think that a company is their private domain. One of the biggest outrages is that many Rhode Islanders who are struggling to pay their premiums, or have lost their health insurance, have to read about these expenditures by a nonprofit health-care institution."

Let me sum up with today's lead editorial in the Providence Journal.

Roger Williams Medical Center President Robert Urciuoli's creative use of his expense account in the late 1990s, and the hospital board's countenancing of same, recalls how some chief executives in the for-profit sector have acted with arrogance, treating their companies as private fiefdoms as they are paid ever more extravagantly. That's bad enough. But in a nonprofit organization such as Roger Williams Medical Center, it seems worse.

At first glance, you might be surprised that the hospital's board did not terminate him for what in some places and organizations would quickly get you fired. But then, many boards, be they of Enron or a hospital, tend to be remarkably tolerant of the senior managers they are supposed to supervise.

Mr. Urciuoli's actions and bad ethics are depressing enough. But, again, what was the board thinking?

Meanwhile, it might be interesting to speculate when the extraordinary greed of our era will end -- a greed that has come to encompass the top of organizations that are supposed to serve the public interest.

Thus the saga of Roger Williams Medical Center is added to the depressing litany of inept and corrupt leadership of health care organizations. But depression is not a health response to this sort of sleaze in health care any more. We need to stand up for health care leadership that is accountable and transparent, and representative and honest too.

If not us physicians, who? If not now, when?

[Update as of Jan 5, 2006: The Associated Press reported that Roger Williams Medical Center itself, CEO Urciuoli, former hospital Vice President for public relations and development Fran Driscoll, and Peter Sangermano, President of an assisted living facility linked to the Medical Center all have been indicted by a federal grand jury for conspiracy and mail fraud related to the hospital's hiring of former RI state Senator John Celona. Watch Health Care Renewal for more on this.]

ADDENDUM (2 January, 2010) - Incoming RI Governor Lincoln Chafee named Robert A Licht, former member of the executive committee of the board of Roger Williams Medical Center (see above), to head the Department of Administration, per the Providence Journal.

A Former Rhode Island Legislator Pleads Guilty to Selling His Office to Local Health Care Organizations

Back to a big, and increasingly messy local story... former RI state senator John A. Celona has agreed to plead guilty to federal charges, according to the Providence Journal. Federal prosecutors stated that Celona and "other persons" created a "scheme ... to defraud the State of Rhode Island and its citizens of their intangible right to his honest services and to have those services performed free from deceit, favoritism, bias, conflict of interest and self-enrichment." Celona was previously indicted on similar charges in a state court action. The charges to which Celona has now admitted include:

1. Accepting over $260,000 from Roger Williams Medical Center, (at the recommendation of its Chief Executive Officer (CEO), Robert A. Urciuoli, according to the newspaper,) channeled through its subsidiary assisted living center, to: influence cities to increase their ambulance transports to the hospital; oppose legislation that would have required the hospital to make payments in lieu of taxes; back legislation to extend a moratorium on construction of new nursing facilities; influence other law-makers to oppose formation of a Cancer Council that would have been lead by former Roger Williams Medical Center medical staff members who had feuded with Urciuoli; pressure a company to pay its debt to the hospital; and pressure another to make a favorable contract with the hospital.
2. Accepting $45,000, and free travel to a golf tournament from CVS to: oppose pharmacy choice legislation; favor legislation that would permit electronic prescription of brand-name drugs; and opposing legislation to allow drug re-importation from Canada.
3. Accepting over $13,000 from Rhode Island Blue Cross to: support a bill allowing insurance companies to design affordable benefit plans; support a bill changing health insurance plan parameters for small business; and oppose a bill requiring health insurers to cover prosthetic devices and modifying limits on their investments.

According to the news article, investigations of the roles of Roger Williams Medical Center, CVS, and Rhode Island Blue Cross in this are on-going.
This single case illustrates that mismanagement is not limited to particular types of health care organizations, and that problems at one organization may easily get tangled up with problems in others.
It also illustrates the wide-ranging effects of mismanagement and corruption.

State Senator Indicted for "Influence Peddling" to Health Care Organizations

A follow-up of a complex local story in the Providence Journal: John Celona, a former Rhode Island State Senator, was just indicted by a state grand jury for using his public office for private gain (or, as the headline said, "influence peddling.")
He was charged with having three financial relationships with one for-profit and two not-for-profit corporations "while he was in a position to influence legislation of interest to these companies."
Relevant to this blog is that all three organizations are in health care. They are the CVS pharmacy chain, Rhode Island Blue Cross and Blue Shield, a not-for-profit health insurance and managed care organization (and by far the dominant such organization in the state), and Roger Williams Medical Center, a not-for-profit university affiliated medical center. Two counts of the indictment "alleged that Celona violated the state's Code of Ethics by accepting employment with Roger Williams Medical Center and CVS ... which 'did impair his independence of judgment'...." One count alleged that he "uses his public office 'to obtain financial gain' for himself and a TV production company... from Blue Cross."
Kim Keough, a Blue Cross spokesperson, said "obviously, the indictment surrounding Mr. Celona's actions are not allegations against Blue Cross whatsoever." CVS' written statement simply stated that the company "will continue to cooperate with any and all inquiries into this matter." Roger Williams declined comment.
The investigation is not yet over, and some matters may well be referred to a federal grand jury.
H. Philip West Jr, Executive Director of Common Cause of Rhode Island, said "Hopefully, this indictment and the trial will demonstrate to the public some of the ways that some lobbying groups have sought to compromise public officials. Until now, CVS and others who paid Celona have come through unscathed."
A brief Providence Journal editorial added, "Mr. Celona's trial might illuminate how special-interest groups use legislators to promote their interest. Meanwhile, people wonder what will happen to those who 'hired' Messrs. Celona and Irons [another State Senator who resigned under fire for accepting "broker commissions from Blue Cross]."
Providence Journal columnist M. Charles Bakst opined, "What about CVS, Blue Cross, and the Roger Williams Medical Center? These are the entities with which Celona is charged with striking private financial deals. If something smelly happened, isn't it reasonable to think they were as much a part of it as this prominent Democrate who chaired a top Senate committee? The public will find it hard to take if Celona lands in the slammer, but the folks he served, or who allowed themselves to be exploited, skate."
As we have noted before, Blue Cross in Rhode Island was known for its rapid premium increases, stingy payments to doctors, and recent lack of interest in maintaining a dialogue with health care professionals. Last year, its CEO resigned after his huge financial compensation package was revealed by the Providence Journal. It is gratifying that the civil authorities are now starting to address dubious relationships between large health care organizations and politicians. But where are the watchdogs within health care who could address how concentration and abuse of power damages patients and health care professionals?