This article originally appeared on ProPublica.

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Series: Arterial Motives:The Big Business of Clogged Arteries

Millions of Americans suffer from clogged arteries. But doctors have dangerous incentives to perform excessive and risky procedures.

Cheryl Lee Carr clutched her phone, willing it to ring. The last time she’d answered it, a hospital surgeon told her he didn’t know if he could save her mother’s leg, let alone her life. But he would try to stop the hemorrhaging from her major leg artery, punctured by a doctor at a nearby clinic.

Carr had spent that morning in February 2020 at the Lehigh Valley Vascular Institute in Bethlehem, Pennsylvania, waiting as her 82-year-old mother underwent what was supposed to be a simple procedure to clear plaque from her arteries. More than four hours in, Carr knew something was wrong. She pushed past the front desk to find her dazed mother in a recovery room, two clinic employees holding a bloody compress over a leg that had turned deep purple.

“Where’s the doctor?” Carr recalled yelling. “Call 911 right now!”

Now, as Carr braced for news about her mother’s fate, her thoughts turned to the clinic’s doctor who, she recalled, was nowhere to be seen as his patient bled. Carr pulled up a search engine and typed in his name: James McGuckin.

A deluge of results poured in.

What the hell? she seethed as she scrolled. Why is he still practicing?

For more than a decade, the Pennsylvania doctor and his national empire of vascular clinics had been scrutinized by agencies at every level — state medical boards, the Food and Drug Administration, the Department of Justice — for conducting experimental or unnecessary procedures on patients, putting their lives and limbs at risk.

He’d been disciplined by medical boards in over a dozen states, lost privileges in multiple hospitals and settled federal allegations of fraud, admitting that his company had performed procedures without any documented need. Pennsylvania had tried to shut his clinics down. Just a few months ago, federal attorneys announced a case against him, claiming he put “profits over the health and safety of his patients” when performing invasive artery procedures, regardless of symptoms or need.

And yet, after all of that, McGuckin is still seeing patients today, still adding to the nearly $50 million he has earned in the past decade in federal insurance reimbursements.

Medical boards are supposed to ensure doctors are not endangering their patients. State health inspectors are supposed to make sure facilities are meeting minimum standards of care. And the federal government is supposed to make sure that doctors are not swindling the nation’s largest insurance program, Medicare, by exploiting vulnerable elderly patients.

But the ability of McGuckin to continue practicing, despite scrutiny from each of these regulators, highlights troubling gaps in the public safety net, ProPublica found. Those charged with identifying and stopping problem physicians are often slow-moving, blind to holes in their oversight and frequently unable — and at times unwilling — to stop doctors from practicing, even in cases of egregious harm or brazen fraud. Punishments are often nominal or easy to avoid, especially for well-resourced doctors like McGuckin.

One area that has become perilous for patients is vascular medicine. ProPublica recently uncovered a pattern of excessive and unnecessary vascular treatments in outpatient facilities. Medicare reimburses generously for these invasive treatments, which include using stents and balloons to widen arteries, and spiraling blades or lasers to clear plaque from blocked vessels, in a procedure called an atherectomy. Though they can be done safely outside of hospitals, they carry risks of complications that include clots, bleeding, limb loss and even death.

Over the past decade, federal investigators have accused more than a dozen physicians or companies in the vascular space of performing unnecessary procedures or making false claims. Some have continued to treat patients and profit from government insurance even after settling misconduct claims, only to be accused of committing similar behavior a few years — and millions of dollars — later.

At 61, with eyes that matched his bluish scrubs, McGuckin earned the trust of his patients, many of whom came to him for help with leg pain or circulation problems; several told ProPublica he appeared knowledgeable, caring and charming. One of the perks of going to see him was a limousine service that ferried them to and from appointments, they said.

Several of his patients faced complications after invasive vascular procedures — two lost their legs and several nearly lost their lives, according to interviews and medical and legal records. “The things that have happened to me have been a disaster,” Maria Rohena, 69, said in Spanish as she wept. Her leg was amputated five days after a procedure in McGuckin’s clinic in July 2021, according to medical records.

McGuckin’s attorney David Heim described him as a “very good, skilled surgeon who has helped thousands of patients,” many of them at higher risk. “Any effort to portray Dr. McGuckin as some ‘greedy’ or ‘bad’ doctor would be completely false and defamatory,” he said. Heim did not respond to ProPublica’s questions about specific patients, citing privacy. McGuckin’s attorneys said that he has never been found personally liable for fraud and that the government’s most recent allegations are “provably wrong.”

