Tulare Hospital Trial Ends First Week, Gaining Insight into MEC Dispute

A lawsuit brought by a group of doctors against Tulare Regional Medical Center (TRMC) is now entering its second week of proceedings.

The case, which has snaked its way through the Tulare County Superior Court since February 2016, centers around the January, 2016 removal of the former medical staff and medical executive committee (MEC) at the hospital — the same action that was recently the subject of a critical report by the California Department of Public Health.

The ousted medical staff argues, in voting to disassociate from the old group, the board violated its own bylaws — and state laws — that require a medical staff to operate as an independent entity of the district to ensure patient care quality.

The hospital argues, the former medical staff was not doing its job – and that conversations with federal inspectors led hospital officials to believe that without quick, drastic changes, the hospital would be forced to close its doors.

The recent report from the California Department of Public Health appears to back up both sides’ statements, finding that the former medical staff did not attempt to improve relations with the hospital’s board of directors — but that the board did not make any effort to allow the former MEC to clear up deficiencies found by regulators.

In opening arguments and throughout the trial, lawyers for the hospital have also stated that the MEC is not, technically, independent — but rather “interdependent” — due to shared responsibilities between the MEC and the district’s board of directors.

Hospital officials say they’re confident that the case will be decided correctly — in their favor.

“Defendants Tulare Local Health Care District and HCCA are confident that when all the evidence is considered by Judge Mathias, he will conclude that the actions taken by the district’s Governing Board on January 26, 2016, were lawful as the legitimate exercise of discretion and business judgment by district board members,” a statement from the hospital read.

Formation of New MEC

Dr. Parmod Kumar, a member of the hospital’s board of directors, emerged in testimony as a key figure — if not the absolute center — of the new MEC’s formation in the days following inspections by the Center for Medicaid and Medicare Services (CMS).

Indeed, in the hospital’s opening statement, Carlo Coppo, a lawyer for the hospital, stated as much.

“[Kumar] was frightened the hospital he loves, where his patients come and he loves, was going to shut down,” Coppo said. “So he went to a number of doctors who pledged to him that they would be collegial and responsible to the board.”

Those doctors were Frank Macaluso, Gary Walter, Anthony Trujillo, Rebecca Zulim, Ronald Ostrom, Parul Gupta, and Kumar, who is Gupta’s husband.

In videotaped depositions, various members of the new MEC stated that Kumar approached them to join the new MEC and form a new medical staff.

Trujillo said he was approached “a day or two” before the January, 2016 vote by the board to join, and form a new medical staff and medical executive committee. He said that Kumar called and asked him to come to his office to discuss something important regarding the hospital.

“Dr. Kumar stated that the board decided that they wanted to certify a new medical staff,” Trujillo said. “He said a new MEC had to be formed.”

Ostrom, the chief of staff for the new MEC, said that Kumar reached out to him and told him that the hospital was in “immediate jeopardy.”

“He said we needed to form a new MEC,” Ostrom said.

Zulim said that she was asked to come to a meeting, and at the meeting, she too was asked to join the new medical executive committee.

Kumar stated during his testimony that “nobody raised the question of forming a new MEC,” instead stating that there was a group discussion about what the best path forward was.

http://www.documentcloud.org/documents/3540548-TRMCMS-v-TLHCD-5-April-2017.html#document/p63/a347941

At a home in Tulare, Trujillo stated the core group voted to form a new medical executive committee. Trujillo said he believed the home belonged to “a friend of Kumar’s.”

He also stated that discussion was had to ensure that “[the group] did this correctly,” meaning that it could not be undone by “those with ulterior motives.”

Part of that meant that all of the doctors not part of the core group were demoted from “active” status to “provisional” status, temporarily stripping them of the right to vote — or to begin a recall process during the first two years of the new MEC’s existence.

“We felt we needed time to implement all of the changes that were required for the sake of certification,” Trujillo said. “[To] maintain the MEC and not have it replaced a month later.”

Ostrom, Zulim and Trujillo all stated in their testimony that they did not see the report from CMS during this time — and that Kumar was the source of their knowledge, as he had been involved in an exit meeting with CMS inspectors.

Kumar stated the same.

“I was the source, but in that meeting, there was 15 or 20 other people,” he said. “It was a scathing review.”

http://www.documentcloud.org/documents/3540548-TRMCMS-v-TLHCD-5-April-2017.html#document/p66/a347967

Kumar stated he had not read the entire CMS report until he was recently deposed, instead stating that Dr. Davis, a CMS inspector, had given him a scathing review of the hospital in person. This was all the knowledge he needed, he said.

