The subcommittee issued a tough report entitled “Fraud, Waste and Abuse in the Medicare Pacemaker Industry.” The FBI investigated. Medicare drastically revamped its payment system in an attempt to get a handle on costs. In 1983, several executives of Siemens-Pacesetter, Inc. (the pacemaker company later acquired by St. Jude, which made my father’s pacemaker) pled guilty and its former CEO pled nolo contendere to federal charges that they’d paid kickbacks to doctors for implanting pacemakers. They were given suspended sentences and fined.
Some troubled cardiologists—often those paid salaries by universities rather than earning a living in private practice—had growing doubts about where the whole enterprise was leading. At a cardiology conference in Manhattan devoted to the elimination of fatal heart attacks, Henry Greenberg, the director of a hospital coronary care unit, delivered a contrarian and prescient paper called “In Praise of Sudden Death.” He’d informally polled his cardiologist friends and their families, he said, and “not one wished anything but a sudden, unexpected exit while in the pink of health. There were not even any votes for a classic death-bed scene, with the family gathered.” The preferred age for this death, he said, was around eighty. “We all want to live to the fullest extent of our capacity as a sapient being capable of joy and delight, but at the proper time life can be quickly and gently rounded with a sleep,” he told his cardiology colleagues in 1982:
What if we are fully successful in the purpose of our gathering? Will we devoutly wish for a new risk factor to call into play as we see memory slipping as our dotage arises? Will we avoid physicians and hospitals for routine ailments because we are afraid that unacceptable illnesses will be prolonged interminably?
In the aftermath of the pacemaker scandal, a committee appointed by the American College of Cardiology wrote a set of clinical guidelines in 1984 intended to discourage overtreatment. On a logic that boiled down to “if it ain’t broke, don’t fix it,” the committee advised against implanting the devices in patients with no troubling physical symptoms and no sign of dis- ease beyond slightly irregular cardiograms, slow heartbeats, or vague diagnoses such as sick sinus syndrome. Over the next five years, pacemaker implantations in Medicare patients dropped by 25 percent. But the basic pattern—maximum promotion, the creeping expansion of diagnoses for which pacemakers and other cardiac devices were supposedly warranted, disguised gratuities to cardiologists, and cat-and-mouse games with Medicare—did not end. No matter how Medicare tried to change its rules and tighten the spigot, money continued to flood into the device companies, and like water seeking its own level, some of that money trickled down to cardiologists. By 1987, the median income of cardiovascular surgeons was $271,555, while most primary care doctors earned considerably less than $100,000.
One former Medtronic sales rep told me that in the 1980s he was sent to a three-day course in fine wines, all the better to wine, dine, and knowledgeably converse with the upscale cardiologists who were his sales prospects. In the early 1990s, one of pacemaking’s pioneers, a respected university-based cardiac surgeon, saw how far things had gone wrong when he flew from the east coast to Los Angeles to supervise the placement of a pacemaker in his mother-in-law, who was then in her early nine- ties. “I went out there on a Saturday to Cedars Sinai, I guess in February,” said the east coast surgeon, who asked to remain anonymous. “It was a very quiet day, and the surgeon and I were sort of waiting around. It turned out we were waiting for the sales rep, and finally he arrived. The doctor put in the pace- maker adequately, and the sales rep handed the surgeon a pack-age and left. The surgeon opened it in front of me, seemingly not at all embarrassed; it was a nice gold wristwatch, as a present.”