More Dumb Things Politicians and Political Appointees Say About Health Policy

As we previously discussed, the fierce debate about whether to revise, or "repeal and replace Obamacare", more formally, the Affordable Care Act, continues in the US.  The legislators in the US House of Representatives, and then the US Senate who have written "repeal and replace" bills have done so without any obvious input from health care professionals, health care policy experts, or patients, much less legislators from the opposition party, and so far have impeded any consideration of these bills by legislative committees.  Nonetheless, many of the politicians involved in the debates, and other politicians who have addressed relevant issues, seem to feel free to comment on health care policy issues with reckless abandon.

We have recently found some more remarkable examples, discussed in chronologic order. 


Senator Ron Johnson (R - Wisconsin): Someone with a Pre-Existing Condition is Like "Somebody Who Crashes Their Car"

As reported by RawStory on June 25, 2017,

The Wisconsin Republican pointed to Obamacare rules that forbid insurance companies from charging more for people with preexisting conditions.

'We know why those premiums doubled,' he opined. 'We’ve done something with our health care system that you would never think about doing, for example, with auto insurance, where you would require auto insurance companies to sell a policy to somebody after they crash their car.'

The last phrase suggests Senator Johnson might be talking about people who deliberately crash their cars, or at best people who were at fault in a car crash.  Setting aside the consideration that sometimes fault in a car crash is hard to assign, he seems to be implying that all people with pre-existing conditions are at fault for for their conditions.  Yet, accidents thay may cause permananent injury are accidental.  Diseases are caused by many factors, or by factors unknown to modern science.  It is very hard to think of a disease whose occurrence is purely caused by choices made by the patient who is afflicted with it.  So it appears that Senator Johnson's argument rests on a logical fallacy: false analogy, in this case between car accidents and pre-existing conditions.

Middletown, OH, Councilman Dan Picard: Town Emergency Medical Technicians Should Deny Naloxone Treatment to Narcotic Addicts Who Have Overdosed Two or More Times Previously

As reported by the Huffington  Post on June 26, 2017,

'I want to send a message to the world that you don’t want to come to Middletown to overdose because someone might not come with Narcan and save your life,' Picard told Ohio’s Journal-News. 'We need to put a fear about overdosing in Middletown.'

Also,

But Picard seems to believe that EMS crews are working a bit too hard to stem the tide of overdoses, and is upset that taxpayers are footing the bill to revive people, many of whom are transients and not residents of Middletown, he says.

Picard also proposed that instead of immediately arresting or jailing overdose victims, they should receive a court summons and be required to work off the cost of treatment by completing community service. But there’s a catch.

'If the dispatcher determines that the person who’s overdosed is someone who’s been part of the program for two previous overdoses and has not completed the community service and has not cooperated in the program, then we wouldn’t dispatch,' said Picard.

Narcotic overdoses left untreated are often fatal. The article also quoted

Martins Ferry Police Chief John McFarland said some people have begun taking these casualties as a foregone conclusion.

'You hear from the public, ‘Why don’t you let them die?’' McFarland told the Dispatch. 'We’re not God; we don’t decide who lives or dies. … We have the ability to save them, so we do.'

That is the point. Emergency medical services have a duty to attempt to treat people with acute conditions that can be immediately fatal, otherwise they would be "playing God."  At best, Mr Picard seems unaware of the mission of emergency health services. 

Note that a Washington Post story on Mr Picard's new policy idea, published June 28, 2017, which quoted this argument the Councilman made in favor of his proposal,

a decision to not save repeat overdosers would be one of many that communities make about how much care they'll provide to dying people.

'If you have a toothache and you call Middletown, we’re not coming,' he said. 'For your heart attack, we’re not going to do the stint or your bypass. Decisions have been made about what services we’re going to provide. We need to make a decision about overdoses.'

Of course, this is another, and whopping example of a false analogy. Revascularization procedures for myocardial infarctions (coronary artery stents or coronary artery bypass grafting) cannot be done by emergency medical technicians and must be done in a hospital given current technology. So decisions about when to deploy these treatments are not made by EMTs, or City Councilmen for that matter.