“[Davis] used the word ‘incompetent.’ He used words, ‘I’m not doing my job,’” Kumar stated earlier in his testimony. “So after that stripping of him by me in a very insulting manner, that’s when I start thinking, ‘What is the best way to go forward? Who should I call? What should I do?’

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Hospital officials agreed that the statements were strong enough to warrant immediate action, in their statement to the Voice.

“The imminent threat created by the old medical staff was communicated to hospital personnel by surveyors from the Center for Medicare and Medicaid Services (CMS),” the hospital’s statement reads. “CMS based their threat of closure in large part on the history of dysfunction between the Governing Board and the leaders of the former medical staff, which led to the failure of the medical staff to conduct appropriate credentialing and peer review of physicians.”

“I have been told enough by Dr. Davis,” Kumar said. “I did not believe I had to see the report.”

Dr. Davis

During his testimony, Kumar said that Davis was so dissatisfied with the state of affairs at the hospital that he left early.

“What he told me, when he was insulting me as a board of director, he’s so disgusted, he was going to leave,” Kumar said. “He was supposed to be here for two more days and complete the survey, and things are so bad here, he’s leaving.”

Davis’s statements were the basis for the panic amongst the board and hospital administration.

Sherrie Bell, a former chair of the hospital’s board of directors, stated in a deposition that she came to the same impression — that the hospital would close without drastic changes to the MEC — based on statements by Davis.

Those statements were provided to her by Dr. Benny Benzeevi, CEO of Healthcare Conglomerate Associates, the company which runs day-to-day operations of TRMC.

Later in 2016, according to Kumar, Davis came back to the hospital to follow-up on the findings from January.

Davis’ follow-up visit to the hospital resulted in a May, 2016 letter that found the hospital had violated standards requiring the medical staff be granted the “right to self-govern to select and remove medical staff officers and initiate, develop and adopt medical staff bylaws.”

Kumar said he could not recollect what Davis had stated during the follow-up visit.

“I don’t know what he told me. I don’t recall that because he was so insulting. I stopped hearing him. Looks like I was some kind of piece of crap in front of him that he has to dehumanize me,” Kumar said. “It was so — I just blocked my mind and looked at 10 or 15 other inspectors in the room, and I said to myself, ‘What is this?’ I don’t know what the hell he was saying to me.”

http://www.documentcloud.org/documents/3540548-TRMCMS-v-TLHCD-5-April-2017.html#document/p66/a347967

Animosity Abounds

Both sides had opened up the first day of proceedings by admitting that there was tension between the board and the former MEC.

“When you have two independent bodies working together, there’s bound to be disputes,” Amir said in his opening remarks. “There’s often tension, but the bylaws require that when there is a conflict, one side just can’t trample on the other side’s rights.”

Coppo was not as generous. In his opening statement, stating the hospital’s case, he noted that the MEC boycotted meetings during Dr. Anil Patel’s tenure as chief of staff of the prior MEC.

Members of the former MEC, he said, boycotted board meetings because Bell did not recognize Patel as the chief of staff, stating that members of the former medical staff had complained that the election was not in accordance with the staff’s bylaws.

That specific feud was crystallized as a very public example of the discord between the board and the former MEC, when it spilled out into a set of dueling lawsuits in 2014 and 2015.

Patel claimed in his testimony that Bell stated the MEC members are “all terrorists, and they should be hanged.”

http://www.documentcloud.org/documents/3540547-TRMCMS-v-TLHCD-4-April-2017.html#document/p66/a347975

Patel said the MEC voted to file a lawsuit against Bell for that statement and others, though a judge later awarded Bell attorney’s fees in the action, according to a Visalia Times-Delta report.

In her deposition, Bell stated that she was told by Tony Jones, the hospital’s former chief restructuring officer, that Patel had made threats against her life.

“Dr. Patel — by Mr. Jones’ statement — was that he went into, like, a raging trance, like he was transported somewhere else and ranted for 20, 30 minutes about how if I had come, he would kick my [ass] and that he would take my hair and take — drag me out and pound my head against the cement,” Bell said in her deposition.

Patel said the accusations were inaccurate — and that his original statement was a hypothetical in response to Bell’s statements.

