|For Top Hospital, Tough Questions About Black Lung and Money|
|By BRIAN ROSS (@brianross) , MATTHEW MOSK (@mattmosk) , CHRIS HAMBY and RANDY KREIDER (@RandyKreider)||Oct 30, 2013, 7:05 PM|
Coal companies have paid millions of dollars to Johns Hopkins Medical Institutions over the last decade for medical opinions that have been used to deny hundreds of ailing mine workers meager black lung benefits, a yearlong investigation by ABC News and the Center for Public Integrity found.
"It is a total, national disgrace," said Sen. Jay Rockefeller, D-W.Va., of the findings. "The deck is stacked in theory and in practice against coal miners, men and women, and it is tragic."
The head of the Hopkins unit that interprets X-rays in black lung cases, Dr. Paul Wheeler, found not a single case of severe black lung in the more than 1,500 cases decided since 2000 in which he offered an opinion, a review by ABC News and the Center found. In recent court testimony, Wheeler said the last time he recalled finding a case of severe black lung, a finding that would automatically qualify a miner for benefits under a special federal program, was in "the 1970's or the early 80's."
"That's my opinion, and I have a perfect right to my opinion," Wheeler told ABC News in a lengthy interview in which he defended his track record. For his work, coal companies pay Hopkins $750 for each X-ray he reads for black lung, about ten times the amount miners typically pay their doctors.
Hopkins said it has no reason to doubt Wheeler's findings, calling him "an established radiologist in good standing in his field."
But the doctor's findings have disrupted lives across coal country.
"If I had my hands around his neck, I'd have squeezed it," said Michael "Steve" Day, whose $1,000-a-month black lung benefits were cut off after a judge denied his claim in 2011, relying in part on Wheeler's testimony in 2009 that Day did not have severe black lung. Day, who spent more than 30 years working in coal mines, had been diagnosed with black lung by his own doctors and the Veterans Administration.
Wheeler said he had "no idea" what happens to miners once he issues his opinions. "It would matter to me if I were wrong, and no one's proven to me that I'm wrong," he said.
But the joint investigation by ABC News and the Center for Public Integrity found that Wheeler has been wrong or mistaken in more than 100 cases in which autopsies or biopsies later found black lung after Wheeler had read the X-rays as negative. Such evidence is not available in the majority of cases.
"The doctor should not be working at Hopkins University or anywhere else," said Sen. Rockefeller after being told about Wheeler and the investigation's findings.
In his interview with ABC News, Wheeler said he considers black lung to be relatively rare and expressed concern that some miners might be trying to cheat the companies by falsely claiming to have black lung.
"That would seem inappropriate to me," he said.
Other experts in black lung disease told ABC News that Wheeler's medical views seem far outside the mainstream, and several bluntly questioned Wheeler's approach. Dr. Michael Brooks, a radiologist at the University of Kentucky who sees thousands of black lung cases, said Wheeler's results were "either a case of someone really having no idea of what they're doing or being willfully misleading. One of those two possibilities."
Hopkins said in a statement to ABC News that Wheeler and other doctors in the black lung unit had "confirmed thousands of cases to be compatible" with black lung over the last 40 years. Hopkins would not say how many of those findings identified the severe form of black lung that automatically qualifies miners for benefits.
"To our knowledge, no medical or regulatory authority has ever challenged or called into question any of our diagnoses, conclusions or reports," in black lung cases, said Hopkins in its statement.
In recent years, however, there have been repeated instances where administrative judges, federal officials, and other medical experts familiar with the work of Wheeler's black lung team have questioned the Hopkins findings.
One judge dedicated an entire section of his ruling in a black lung benefits case to the Johns Hopkins specialists. Wheeler and two colleagues "so consistently failed to appreciate the presence of [black lung] on so many occasions that the credibility of their opinions is adversely affected," Administrative Law Judge Stuart A. Levin wrote in 2009.
"Highly qualified experts can misread X-rays on occasion," Levin wrote. "But this record belies the notion that the errors by Drs. Wheeler [and two colleagues] were mere oversight."
The ABC News investigation found that doctors like the team from Johns Hopkins are part of a professional corps of lawyers and experts that have helped coal companies tamp down the number of black lung awards to mine workers. The most recent figures released by the U.S. Department of Labor indicate that only 14 percent of miners who claim to be sick are initially granted benefits. A 2008 study by the Government Accountability Office found that coal companies appeal about 80 percent of those cases. After appeals, about half of the miners who initially were awarded benefits – or less than 10 percent who initially applied – actually receive them.
Luke Popovich, a spokesman for the National Mining Association, declined to comment when reached by phone and would not respond to emailed questions.
The impact on the lives of coal miners has been dramatic, especially at a time when government researchers have documented that, after decades of decline, black lung disease is back on the rise. The incurable ailment, which is the result of damage to the lungs caused by dust particles churned up during underground mining activity, leaves miners gasping for breath in their living rooms, even after minimal amounts of exertion. The symptoms often grow progressively worse over time, and the disease is frequently a killer.
In the late 1960s, the federal government recognized the unique risk of sickness faced by coal miners and established a special form of workman's compensation to help offset the expense of treatment and loss of income black lung disease was causing. A government-run trust fund covers the initial payments if a miner wins the initial benefits claim and the company appeals, but ultimately, if a miner can prove he was debilitated by his coal mine work, the company where he last worked is responsible for payments that typically amount to about $1,000-a-month.
