Day of the Dead

IN THESE TIMES — Sunday, 19 April 1998

The day I met Herrera, he was on his way to a funeral home to perform an autopsy on a 36-year old man who died of AIDS-related complications. The dead man's family had contracted Herrera because they had no insurance and wanted to determine if he'd had emphysema prior to death.

The declining autopsy rate is hurting medical science.

By Alyson Mead

Vidal Herrera sets off to work at six each morning in a white van with 1-800-AUTOPSY emblazoned in huge black letters on the side. En route to his first dead body of the day, he coordinates his team of nine pathologists by cellular phone. Sometimes, he is interrupted by the heckling of other motorists, who lean out their car windows to call him El Muerto or Mr. Death.

The day I met Herrera, he was on his way to a funeral home to perform an autopsy on a 36-year old man who died of AIDS-related complications. The dead man's family had contracted Herrera because they had no insurance and wanted to determine if he'd had emphysema prior to death.

Wearing a tie-dyed T-shirt over green scrubs, Herrera was open and garrulous, quite the opposite of what I'd expected from a guy who spends most of his day in the company of corpses and body parts bobbing around in jars. In the funeral home parking lot, we unloaded the van: a hazardous materials container, a few rudimentary surgical tools, specimen jars, and extra pairs of scrubs for the pathologist, the attending physician, and me. Since Herrera is not a medical doctor, he hires local pathologists to oversee the procedures.

The autopsy took 45 minutes. Herrera collected tissue samples from the heart and lungs. At the end of the procedure, the pathologist concluded that the lungs showed signs of emphysema. Herrera had a relatively light schedule that day. There were only three more appointments - two full autopsies and one partial, just a brain.

Herrera learned to perform autopsies in the early '80s, while working as an investigator in the Los Angeles County Coroner's Office. Noticing that the office had more bodies than it could handle, he sensed opportunity. In 1988, he established 1-800-AUTOPSY, which provides mobile-based postmortem services at a reduced cost. In addition to conducting complete autopsies, Herrera exhumes bodies for legal or research purposes, does serology and toxicology reports, and provides medical photography. Though business is currently restricted to the Los Angeles area, Herrera recently placed ads in national business magazines offering to place franchises in 24 other locations nationwide.

Herrera's eccentric small business is a response to a wider trend: the declining rate of autopsies nationwide. Doctors are reluctant to request them, scared to discover a misdiagnosis that could lead to an expensive malpractice suit. Health maintenance organizations (HMOs) and government agencies are reluctant to pay for them. And there is a shortage of doctors trained to perform the procedure.

The biggest loser is medical science. “People don't want to invest the time and money is something that doesn't have an immediate result,” says Minneapolis pathologist Norman Berlinger. “At the end of an autopsy, you have a treasure trove in these jars of tissue and parts. We're not building up our treasure trove and will miss out on the continuum of learning. It's like cutting class early.”

Since Pope Clement VI authorized physicians to perform internal examinations on dead plague victims in Europe in the 14th century, autopsies have become an invaluable method for understanding the origin, nature and course of disease. In the more controlled environment of the morgue, doctors, an test and refine scientific theories developed from observations made at a patient's bedside. Diseases such as pneumonia, emphysema and liver disease were first understood through autopsy.

The procedure continues to be critical for medical research. “In the past 10 to 15 years, many critical medical discoveries have come through autopsy,” says Dr. George Lundberg, editor of the Journal of American Medical Association (JAMA). “A good recent example is the delineation of HIV and AIDS-related diseases. Alzheimer's disease was primarily diagnoses through autopsy as well.”

Autopsies are also valuable in evaluating the effectiveness of new drugs and treatments. “Autopsies are the best quality-control tool we have to make sure we are using the right treatments and medications,” says Dr. Michael Fishbein, chief of autopsy department at the UCLA Medical Center. The side effects of new drugs such as the diet pill Phen-Fen and the anti-depressant Prozac, he says, could be identified sooner if more autopsies were being performed.

Autopsies can also help determine hereditary disease pattern, which alerts family surviving family members to potential medical problems. Recently, for example, Herrera provided pro bono autopsy services for a poor family concerned about a potential congenital heart problem. After a brief procedure, he was able to reassure them that their dead relative had no signs of heart disease.

Not so long ago, government agencies mandated a minimum autopsy rate. Since 1953, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a nonprofit organization designed to evaluate care, has offered accreditation to health care facilities, nursing homes and clinical laboratories. The JCAHO used to required hospitals to assure quality control by performing autopsies on a minimum of 20 to 25 percent of deaths. In 1970, however, the JCAHO dropped this requirement. The JCAHO continues to regard autopsy as an important learning tool, says spokeswoman, Janet Mcintyre, but “our focus is on performance and not percentages.”

