State confronts J-1 complaints

By Marshall Allen

Friday, Aug. 8, 2008 | 4:53 p.m.

In a series of unprecedented actions, state officials and a committee that oversees the hiring of foreign doctors have introduced new levels of accountability to a beleaguered program that allows foreign doctors to work in medically needy communities.

Officials launched a Medical Examiners Board investigation by forwarding recently uncovered complaints by foreign physicians who said they were taken advantage of by their employers in Nevada.

The state also announced it is analyzing the Medicaid billing records of all 42 foreign physicians participating in the J-1 program in Nevada. The review is expected to show whether the doctors were allowed to work in medically underserved areas, as the law requires, or whether their bosses have been assigning them to more profitable hospital work.

And in a showdown with the attorney of a prominent doctor, the committee that oversees the J-1 program showed it would not be bullied by the Las Vegas medical community. In the most significant exercise of its authority to date, the committee ordered Dr. Rachakonda Prabhu, a prominent physician who has served as an adviser to Nevada governors, to rewrite portions of a contract with a foreign doctor he wants to add to his practice. The committee’s intent is to make the terms more equitable and more clearly defined so they can be enforced.

The actions were unprecedented because, in previous years, the state had shown little interest in monitoring whether foreign doctors have been exploited by the program, which was created by Congress but is administered by the states.

Thursday’s meeting of the Primary Care Advisory Council was the outgrowth of months of reform efforts by the Nevada State Health Division in response to a 2007 Sun investigation of the J-1 program.

Foreign physicians participating in the program complained to the Sun that a half dozen employers, most of them immigrant doctors, were enriching themselves on the backs of the foreign doctors — by overworking them, underpaying them, and/or assigning them to hospital calls instead of working in clinics in needy neighborhoods. Prabhu, who was represented at the meeting by his attorney and chief operating officer, has denied the accusations leveled at him.

The meeting was the first time the newly formed committee had considered an application to hire a J-1 doctor by one of employers accused of wrongdoing. Prabhu is the largest employer of J-1 physicians in the history of the program.

In previous years, Prabhu has sailed through the process of getting J-1 doctors approved by the state. That was not the case Thursday, though his attorney, Dominic Gentile, sounded tough at the outset.

Before the committee debated Prabhu’s application to hire kidney specialist Dr. George Baramidze, Gentile warned that it would violate the state’s open meeting law if the discussion included the Sun’s reports, because the allegations have no bearing on Prabhu’s application to hire Baramidze. The Sun’s reporting is “way outside” the posted agenda for the meeting, he said.

If the committee responds to “rumor and hearsay in the public domain” it will be “treading on ground that could become very problematic for you legally,” Gentile said.

Then, for more than an hour, the committee picked apart the application and contract. The confrontation was characterized by an exchange between John Hickok, Prabhu’s COO, and committee member Dr. Carl Heard, interim chief executive of Nevada Health Centers, a nonprofit organization heralded for its participation in the J-1 program. Heard expressed incredulity that the contract being offered by Prabhu allowed the employer to terminate the employment without cause without extending the same right to Baramidze.

“Am I missing something?” he asked Hickok.

“There is not a ‘not for cause’ termination on the physician side, no,” Hickok said.

“So if he has an extraordinary family demand that forces him to move to another part of the country, he cannot attend to that?” Heard pressed.

Such a contract clause could be easily exploited, Hickok said.

“We have that in our contracts,” Heard replied. “Every contract I’ve signed in my career has always had that.”

Heard stressed that the panel must create parity between employers and employees. And in some cases, a J-1 doctor may need to leave a contract, he said.

Hickok questioned whether Heard was taking the role of the committee too far.

“At this point, my job is to ask as many questions as I need to and to understand that there is a fair and reasonable relationship that we are participating in,” Heard said.

The committee also wanted assurance that Baramidze would fulfill the aim of the program by working 40 hours a week as an internal medicine doctor and not a kidney specialist. The language in the contract and application was fuzzy, they pointed out, and Prabhu has a kidney dialysis center that shares the North Las Vegas clinic’s site.

Hickok assured the committee the dialysis center will be staffed by non-J-1 doctors. In addition to his 40 hours a week of primary care, Baramidze might help staff the dialysis center, and may also work call shifts and do consultation visits at local hospitals, Hickok said.

That led to questions from the committee about Prabhu’s business plan. How hard was he planning to work Baramidze?

Hickok assured the committee that Baramidze would not be forced to work more than 40 hours a week, and would receive additional compensation if he took on more shifts.

At first Gentile and Hickok bristled at a repeated request by Charles Duarte, administrator for the Health Care Financing and Policy Division and a member of the committee, to shore up the promises they made in writing before the application’s approval. Duarte suggested that Prabhu’s application could be tabled.

Prabhu’s team, not wanting any delays, became more compliant as the meeting went along.

Dr. Amir Qureshi, chairman of the committee, questioned the $300,000 penalty that would be assessed against Baramidze if he breaches the contract.

“This monetary penalty thing is a sword on the neck of the physician,” Qureshi said.

Hickok started to defend the penalty, but then relented and agreed to remove it.

The committee eventually voted to table the contract and order it rewritten to state that Baramidze will work 40 hours a week, doing only primary care, in the underserved clinic, among other things.

Heard said afterward he will not vote for the contract unless there’s a way for Baramidze to terminate it without cause. He recommended the panel create a checklist for contracts to ensure they are equitable for the foreign doctors.

The advisory panel recommended that three other agreements between employers and J-1 doctors be approved at the meeting. They sent one back to the employer for more information.