By the way, the Huffington Post article noted that Mr Picard was not the first one to come up with the policy of withholding Naloxone to save money.  Maine Governor Paul LePage (R) apparently floated something similar in 2016. As reportedy by the Huffington Post in April, 2016:

LePage explained Wednesday that he blocked a bill to increase access to a life-saving overdose medication because the people it could save are just going to die later anyway.

'Naloxone does not truly save lives; it merely extends them until the next overdose,' LePage wrote.

It was not the first time LePage had shared such a belief, but attaching it to his veto elevated it to a statement of official policy.

The state legislature later over-rode his veto. Note that Governor LePage apparently based his article on a faulty perception of the prognosis of patients who overdose.

'Creating a situation where an addict has a heroin needle in one hand and a shot of naloxone in the other produces a sense of normalcy and security around heroin use that serves only to perpetuate the cycle of addiction,' he wrote.

While a staggering number of people have died as the result of the heroin and opioid epidemic, many have also recovered, and many more are waging battles with addiction they will eventually win. LePage’s assertion that everyone who overdoses once and lives will surely overdose again, rather than seek treatment and recover, is divorced from reality.

Counselor to the President Kellyanne Conway: Instead of Getting Medicaid, Able-Bodied People Should Find Jobs "Then They'll Have Employer-Sponsored Benefits Like You and Me"

As reported by Fortune on June 26, 2017,

In an interview on ABC's This Week on Sunday, Conway, counselor to President Trump, said that Obamacare expanded Medicaid to those who did not truly need it, because they were able to work. She was defending the Senate's proposed health care bill, which would make big cuts to Medicaid, by lowering the income limit for those who qualify, among other measures.

'Obamacare took Medicaid, which was designed to help the poor, the needy, the sick, disabled, also children and pregnant women, it took it and went way above the poverty line and opened it up to many able-bodied Americans,' she said. Those 'should probably find other — at least see if there are other options for them.'

She continued:

'If they are able-bodied and they want to work, then they'll have employer-sponsored benefits like you and I do.'

This was just a straight-forward, but important factual error.  Per Fortune,

Many Americans who are covered by Medicaid are already working, often in lower-paying jobs that may not have health insurance benefits, according to a report by the Kaiser Family Foundation, cited by CNBC.

Representative Paul Ryan (R-Wisconsin): If Insurance Prices Go Up, "It's Not Like People are Getting Pushed Off the Plan, It's That People Will Choose Not to Buy Something That They Don't Like or Want"

As reported by RawStory on June 27, 2017,

During an interview that aired on Tuesday, Fox News host Brian Kilmeade asked Ryan to respond to a recent Congressional Budget Office (CBO) report that said there would be 22 million more people without health insurance by 2026 if the Senate’s version of the health care bill is signed into law.

'What they are basically saying at the Congressional Budget Office, if you’re not going to force people to buy Obamacare, if you’re not going to force people to buy something they don’t want, then they won’t buy it,' the Speaker opined. 'So, it’s not that people are getting pushed off a plan, it’s that people will choose not to buy something that they don’t like or want.'

'And that’s the difference here,' he added. 'By repealing the individual and employer mandate, which mandates people buy this health insurance that they can’t afford, that they don’t like — if you don’t mandate that they’re going to do this then that many people won’t do it.'

Please note that the mandate to which he refers is a relatively small tax under "Obamacare" paid by people who do not have health insurance. Further note that under the proposed Senate bill, many poorer people would lose substantial subsidies of their health insurance. So Mr Ryan seems to be using linguistic sleight of hand.  He accepts the term "mandate" as literally true, allowing him to claim that the negative financial incentive which the "mandate" imposes while the negative financial incentive caused by losses of subsidies and increases in insurance prices is not.  A rose is not a rose when it's called something else? This is the logical fallacy of ambiguity, using double meanings or ambiguity of meaning in language to disguise the truth. 

Summary

Whether to maintain our current - admittedly Rube Goldberg-esque - system of financing health care, or to radically change it is a serious question.  The answer will affect the wellbeing, health, and even lifespan of many people.  The question should not be taken lightly.