“I told [Jones], ‘Let me give you an example. Let’s say if I kick her butt, and then I say let’s forget about it and work together, would she work together or want some form of apology to do that?’,” Patel said. “Our attorney contacted each and every MEC member, including Tony Jones and Angie Graziano, said, ‘Dr. Patel never made that statement.’ [The MEC’s lawyer] wrote a letter. Still they filed [their] lawsuit.”

“Then, also, in the court mediation, we met with the ex-retired judge, and he agreed that there was nothing there.”

“Not given due process”

Before CMS inspectors set foot in the hospital, the former MEC had required that Kumar seek anger management and document compliance training, and had set a deadline of January 27, 2016 to complete such training.

The board took its action to disassociate from the former MEC, with Kumar abstaining, on January 26.

Zulim said that Kumar was “upset and frustrated” that the MEC had forced him to take such action, and felt that he was being treated unfairly.

“I was not given due process,” Kumar said.

During the testimony, Michael Amir, representing the ousted MEC, asked why Kumar was being forced to go to anger management training.

“That was a concocted, self-made, friends of the MEC type of a ‘got you’ mentality type of a deal for me,” Kumar said.

In a declaration filed in a separate case by Kumar against Dr. Abraham Betre, chief of staff of the prior MEC, Kumar gave a more specific answer.

http://www.documentcloud.org/documents/3213535-Betre-Separate-Statement.html#document/p23/a348170

“I received a letter from Dr. Betre […] informing me that the [former] MEC was investigating me for using foul language in front of a subordinate on one occasion,” Kumar’s declaration read, “and for ‘backdating’ chart notes in three cases.”

“[…] the ‘backdating’ accusation was made after I had inadvertently listed the dates of my dictation as the dates of three patients’ physical examinations, at a time when I had performed approximately 150 procedures [in] 18 month[s].”

In the declaration, Kumar said he was “outraged” that the MEC would “even consider suspending” him.

Kumar later completed all of the training requested by the former MEC, he said, though he did not do so by the January 27 deadline due to an error on the part of those organizing a required course.

“[The course coordinators] said, ‘Oh my God, Dr. Kumar, we never sent you the material. We are at fault. So if you come to the course, you will not be recognized that you attended the course. This is our fault,’” Kumar said.

In the declaration from the case against Betre, Kumar said that the new MEC “reviewed my cases and found that there had been no basis to investigate [him] at all,” but that he insisted he take the recordkeeping class and see a psychiatrist to ensure that there were no claims of bias or impropriety against the new group.

“Unprecedented and illegal”

Dr. Robert Orth was on the MEC at the time of the incident.

He interviewed Tony Jones via telephone as the MEC worked to investigate the claims and reach a conclusion, he stated in his testimony.

Jones is currently the president and CEO of Alliance Health Partners, LLC, a hospital and healthcare management/consulting company.

According to his LinkedIn page, as an assignment from Alliance, he came to TRMC to serve as a Chief Restructuring Officer and Interim CEO, and has worked at other hospitals before serving at Alliance or TRMC.

“At the end of the five questions, we started talking about the hospital, and [Jones] told me, ‘Good luck,’” Orth said. “He said that he, in all his years being [a] CEO and helping [various] hospitals, he’s never seen such treatment of the physicians and the MEC from [an] administration and a board in all of his time.”

Orth responded by stating that he and a few other physicians believed that hospital officials would “fire us one day.”

“His words were, after [a] long pause […] ‘I can neither confirm nor deny that I have been in any meetings where that topic was discussed,’” Orth said.

“I was shocked, to be honest with you. And then he said, ‘But if that does happen, you guys need to find some defense because this is unprecendented and illegal.’”

Hospital officials maintain their actions were legal and required — and that since the hospital disassociated from the former medical staff, it’s been smooth sailing.

“Following the disassociation, TRMC complied with every deficiency cited by CMS, and received a clean bill of health in June, 2016, and remained fully certified as a Medicare and Medicaid Provider,” the hospital’s statement read.

“The hospital, HCCA and the Governing Board have enjoyed a harmonious working relationship ever since contributing to the betterment of quality of care at TRMC for the people of Tulare.”

Dr. Parmod Kumar did not return requests for comment by the time this article was published. If the Voice receives a response, the article will be updated.

Trial transcripts are available below.

http://www.documentcloud.org/documents/3540547-TRMCMS-v-TLHCD-4-April-2017.html

http://www.documentcloud.org/documents/3540548-TRMCMS-v-TLHCD-5-April-2017.html

http://www.documentcloud.org/documents/3540545-TRMCMS-v-TLHCD-6-April-2017.html