Sixth Circuit Sets Out Standard of Causation to Prove Death from Health Care Fraud
The Sixth Circuit Court of Appeals issued an interesting opinion last week regarding the standard of causation required to prove that a health care practitioner’s fraudulent practices resulted in the death of a patient under 18 U.S.C. §1347(2). In United States of America v. Martinez, Case Nos. 06-3882/4206, the Sixth Circuit held that where the death of a patient is a “natural and foreseeable result” of a defendant’s violation of the health care fraud statute, a defendant may be held criminally liable under the statute.
In Martinez, the Federal Bureau of Investigation (FBI) began investigating the defendant anesthesiologist, Dr. Jorge A. Martinez, for health care fraud in the summer of 2002. Martinez operated a pain-management clinic in Parma, Ohio, where he regularly prescribed controlled substances and administrated injections for pain relief and billed private insurance carriers, Medicare, Medicaid, and the Ohio Bureau of Workers’ Compensation. The Government’s investigation revealed that Martinez engaged in fraud by omitting physician examinations, giving his patients more injections than were medically necessary or advisable so as to boost billings and leave them dependent on such drugs, and conducting “quickie” office visits where he saw a patient for only 2 or 3 minutes then billed for a much longer visit.
At trial, the government presented evidence that Martinez’s administration of injections to patients far exceeded the state average for pain-treatment doctors in Ohio. The Government also showed that on the days the patients received injections, Martinez only gave his patients an average of 4.14 shots in one visit, while the statewide average was 1.18; and that Martinez saw many more patients per day than other doctors, which evidenced that Martinez provided substandard medical care. This was supported by numbers from practice sign-in sheets, and testimony from Martinez’s staff saying that he frequently spent only two to five minutes with patients during appointments. An expert also opined that a doctor who was properly treating patients for pain could not possibly see that number of patients each day.
At trial, Martinez was convicted on several counts, including two charges of health fraud resulting in the death of a patient under 18 U.S.C. §1347(2). The statute provides in pertinent part that “[I]f the violation [of the health care fraud statute] results in death, such person shall be fined under this title, or imprisoned for any term or years or for life, or both.” At trial, the Government proceeded under the theory that Martinez’s prolonged fraudulent treatment of two patients, John Lancaster and Blair Knight, rather than any single treatment or dose, resulted in the patient’s death. On appeal Martinez alleged that the Government failed to show that a rational jury could find he had caused their deaths. Thus, in a matter of first impression, the Sixth Circuit addressed the standard of causation required to show such fraud had “resulted in death”.
The Court noted that while Section 1347 is silent on the issue, other federal statutes elevate punishment when certain willful crimes “result in death.” For example, 18 U.S.C. §242 allows for a life sentence if death results from certain intentional civil rights violations. Courts have previously interpreted 18 U.S.C. §242’s requirement for enhanced punishment to be met when the defendant’s willful violation of the statute is a “proximate cause” of the victim’s death.
Using this standard of review, the Court concluded that the death of John Lancaster was a “reasonably foreseeable consequence” of Martinez’s treatment, since the evidence demonstrated that Martinez treated Lancaster nearly every week for two years, provided him with excessive injections and prescriptions, inadequately monitored him, and failed to provide him with individualized care. Although Lancaster exhibited warning signs such as a raging temper and exhaustion, Martinez failed to remedy or alter the care provided.
Similar evidence was presented with respect to patient Blair Knight – the record showed that during the two weeks preceding Knight’s death, he visited Martinez twice in extreme pain and was so bloated he could not wear socks or shoes and was covered in a rash. There was no evidence or support that Martinez altered his treatment of Knight in any way, even though such symptoms were indicative of drug use.
After review, the Sixth Circuit affirmed Martinez’s conviction under 18 U.S.C. §1347. (Other issues in the case, though not addressed here, include the propriety of the admission of a video portraying a non-witness physician performing medical procedures; sufficiency of the evidence to support Martinez’s convictions of 8 counts of distribution of controlled substances; 15 counts of mail fraud, 10 counts of wire fraud; and 21 counts of healthcare fraud; and whether Martinez’s sentence was both procedurally and substantively reasonable.)