So what to make of so many politicans and political appointees making pronouncements on whether to keep, or "repeal and replace Obamacare" that are based on major factual errors and logical fallacies?  The last time I took this on, I speculated whether health care policy has sunk into a swamp of postmodernism generated by years of exposure to the post-modernist stance of many in academia.  That may have been fanciful.

On the other hand, another speculation is that this is the result of "managerialism."  We have discussed the doctrine promoted in business schools that people trained in management should lead every type of human organization and endeavor.  Management by people from the disciplines most relevant to the mission and nature of particular organizations should be eschewed.  So managers, not physicians or other health care professionals, should lead health care organizations.  Following that theme, managers, or those like them, rather than health care professionals and health policy experts should lead health policy. 

However, managers who run health care organizations, or make policy, have an unfortunate tendency to be ill-informed (as well as unsympathetic if not hostile to health care professionals' value and the health care mission, and subject to perverse incentives that often put short-term revenue ahead of the health of patients and the population.)  And in the latest health care reform debate, some of the politicians and political appointees who are the de facto managers of health policy have disdained the advice of health care professionals and health policy experts.  

The causes of this trend are certainly open to debate.  However, I believe we should all be really worried about continued health care policy making by people who are driven by factual errors and non-evidence rather than evidence, and logical fallacies rather than sound reasoning.  We need health policy leadership that is well-informed, understands the health care mission, avoids self-interest and conflicts of interest, and is accountable, ethical and honest.   (Of course, we have often said we need leadership of health care organizations with these characteristics.)  Right now, we are not coming close.  Woe is us.

Follow the Money: Non-Profit Hospital CEOs Quietly Collect Their Millions While US Health Care Reform Battle Rages

In Washington, DC the health care policy wars continue, with a few Republican senators working behind closed doors on a bill to "repeal and replace" Obamacare, aka the Affordable Care Act, and Democrats decrying their secrecy.  Just as during the era in which Obamacare was enacted, there is constant discusison of how US health care costs continually rise, driving up insurance premiums, and how access to health insurance is continually in peril.

However, while the current Republican process to write new legislation seems strikingly opaque, in neither era has there been a frank discussion of why US health care costs are so amazingly high, and disproportionate to our mediocre health care outcomes. In particular, there has hardly been any discussion of just who benefits from the rising costs, and how their growing wealth may impede any real cost-cutting measures.

Extreme Compensation for Top Managers of Non-Profit Hospitals

An obvious example is the gravity defying pay given to top health care managers, particularly the top managers of non-profit hospital systems.

Such systems provide much of the hospital care to Americans, and most have declared their missions to be providing the best possible care to all patients, or words to that effect.  Many explicitly include care of the poor, unfortunate and vulnerable as a major part of their missions.  As non-profit organizations, their devotion of mission provides some rationale to their freedom from responsibility for federal taxes.

As we last discussed in detail in May, 2016, we have suggested that the ability of top managers to command ever increasing pay uncorrelated with their organizations' contributions to patients' or the public's health, and often despite major organizational shortcomings indicates fundamental structural problems with US health, and provides perverse incentives for these managers to defend the current system, no matter how bad its dysfunction.

In particular, we have written a series of posts about the lack of logical justification for huge executive  compensation by non-profit hospitals and hospital systems.  When journalists inquire why the pay of a particular leader is so high, the leader, his or her public relations spokespeople, or hospital trustees can be relied on to cite the same now hackneyed talking points.

As I wrote in 2015,  and in May, 2016,

It seems nearly every attempt made to defend the outsize compensation given hospital and health system executives involves the same arguments, thus suggesting they are talking points, possibly crafted as a public relations ploy. We first listed the talking points here, and then provided additional examples of their use. here, here here, here, here, and here, here and here. 

They are:
- We have to pay competitive rates
- We have to pay enough to retain at least competent executives, given how hard it is to be an executive
- Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job).

