Two years ago Maria Garcia, a 39-year-old mother of five, came to a suburban office park in Anaheim Hills for outpatient plastic surgery. By day's end, she had bled to death from a puncture wound.
FOR THE RECORD
An earlier online version of this article incorrectly gave Maria Garcia's first name as Marcia.
Garcia did not know that the widely advertised Hills Surgical Institute Inc., recommended by a friend, had opened only 90 days earlier. Family members said she had no idea that one of her doctors was under investigation by the California Medical Board.
She also did not know that Hills Surgical Institute failed to meet the state's requirements for surgical centers that use general anesthesia, according to her family's attorney, Jin Lew. It was not state-licensed, Medicare certified or privately accredited. The center instead fell into a gap in the patchwork of rules that loosely govern the state's billion-dollar cosmetic surgery industry.
In 2007, California stopped licensing surgery centers owned at least partly by a licensed doctor. The move came after a doctor successfully challenged the state's regulatory authority in court. According to the state Department of Public Health, only 45 surgical centers are now state-licensed, compared with about 480 before the law changed. An additional 715 are certified to bill Medicare for treatments such as orthopedic care, eye surgeries and weight-loss related procedures. Hundreds more operate as cash-only businesses that specialize in elective cosmetic procedures, many without accreditation, experts say.
"There are a lot of facilities that completely ignore the law and are not accredited or licensed or anything," said Dr. Michael F. McGuire, chief of plastic surgery at St. John's Health Center in Santa Monica and past president of one of the four private accrediting agencies, the American Assn. for Accreditation of Ambulatory Surgery Facilities.
Unlike state regulators, accrediting groups do not fine surgery center owners or doctors who violate rules on patient safety, although they can pull a center's accreditation. By law, the state medical board can pursue fines against surgery centers without accreditation $1,000 a day, but rarely do, McGuire said. The state lacks an accurate list of facilities with current accreditation.
The accrediting groups can keep confidential their records of complaints against surgery centers and investigations. They have been criticized by lawmakers for allowing clinic owners who have lost accreditation with one agency to immediately reapply and become accredited by another.
"They would shop around and go someplace else and get somebody else to accredit them," said state Sen. Gloria Negrete McLeod (D-Chino). "What we would like to see is for those clinics to be overseen by the Department of Public Health."
Negrete McLeod proposed legislation this year that would have required all doctor-owned surgical centers to be state-licensed. The legislation passed the state Senate and won support from the governor, but doctors' groups balked and lawmakers in the Assembly blocked a vote. Negrete McLeod said she plans to propose similar legislation again next year, and is hopeful that Gov.-elect Jerry Brown will support it.
Doctors who oppose mandatory state licensing say the process can take years and requires surgery centers to meet building standards designed for much larger hospitals.
"A majority of them would have to close down without any benefit to patient safety," said McGuire, who instead advocates better state enforcement of accreditation requirements.
In the meantime, patients like Garcia, a Verizon sales rep, may be undergoing procedures without knowledge of how their doctors and surgical centers are being regulated.
Garcia came to Hills Surgical Institute on March 13, 2008, for a vaginal reconstruction, liposuction and a "Brazilian butt lift," according to her medical records, which are part of public record in a lawsuit filed by her family against her surgeons, nurse and surgery center. The individuals named have all denied wrongdoing in Garcia's death. The case is scheduled for trial in April.
Garcia had scheduled the procedures, as well as a breast augmentation and a tummy tuck to be done later, weeks before her death and agreed to pay $19,500 with her credit card and a financing plan.
An accusation filed by the state medical board against her surgeon, Dr. Lawrence Hansen, and her autopsy lay out what officials say happened next:
The day of Garcia's surgery, Hansen arrived at the office in a suburban office park less than half an hour before the procedure, his first operation at the surgical center. Hansen, then 82, had not performed the vaginoplasty procedure in five years, had never met Garcia and, according to the medical board accusation, did not record her patient history or perform a physical exam.