Carr could not anticipate, as she waited for the call that winter day, just how bleak it would get. “My mother would never have gone under the knife with that guy if I had known anything about him,” she said.

“A Question of Accountability”

From an early point in his career, McGuckin wanted to be calling the shots.

After completing his medical degree in 1987 from Philadelphia’s Hahnemann University School of Medicine, now Drexel University College of Medicine, he earned his board certification in radiology, eventually publishing articles in academic journals and participating in several professional societies, including the American Board of Radiology, the Society of Interventional Radiology and the Pennsylvania Medical Society.

While working in hospitals, he felt he was just “a small cog” in the system, he said in an interview. So, in 2002, a few years after completing his medical training in Philadelphia, he opened his first private practice office.

Before long, he would open a chain of facilities, Vascular Access Centers, that would reach a dozen states under his leadership, and thousands of patients.

“Here, the physician gets to be the pitcher or quarterback,” he said in the interview, of running an office. “We call the plays, set the schedule, drive the tempo. … There is never a question of accountability or the primacy of the customer.”

But there were soon questions of accountability and appropriate care.

Around 2010, McGuckin started offering a controversial procedure: an invasive, experimental treatment for multiple sclerosis, which involved deploying balloons and stents in veins across the body to improve blood flow. The treatment, which lacked substantial evidence that it improved patient symptoms, was rejected by the medical establishment, and the use of devices for the treatment was unapproved by the FDA. Only about 30 doctors performed it, often charging thousands of dollars to do so.

McGuckin became a leading evangelist for the treatment, conducting hundreds of the risky procedures on patients, including a South Carolina woman who, in May 2012, nearly died after a stent dislodged and traveled to her heart. The Milwaukee Journal Sentinel, which wrote about the case, reported that the patient sued McGuckin in 2015 and the case was confidentially resolved two years later.

In July 2012, FDA inspectors showed up at one of his facilities and cited him for multiple violations, which are spelled out in an April 2013 letter. They included enrolling patients in unapproved clinical research; failing to screen for abnormal kidney function, which could have subjected patients to renal failure; and not reporting serious adverse events.

Despite evidence that such treatments put patients in grave danger, none of the medical boards in the more than a dozen states in which he was licensed to practice took action for more than a year. Some boards took four years.

State medical boards serve as the first line of defense against unscrupulous physicians. Typically composed of doctors and laypeople working part time, boards regulate who can practice medicine and investigate complaints of poor care.

But they are not set up for aggressive or speedy detective work. Take the board in McGuckin’s home state of Pennsylvania, which oversaw more than 75,000 health care workers as of 2021; it had a budget of roughly $1.2 million to investigate misconduct that year, or about $290 per case opened.

For this reason, boards don’t typically seek out investigations; they wait for patients, staff or other doctors to formally complain. They are slow to act and notoriously lax with their sanctions, aware that bold actions may provoke a costly and time-consuming appeals process.

Washington was the first state to sanction McGuckin, in November 2015, after a lengthy investigation that began four years earlier. It charged him with “unprofessional conduct” for performing more than 200 procedures, fined him $17,500, made him return the money patients paid out of pocket and ordered him to stop the treatments.

It also required him to pass an ethics course by writing an essay, which evaluators found unacceptable, saying McGuckin didn’t “demonstrate a capacity to think ethically about why he is being held to account.” McGuckin filed a second draft, which was also unsatisfactory. He only passed the course with help from a one-on-one tutor.

The Washington Medical Quality Assurance Commission, which oversees doctors in the state, also made him sign a consent decree, admitting that the invasive procedures were inappropriate. Years later, during a lengthy bankruptcy lawsuit involving his chain, he would testify that he signed it because he felt he had to but didn’t feel he was guilty of the misconduct.

“It is clear to the Court that McGuckin is willing to sign documents, like the Consent Decree, even if he does not believe that his statements are true,” U.S. Bankruptcy Judge Ashely M. Chan, in Philadelphia, would say in 2020. “The Court finds that McGuckin is not truthful and cannot be relied upon for anything that he says.”

By 2017, 15 other state medical boards had followed Washington in citing McGuckin for the MS treatments. Most of the sanctions, however, constituted minimal fines, often less than what McGuckin could bill for a single two-hour vascular procedure.

Pennsylvania, for instance, charged him $10,000 in 2016. That year, he took in almost $4 million in federal reimbursements alone.

In a letter shared with ProPublica, McGuckin’s attorney George Bochetto said the doctor “was not disciplined because he performed a so-called ‘unproven and risky procedure,’ but rather was ensnared in a complicated administrative bureaucracy.”