Yet as we discussed recently, these talking points are easily debunked.  Additionally, rarely do those who mouth the talking points in support of a particular leader provide any evidence to support their applicability to that leader.

But since May, 2016, we have steadily accumulated more stories about million-dollar plus pay for CEOs and other top managers of non-profit hospitals and hospital systems.  The reports may be shorter than they used to be, as journalism comes under economic and other attack, and as more journalistic resources go to cover the current president.  Here are some examples, in chronologic order per the date of the published article, rather telegraphically.

Examples of High Executive Pay

Boston, Massachusetts area, August, 2016 (Per the Boston Business Journal)

Brigham and Women's Hospital CEO Dr Elizabeth Nabel, total compensation $5.5 million in 2014, 20% higher than 2013.  Talking points =  brilliant: "committed to retaining a team of top professionals," per Edward Lawrence, Chair, Partners Board of Trustees

Tufts Medical CEO Dr Michael Wagner, $1.1 million, 82% increase.

UMass Memorial Medical Center CEO Dr Eric Dickson, $1.6 million, 74% increase, Patrick Muldoon, President UMass Memorial Center's biggest hospital, $1.2 million, 67% increase

West New York State, August, 2016 (Per the Buffalo News)

Catholic Health System CEO Joseph D McDonald, $1.4 million.

Roswell Park Cancer Institute CEO Candace S Johnson, $1 million

Kaleida Health CEO Jody L Lomeo, $1 million:

Talking points = brilliant "few executives have the required skill set and experience to fill these posts"

New Jersey, September, 2016 (Per NJ Advance Media)

Top 10 hospital CEOs received total compensation from $1.94 million to $4.7 million

New Orleans, Lousisiana, September, 2016 (Per the Times-Picayune)

Ochsner Health System former CEO and board chair Dr Patrick Quinlan, $3.3 million in 2014, current CEO and board member Warner Thomas, $1.49 million.  Talking points = competitive rates and brilliant: "we must compete nationally to recruit top talent"

Touro Infirmary CEO James Montgomery, $1.3 million

Children's Hospital Inc Chief Medical Officer Alan Robson, $1.26 million

General talking points = competitive rates: "you're looking to attract hospital executives from Californai or New York where they're paid a lot of money"

Gastonia, North Carolina, February, 2017 (Per the Gaston Gazette)

CaroMont CEO Doug Luckett, $1.03 million in 2015.  Talking points = retain and brilliant "paying what it takes to ensure they attract and retain top-level talent that can help provide premiums health care"

Dayton, Ohio, March, 2017 (Per the Dayton Daily News)

Kettering Health System CEO Fred Manchur, $1.65 million in 2015, former president Terri Day, $1.23 million, current president Roy Chew, $1.07 million

Premier Health former CEO James Pancoast, $1.42 milllion (excluding retirement payments) in 2015. Talking points = brilliant "you've got one person at the top who's trying to provide oversight, direction, and strategy.  At the same time, health care continues to grow in scope, complexity, regulation, and compliance."

York County, Pennsylvania, April, 2017 (Per the York Daily Record)

WellSpan Health president Kevin Mosser, $1.6 million in 2014.  Talking points = competitive rates Forrest Brisco, associate professor, Penn State Smeal College of Business, "nonprofit hospitals are competing with for-profit hospitals"; brilliant: "If you are at the top of a health care organization, you're going to have pay that's higher than many members of the organization. The the skill and knowledge to understand and interact with surgeons and physicians can command a high salary" [ed note: which often seems higher than those of some surgeons and physicians, though]; also brilliant: Robert Batory, senior vice-president and chief human resources officer, Wellspan, "Kevin has 24/7 responsibility for Wellspan."