For years, coal companies have appealed the majority of black lung claims by their workers, according to John Cline, a West Virginia lawyer who helps miners navigate the complex claims process. In the administrative court system, companies are permitted to have their own doctors examine the miners who file claims.
The decision ultimately falls to administrative law judges, who often are forced to weigh conflicting accounts from doctors hired by each side. One factor they use in deciding the case is the background of the doctor who makes the decision, said retired Administrative Judge Edward Miller. And few doctors reading black lung X-rays have better credentials than Wheeler.
"His paper credentials are excellent," Miller said. "He was a Harvard undergraduate. I think he went to Harvard Medical School. He's been associated with-- Johns Hopkins for years and years and years. And I think is credited with a very distinguished career."
Miller is the father of an ABC News employee.
What judges cannot consider, Miller said, is whether a doctor exhibits a pattern in how they read coal miner X-rays. And among judges, Miller said, there is little doubt about the pattern displayed by Wheeler and the Hopkins team. Coal companies hire Wheeler, Miller said, "because they're apparently assured, I think, that he is one of the reliable doctors that they can expect will not find [black lung disease] when he reads the X-ray."
Wheeler said in his interview with ABC News that he simply called cases as he saw them. In sworn depositions, he has acknowledged that he cannot recall finding a severe case of the disease in decades. Wheeler said he believes coal companies turn to his Johns Hopkins team less for his findings than because of the hospital's respected name.
"I'd rather have them come to an academic center that's got worldwide recognition than go to a facility that nobody's ever heard of outside of Baltimore," Wheeler said.
One such case involved Day, the longtime miner from Glen Fork, West Virginia. Day said he promised his wife he would never work underground in the mines, but the money was alluring and the options were slim.
"Now I'm paying the price," Day told ABC News.
Today, Day spends most of his time hooked up to an oxygen machine, slumped in a reclining chair in the small clapboard house he shares with his wife, his daughter and her family. Even though he has been treated for black lung disease for years, an administrative judge turned down his claim for benefits. The decision was based largely on testimony from Wheeler, who said Day was more likely suffering from tuberculosis or a disease called histoplasmosis – which is a fungal infection caused by bird or bat droppings.
In his interview, Wheeler explained why he often writes in his reports that he considers histoplasmosis the most likely cause of the lung damage he's seeing. The disease is endemic to the region of the U.S. where most coal mining occurs, and while it is harmless to most people, it can produce spots on the lungs that resemble the damage caused by black lung, he said.
"If I were a betting person, I would always bet on histoplasmosis, because it's very common," he said.
Dr. Daniel Culver, a pulmonologist who treats black lung disease at the Cleveland Clinic, said Wheeler is missing a crucial factor when he identifies the lung damage he is seeing as being compatible with histoplasmosis – that the patients have spent decades working in coal mines.
"The tenure of mining influences the likelihood of black lung disease," Culver said. "And that has to go into the calculation."
As he does in nearly every report he writes, Wheeler also concluded Day's definitive diagnosis would only be possible if he submitted to a biopsy of his lung tissue. "The diagnoses come out of pathology," he told ABC News. "They do not come from X-rays."
This too, is an issue that raises concerns among Wheeler's critics. The process of awarding black lung benefits was never intended to require miners to prove, beyond any doubt, that they had contracted black lung disease, said Cline, the attorney. The law never required a biopsy, he said, only an X-ray that showed there was damage compatible with black lung, and evidence that the damage was severe enough to keep the miner from being able to work.
Other doctors interviewed by ABC News said they do not believe, as Wheeler asserts, that a biopsy is necessary to reach a conclusion when coal workers are seeking black lung benefits.
"I have actually never done a biopsy to determine if a patient had black lung," Brooks said. "It's just simply not necessary."
Moreover, it can be risky, Brooks said. He said in about 10 percent of cases, the act of inserting a needle to extract tissue can cause a lung to collapse. And though it is rare, biopsies can lead to complications that are even more serious. "It's not like going to the dentist and having your teeth cleaned," he said.
Day said his doctor considered the invasive procedure too risky.
With Steve Day's permission, ABC News and the Center for Public Integrity sent his medical records to Dr. John Parker, chief of pulmonary and critical-care medicine at West Virginia University. Parker was not told of Wheeler's earlier involvement in Day's legal case. But after reviewing the X-rays and CT scans, he said he was surprised that any doctor could look at the images and not immediately identify the cause of the lung damage. It was, he said, "a classic presentation" of black lung.
"I think that there is bias in someone's interpretation if they don't consider black lung the major, if not only, explanation for this radiograph," Parker said. "It disappoints me," Parker added, "because physicians are in a special fraternity, sorority, a profession in which scientific and intellectual honesty is paramount to our patients and to society."
Day confesses he is still angry about the doctors whose opinions left him without the benefit payments that could help his wife and family through the winter. Not only were they denied the compensation, they were asked to return $46,000 in payments they had received after initially winning, then awaiting an administrative court ruling on the company's appeal.
Ultimately, the government forgave their debt, but Day's wife, Nyoka said the added stress it induced was just one more insult to her husband, and to all coal miners. Asked how she felt about the government's efforts to support coal miners who are suffering from black lung, Nyoka Day returned again and again to the same word.
"My kids were cheated. My grandchild is cheated. He's cheated," she said tearfully, pointing to her husband. "He gave his life in the mines … And it's unfair. If he doesn't have black lung, black lung never did exist for anybody."
Chris Hamby is an investigative reporter for the Center for Public Integrity.