While he lost hospital privileges across four facilities in Pennsylvania and New Jersey, no medical board limited his ability to practice.

“Bang ’Em All”

All the while, federal agents were investigating McGuckin for an entirely different set of allegations.

While states regulate medical facilities and doctors, the Department of Justice attempts to protect the nation’s largest insurance systems, like Medicare, from fraud. Its investigations are often instigated by whistleblowers, whose inside testimony is crucial to uncovering details of wrongdoing.

Dr. Michael Levine, a seasoned nephrologist with an expertise in hemodialysis vascular access, started working for McGuckin in 2009 at multiple New Jersey clinics that were part of Vascular Access Centers.

“At first, there was no red flag,” Levine told ProPublica. The clinics mostly treated patients with renal disease whose vessels occasionally needed treatment related to their dialysis lines. But Levine said he quickly learned that patients were being put into treatment loops where they were regularly booked for unneeded tests and procedures. “They were having the patients come back every three months, which to me is corruption,” he said.

While the procedures were relatively low risk, each time a doctor puts a foreign device in a patient’s body, it carries a chance of complication. Levine said he was therefore shocked when McGuckin pushed him to do more procedures without a clear clinical need.

McGuckin ordered each dialysis patient to be “squirted with dye,” Levine said in court records, implying that all patients should be subjected to an X-ray test to fish for blood clots or narrowed vessels to treat, regardless of whether their primary doctor ordered it.

McGuckin also allegedly told Levine to treat patients’ vessels with inflatable balloons and implant stents without a medical need. “Bang ’em all,” McGuckin allegedly told him, according to legal filings.

When Levine refused to go along with this practice, he said he was fired. Shortly after, in 2012, he filed a whistleblower lawsuit, which spurred a federal investigation.

“It’s not an issue of competency,” he told ProPublica. “It’s the issue of using his skills for his own self benefit and seeing his patients not as human beings, but as sources of income.”

David Stebbins, who was the administrator director of the centers from 2006 through 2018, said he also witnessed McGuckin’s drive to increase profits with unnecessary procedures. “McGuckin exerted pressure on all of the MDs working for him to increase procedural ‘acuity,’” he told ProPublica in an email. After more than a decade of working for McGuckin, when Stebbins questioned whether the clinics were possibly violating state regulations, he said he, too, was let go.

“McGuckin is an arrogant Charlatan who expects his senior staff to do whatever they’re told, or they may find themselves looking for work,” said Stebbins, who filed a separate whistleblower complaint in 2020, which is ongoing. “Under incredible pressure, they comply.” Attorneys for McGuckin did not respond to Stebbins’ allegations.

Despite allegations that patients might be at risk of unnecessary, invasive procedures, it still took six years for the Justice Department to settle the claims initiated by Levine.

In October 2018, Vascular Access Centers signed a settlement with the federal government, agreeing to a $3.8 million fine. As part of the agreement, the company had to admit that it regularly scheduled, performed and billed for procedures without any evidence of need.

But as is the case with many federal settlements involving doctors, they are rarely held personally liable, or they can just pay steep fines to get out of trouble.

While McGuckin signed the company’s agreement with the federal government, as the company’s general partner and manager of each of its clinics, he was not held personally responsible for its misconduct. No physicians were specifically called out in the federal settlement; McGuckin’s attorney said the government chose not to pursue a case against him because there was no evidence implicating his physician services.

But McGuckin’s business partner claimed in the bankruptcy case that McGuckin had negotiated with the government and agreed to the terms of the burdensome settlement in exchange for securing his own personal release.

At his clinics across Pennsylvania that were not affiliated with the embattled chain, McGuckin could still continue to treat patients unchecked.

Other doctors have gotten a similar deal.

Take Dr. Feng Qin, a vascular surgeon in New York.

In 2015, he settled allegations of fraud, admitting that he had routinely performed unnecessary procedures on end-stage renal disease patients. He paid a $150,000 fine but was able to continue practicing.

Even after the settlement, Qin performed unnecessary procedures, according to federal legal filings. “The monitoring by the feds, I know how to play Medicare’s asses now,” he told his billing assistant in 2015, according to a later whistleblower complaint.

Three years later, the Justice Department indicted and arrested Qin for fraud, after which he agreed to another settlement, paying $800,000. Lawyers for Qin, who left the country after the settlement, did not respond to ProPublica’s emailed questions.

Though Qin was temporarily excluded from federal health care programs, other doctors have continued to receive government payments even after multiple settlements.