Ephrata Community Hospital (WellSpan subsidiary) CEO  and WellSpan Medical Group (WellSpan subisidiary) CEO  "more than $1 million"

Winston-Salem, North Carolina, May, 2017 (Per the Winston-Salem Journal)

Novant Health Inc CEO Carl Armato, $1.31 million in 2015.  Talking points = retain and brilliant "high compensation levels are necessary to recruit and retain executive to run a 'very complex organization'"

Tri-Cities region, Tennessee and Virginia, June, 2017 (Per WJHL)

Wellmont Health System CEO Bart Hove, $1.4 million in 2015.  Talking points = competitive rates: Wellmont board of trustees chair Roger Leonard, "we have to compete on a national level and we're competing not just with other non-profits, but we're competing with other for-profits"

Mountain States Health Alliance CEO Alan Levine, $1.3 million in 2015. Talking points = competitive rates: HSHA board of trustees chair Barbara Allen, "make sure CEO pay is comparable to similarly sized facilities across the country with similar complexities"; retain and brilliant, "we want to attract the best talent ... and be able to retain him."

Connecticut, June, 2017 (Per the Connecticut Post)

Yale New Haven Health System CEO Marna Borgstrom, $3.8 million in 2015.  Nine other employees paid over $1 million, including Bridgeport Hospital CEO William Jennings, $1.5 million, Greenwich Hospital CEO Norman Roth, $1.3 million.  Talking points = brilliant: Yale senior vice president of public affairs, "Yale New Haven Health is the largest and most complex health system in the state."

Also, a total of 39 people, including the above, received over $1 million in 2016.

General talking points = brilliant: "there are a limited number of executives experienced enough to guide a state-of-the-art hospital and growing healthcare system in an increasingly competitive and complex industry"; competitive rates: "pay and benefits for such executives need to be comparable to what they could receive at another leading national hospital system or another industry"  
  
Summary and Conclusions

The current inflamed discussion of "Obamacare" and Republican attempts to "repeal and replace" it focuses on the costs of care and how they affect individual patients.  Examples include concerns about health insurance premiums that are or could be unaffordable for the typical person; insurance that fails to cover many costs, and thus may leave patients at risk of bankruptcy due to severe illness; poor people unable to or who might become unable to obtain any insurance, and perhaps any health care.  Yet there is little discussion of what really drives high and ever increasing health care costs (while quality of health care remains mediocre).

That may be because those who are benefiting the most from the status quo want to prevent discussion of their role.  There are many such people, but top management of non-profit hospitals provide a ready example.  Their institutions' mission is to provide care to sick patients.  Many such hospitals specifically pledge to provide care to the poor, vulnerable, and disadvantaged.  Non-profit hospitals have no owners or stockholders to whom they owe revenue.

Yet these days the top executives of non-profit hospitals receive enough money to become rich.

See the examples above. 

The justification for such compensation is pretty thin.  Consider the talking points above.  Apparently hospitals are extremely concerned about paying top management enough to recruit and retain them.  Yet there is much less evident concern about paying a lot of money to recruit and retain the health care professionals who actually take care of patients to fulfil the hospitals' mission.  Hospital CEOs are frequently proclaimed to be brilliant, visionaries, or at least incredibly hard workers with very complex jobs.  I wonder if those who make such proclamations have any idea what it takes to be a good physician or a good nurse.  Yet such health care professionals' hard work, long training, devotion to duty, and ability to deal with trying situations and make hard decisions rarely inspire hospitals to shower them with money.

Furthermore, hospital CEO compensation is almost never justified in terms of their ability to uphold and advance the fundamental hospital mission, taking care of sick people.  The articles above do not contain any justifications of generous CEO compensation based on hospitals' clinical performance or health care outcomes.  At best, hospital executive pay seems to be justified by the hospitals' financial, not clinical performance.

So why do non-profit hospital CEOs get paid enough to become rich?  Apparently, because they can.

As we discussed here, there is a strong argument that huge executive compensation is more a function of executives' political influence within the organization than their brilliance or the likelihood they are likely to be fickle and jump ship for even bigger pay.  This influence is partially generated by their control over their institutions' marketers, public relations flacks, and lawyers.  It is partially generated by their control over the make up of the boards of trustees who are supposed to exert governance, especially when these boards are subject to conflicts of interest and  are stacked with hired managers of other organizations.