Nevertheless, the autopsy rate has plummeted. University and teaching hospitals perform the most autopsies, on around 10 to 12 percent of their deceased patients. Community hospitals do the fewest, performing the procedure in less than 5 percent of deaths.

The circumstances of death usually determine whether or not an autopsy is ordered. If the death is sudden or possibly unnatural, the local coroner or medical examiner requests and conducts the autopsy. If the death is natural, the doctor of the deceased can request an autopsy. This is usually done only if the doctor deems the death worthy of further study. Families also have the right to demand an autopsy at no cost.

In the past, hospitals worked with health insurance companies to weave the cost of autopsies into their reimbursable expenses or paid for them out of their own coffers. But now many cash-strapped hospitals complain that they cannot afford to pay for the procedure and cost-conscious HMOs routinely refuse to cover them, even in possible cases of malpractice. “We believe in the need for medical research but, in actuality, we're focused on financing health care, which provides reimbursement for the cost of getting someone well,” says Richard Coorsh, a spokesman for the Health Insurance Association of America. “Death and autopsy have little to do with this.”

Medicare coverage of autopsies is critical since, according to JAMA editor Lundberg, 75 percent of deaths in this country are Medicare patients. Some doctors, however, accuse the Health Care Financing Administration (HCFA)-the federal agency that administers Medicare and Medicaid-of not adequately reimbursing hospitals that perform autopsies. At a 1995 conference sponsored by the College of American Pathologists in Washington, D.C., some physicians called upon the HCFA to encourage hospitals to perform more autopsies by increasing the fee they pay for the procedure and reinstating a minimum rate. The doctors also asked HCFA to establish autopsy as a legitimate professional service, which would make payments to hospitals and physicians less complicated.

Making matters worse, in many parts of the country doctors qualified to conduct autopsies are in short supply. This seller's market has driven up prices. For example, the Harris County Medical Examiner's Office in Houston has begun charging neighboring counties $1,200 for each autopsy it performs for them.

Some doctors are unbothered about the declining autopsy rate, arguing that new technology makes postmortem examinations unnecessary. “This is not the '60s,” says Dr. Gary Dennis, a pathologist at Howard University Hospital in Washington, D.D. “Back then, we didn't have computerized scans or magnetic resonance imaging devices, so we didn't have the knowledge concerning the causes of death that we have today. Usually we know why the patient is dying even before the patient comes to the hospital.”

Other doctors, however, argue that autopsies are the only surefire way to determine the cause of death and the effects of new treatments and medications. Lundberg says that, depending on the hospital, autopsies reveal a discrepancy of 10 to 40 percent between what a doctor originally diagnosed and what eventually killed the patient. “This suggests that we do not always already know the cause of death,” says Dr. Steven C. Campman, a Sacramento-based pathologist.

With the rising number of malpractice lawsuits, doctors are reluctant to request autopsies that might open a Pandora's box. Of the approximately 2.65 million autopsies conducted in the United States in 1996, the National Center for Health Statistics reports that 10.5 percent of the patients were victims of medical malpractice and 20 percent had been misdiagnosed or given appropriate or unnecessary treatments. Of course, if more autopsies were being performed on a routine basis, these numbers would probably decline.

Ironically, there is one area where autopsies are in demand. In 1992, the Los Angeles Police Department developed a new program targeting drunk drivers aged 16 to 21. As part of their sentencing, drivers convicted of driving while intoxicated in this age group are required to attend a three-hour seminar, which includes viewing an autopsy. According to Juan Jimenez, assistant chief of the Investigation Bureau in the Los Angeles Coroner's Office, the program, which was the first of its kind in the country, has had encouraging results. “In the five or six years that I've been doing this, I can only remember three or four people (out of 22 to 25 per week) who have come back,” he says.

The El Paso Police Department has adapted the Los Angeles program to help deter gang violence. Their rehabilitation project, which went into effect in March, requires gang members convicted of a violent crime to watch an autopsy being performed. In the case of murder, the gang member watches the autopsy on the person they killed, if the family give its consent. This bare-knuckled approach is coupled with counseling. A similar program is implemented last year in San Diego reports a recidivism rate of 2 percent. “We want these offenders to smell the blood and guts of the morgue.” says Sam Santana, director of the El Paso Juvenile Probation Department. “It's not fun and games in there when they're cutting up the body.”

While medical science suffers from the decline in autopsies, business at 1-800-AUTOPSY is flourishing. As he drives around Los Angeles in what may be the city's most conspicuous vehicle, he says, “I want my name to be synonymous with death. After all, it's the most recession-proof business there is.”