Consider Dr. Mubashar Choudry, a cardiologist in Maryland. He was never found guilty of patient harm, but his medical practices have twice been scrutinized by the Justice Department for alleged misconduct.

In 2014, his medical group agreed to pay about $1.9 million to settle allegations that it was involved in an overbilling scheme. Then in 2020, Choudry and his practices settled allegations of kickbacks with the federal government, paying $750,000. In both cases, neither Choudry nor the companies were required to admit liability.

Kirk Ogrosky, Choudry’s attorney, said such arrangements are typical, and his client settled to “avoid the cost and uncertainty of litigation.” His attorney emphasized that Choudry’s settlement was not about the quality of patient care.

Choudry has not been limited from practicing or accessing federal payment programs. In 2021, the most recent year of public Medicare data, Choudry earned $1.5 million in federal reimbursements.

The settlement against McGuckin’s clinics also didn’t prevent him from continuing to bill Medicare.

Between 2019 and 2021, the most recent years of federal payment data available, McGuckin made more than $17 million.

Putting “Profits Over the Health and Safety of His Patients”

While medical boards oversee doctors, state health departments regulate medical facilities, which can include clinics like McGuckin’s. Their investigations, too, are largely driven by complaints and rarely result in major consequences.

So it was remarkable that, in 2019, Pennsylvania’s Health Department decided to take on McGuckin after officials read about his company’s federal settlement in The Philadelphia Inquirer.

At the time, he owned four clinics in the state that weren’t affiliated with the chain.

The department reviewed their license applications and found that the clinics had “failed to fully, completely, and accurately” disclose pertinent details about the federal scrutiny involving McGuckin and his other company. In January 2019, the department issued rare orders for four of his private clinics, revoking their licenses and cutting off their ability to operate.

McGuckin appealed the orders and his lawyer argued that a shutdown would expose his clinics’ patients to “irreparable harm” without their care. His lawyer also noted that the department had based the order on the assessment that McGuckin was “not a responsible person,” instead of relying on claims of patient harm or complaints. His lawyer also said that because McGuckin was not held personally liable in the settlement, he had been exonerated from its “salacious” allegations.

Garrison Gladfelter, who oversees surgical centers for the state, told McGuckin’s attorney in letters that, pending the appeal, McGuckin’s facilities could continue to operate on one condition: that he not personally perform procedures or provide training to the medical staff.

In response, McGuckin sued Gladfelter as well as the state’s health secretary, Dr. Rachel Levine, alleging that his clinics’ licenses were unlawfully revoked and their attempt to ban him from working at his own practices infringed on his “constitutional right to practice medicine.”

The lawsuit continued for eight months, and in October 2019, it was dismissed with an acknowledgment that the issues between McGuckin and the state had “been settled.”

The details of this settlement were kept secret. There’s no public evidence of why McGuckin’s facilities were allowed to continue to operate, with him performing procedures. The Health Department told ProPublica that, after the confidential settlement, it increased oversight at two of McGuckin’s facilities.

But against the tide of litigation, the Health Department largely backed off, and like the state medical boards and the Justice Department before it, it allowed McGuckin to continue to practice.

And so he did, for almost four years.

All the while, federal authorities had more information indicating his patients were at risk.

Two months after the federal settlement, in December 2018, yet another whistleblower filed a complaint: Dr. Aaron Shiloh, who was employed by McGuckin in his private practice in Pennsylvania. In a letter, McGuckin’s attorney Bochetto called him “disgruntled.” Shiloh’s attorney pushed back, requesting further details, but McGuckin’s attorneys did not respond to ProPublica’s request for more information.

His claims would lead attorneys from the Justice Department to conclude that from 2016 through 2019, McGuckin performed more than 500 medically unnecessary or insufficiently documented procedures, which allowed him to earn at least $6.5 million in Medicare reimbursement. They also found that McGuckin performed several invasive procedures on many patients, regardless of their symptoms, putting “profits over the health and safety of his patients.”

The procedures are intended for patients with peripheral artery disease, a condition that afflicts 6.5 million Americans over the age of 40. According to the federal government, McGuckin not only performed procedures on patients with only “moderate” leg pain, against the widely accepted standards of care, he also performed procedures on patients who were disabled and and unlikely candidates for such interventions.

He performed procedures for leg pain in a patient who was paralyzed on one side of her body and did not walk at all, according to the complaint. On another patient, the government said, he conducted “unnecessary below-the-knee procedures in the small portion of what remained of a patient’s already amputated leg.” One patient told the federal government, according to legal filings, that he felt like McGuckin “was just experimenting on him.”