Furthermore, such pay may provide perverse incentives to grow hospital systems to achieve market domination, raise charges, and increase administrative bloat.  As an op-ed in US News and World Report put it about executive pay in general,

But the executive pay decisions made inside corporate boardrooms have an enormous impact in the outside world. Outrageous pay gives top executives an incentive to behave outrageously. To hit the pay jackpot, they'll do most anything. They'll outsource and downsize and make all sorts of reckless decisions that pump up the short-term corporate bottom line at the expense of long-term prosperity and stability.

So I get to recycle my conclusions from many previous posts....

We will not make any progress reducing current health care dysfunction if we cannot have an honest conversation about what causes it and who profits from it.  In a democracy, we depend on journalists and the news media to provide the information needed to inform such a discussion.  When the news media becomes an outlet for  propaganda in support of the status quo, the anechoic effect is magnified, honest discussion is inhibited, and out democracy is further damaged.

True health care reform requires publicizing who benefits most from the current dysfunction, and how and why.  But it is painfully obvious that the people who have gotten so rich from the current status quo will use every tool at their disposal, paying for them with the money they have extracted from patients and taxpayers, to defend their position.  It will take grit, persistence, and courage to persevere in the cause of better health for patients and the public. 


And for our musical interlude, the beginning of "For the Love of Money," sung by the O'Jays, used in the official intro of season 2 of guess what show?

Evidence-Based Policy Making? - Dumb Things Politicians Say About Health Care Policy

There have been multiple legislative attempts at major health care reform in the US.  Typically, such attempts feature considerable public debate, including speechs, congressional committee hearings, sometimes progressing to debates by the House and Senate.  (For example, see this Frontline chronology of the proceedings up to the passage of the Affordable Care Act, aka "Obamacare," in 2009.)  Usually the discussion includes some real experts on health care policy, and some real health care professionals, and at least appears to reference some data about medicine, health care, and health economics. Whether previous debates were truly evidence-based is not clear, but it appeared to me that they at least acknowledged the importance of evidence, and maybe even at times a rigorous approach to it.

However, the proceedings up to the passage of the American Health Care Act seemed somewhat different.  There were no public committee hearings or debates.  Per a Los Angeles Times article in April, 2017 (via the Chicago Tribune):

President Trump and House Republicans, in their rush to resuscitate a bill rolling back the Affordable Care Act, are increasingly isolating themselves from outside input and rejecting entreaties to work collaboratively, according to multiple healthcare officials who have tried to engage GOP leaders.

In particular,

And senior House Republicans and White House officials have almost completely shut out doctors, hospitals, patient advocates and others who work in the healthcare system, industry officials say, despite pleas from many healthcare leaders to seek an alternative path that doesn’t threaten protections for tens of millions of Americans.

'To think you are going to revamp the entire American healthcare system without involving any of the people who actually deliver healthcare is insanity,' said Sister Carol Keehan, president of the Catholic Health Assn., whose members include many of the nation’s largest medical systems.

While the experts have been shut out, some of its supporters of the AHCA in the US House of Representatives have been free with their explanations of their actions.  Some have been rather alternative, so to speak.   Some recent examples, in chronologic order,

Rep Roger Marshall (R-Kansas): the Poor "Just Don't Want Health Care"

As reported by the Washington Post, March 9, 2017

'Just like Jesus said, ‘The poor will always be with us,’ ' Marshall said in response to a question about Medicaid, which expanded under Obamacare to more than 30 states. 'There is a group of people that just don’t want health care and aren’t going to take care of themselves.'

He added that 'morally, spiritually, socially,' the poor, including the homeless, 'just don’t want health care.'

'The Medicaid population, which is [on] a free credit card as a group, do probably the least preventive medicine and taking care of themselves and eating healthy and exercising. And I’m not judging; I’m just saying socially that’s where they are,' he told STAT, a website focused on health-care coverage.

The problem is that Marshal, who is a physician, did not provide evidence that there is some essential characteristic of the poor that causes them to make bad health decisions, or discus whether perhaps the poor face constraints on their health care decision making that the rich do not.  The implication appears to be that Marshal is treating an promoting an ideological or religious opinion as if it were derived from epidemiology.