Earl Toler of Long Pond, Pennsylvania, told ProPublica he also felt part of an experiment. He sought treatment at 74 after experiencing weakness in his leg when walking. Over about a year, Toler underwent 10 vascular procedures, according to later legal filings. His condition progressively worsened until his left leg grew swollen and mottled and one of his toes turned dark blue.

To save his life, in November 2018, doctors at a local hospital needed to amputate his leg above the knee. During a malpractice lawsuit against McGuckin and other doctors at his clinic, medical experts who testified on Toler’s behalf claimed the doctors had deviated from the accepted standards of care, particularly in not referring Toler to a vascular surgeon for more advanced treatment, which they alleged eventually led to his limb loss. In legal filings, McGuckin denied the allegations. The lawsuit went to trial last year, and the jury sided with McGuckin and his doctors, clearing them of any wrongdoing.

Despite the verdict, Toler, an excavation contractor by trade who can largely no longer work after his amputation, still holds them responsible for his condition. And when he read over the allegations of the current Justice Department lawsuit, he was floored. “It’s a pattern,” he said. “I knew I wasn’t the only one.”

Two and half years after Toler’s amputation, Rohena, a churchgoing grandmother from the Allentown area, blacked out and had a heart attack in McGuckin’s recovery room, according to medical records. The clinic called an ambulance to take her to the nearest hospital, where medical staff found a main artery had been nicked, causing extensive blood loss. Rohena was treated for five days before her leg was amputated.

A lawsuit has been initiated, according to her attorney Frank Mangiaracina. “Maria is stuck living in a nursing home, and she doesn’t have her leg or life anymore,” he said.

According to clinic medical records, Rohena had undergone four treatments with McGuckin in two months.

A ProPublica analysis of federal payment data from 2017 through 2021 found that McGuckin ranks among the 5% of doctors who perform the most atherectomy procedures like the one Carr’s mother, Toler and Rohena underwent before facing complications.

Recent research has shown that a substantial number of doctors who treat peripheral arterial disease are quickly resorting to device interventions in the earliest stages against best practices. Doctors have used scare tactics to convince patients to get these painful and risky procedures; McGuckin, for instance, allegedly told patients the interventions were necessary to “save their leg” or “stop the chop.” But patients in early stages of vascular disease have less than a 2% risk of amputation after five years, researchers have found. That risk could surge up to 5% or even 10% with aggressive interventions.

McGuckin’s attorneys argued the federal allegations are “baseless” and “irreparably tarnish” his reputation. “McGuckin did not violate any medical standards of care in treating his patients,” his attorneys wrote in legal filings. “The Government’s medical necessity claims amount to nothing more than a ‘scientific disagreement.’”

Justice Department investigations into whistleblower claims are kept secret until prosecutors are ready to file a lawsuit. They did so in May 2023. Despite McGuckin’s arguments that it should be dismissed, it is ongoing.

According to the Health Department, McGuckin has closed or relinquished ownership of his clinics across Pennsylvania in the past few years. When ProPublica called the Lehigh Valley Vascular Institute in July to inquire whether he was still practicing, the receptionist said he was taking appointments.

“Penniless and Paralyzed”

A few weeks ago, Carr pored over the details of the new federal case. It brought her to tears.

Though that phone call back in 2020 brought good news — the hospital surgeon managed to save her mother’s life and leg — the aftershocks took a lasting toll.

While recovering at the hospital, her mother, Elaine Micelli, struggled to use her left arm, and one side of her face drooped. Carr suspected her mother had developed a neurological issue. “She asked me to go down the hall and get her a box of tissues from her closet — she thought she was at home,” she said.

An assessment at the hospital revealed she had suffered strokes, medical records show, likely due to the low blood pressure, which she had when she was admitted.

Before her visit to McGuckin, the 82-year-old still mowed her 2 1/2 acre lawn in the summer and cleared snow with her blower in the winter. She volunteered for the crime watch at the local fire department and, every week, called bingo numbers at the senior center.

Now, she lives in a nursing home and requires 24-hour care. She no longer walks, requires assistance to eat and wears diapers. She cannot speak fluidly or remember key moments of her past. “He destroyed my mom’s life,” Carr said of McGuckin. “She’s penniless and paralyzed … just waiting to die.”

Shortly after her mother’s injury, Carr said she filed a formal complaint about McGuckin with both the state’s Medicare office and its medical board.

Three years on, she said, she has not received a response.