House Speaker Paul Ryan (R-Wisconsin) The Problem with "Obamacare" is "the People Who Are Healthy Pay for the People Who Are Sick."

As reported by MSNBC, March 9, 2017

Take today, for example, when the GOP House Speaker did a little presentation on Capitol Hill for reporters in defense of his controversial American Health Care Act, which some have begun calling 'Trumpcare.' At one point during the slideshow – complete with Ryan’s sleeves rolled up – the Wisconsin Republican tried to explain what he sees as the Affordable Care Act’s fatal flaw:

'The fatal conceit of Obamacare is that we’re just gonna make everybody buy our health insurance at the federal-government level, young and healthy people are going to go into the market and pay for the older, sicker people. So, the young healthy person is going to be made to buy health care, and they’re going to pay for the person, you know, gets breast cancer in her 40s or who gets heart disease in his 50s. […]'

'The whole idea of Obamacare is … the people who are healthy pay for the people who are sick. It’s not working, and that’s why it’s in a death spiral.'

As MSNBC reported, the problem is with that is

that Ryan doesn’t seem to understand what “insurance” means.

Look at that quote again: The whole idea of Obamacare is … the people who are healthy pay for the people who are sick.' Well, yes. The whole idea of health insurance is to establish a system in which the people who are healthy pay for the people who are sick.

This really isn’t that complicated. In fact, it’s incredibly common for the vast majority of Americans: we pay premiums, the money goes into a pool, funds from that pool pay for care. It’s Insurance 101.

If Ryan disapproves of this model – which is weird, given that his own reform bill is built on consumers getting coverage through traditional insurance – there are effectively three alternatives. If the healthy aren't going to pay the sick, who will? The sick can try to pay for themselves, the government can pick up the tab, or the sick simply won't get care.

Rep John Shimkus (R-Illinois) Why Should Men Have to Purchase Prenatal Care? 

As reported by the Washington Post, March 9, 2017, regarding a hearing in the House of Representatives Energy and Commerce Committee

'What mandate in the Obamacare bill does he take issue with?' Doyle asked Shimkus, using the formal parlance of congressional committees.

'What about men having to purchase prenatal care?' Shimkus said.

At that point, one could hear the room start to stir.

'I’m just . . . is that not correct?' Shimkus said. 'And should they?'

Rep Shimkus, apparently like Rep Ryan, does not seem to understand the concept of health insurance.  The Post article put it this way,

Here’s how insurance expert and columnist Nancy Metcalf answered a similar question from a Consumer Reports reader that year:

Health insurance, like all insurance, works by pooling risks. The healthy subsidize the sick, who could be somebody else this year and you next year. Those risks include any kind of health care a person might need from birth to death — prenatal care through hospice. No individual is likely to need all of it, but we will all need some of it eventually.

So, as a middle-aged childless man you resent having to pay for maternity care or kids’ dental care. Shouldn’t turnabout be fair play? Shouldn’t pregnant women and kids be able to say, 'Fine, but in that case why should we have to pay for your Viagra, or prostate cancer tests, or the heart attack and high blood pressure you are many times more likely to suffer from than we are?' Once you start down that road, it’s hard to know where to stop. If you slice and dice risks, eventually you don’t have a risk pool at all, and the whole idea of insurance falls apart….

Rep Mo Brooks, (R-Alabama): "People who Lead Good Lives" Do Not Get Sick

As reported by Vox on May 2, 2017, Rep Brooks said in an interview on CNN to explain why people with pre-existing conditions should personally pay for their health insurance

allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool that helps offset all these costs, thereby reducing the cost to those people who lead good lives. They’re healthy; they’ve done the things to keep their bodies healthy. And right now, those are the people who have done things the right way that are seeing their costs skyrocketing.

He seems to be arguing first that people who virtuous ("good") are healthier than others.  He certainly provided no evidence for this assertion, which, like the assertion by Rep Marshall above, appears to be ideological or religious judgment disguised as epidemiology.


Rep Paul Labrador (R - Idaho) "Nobody Dies Because They Don't Have Access to Healthcare"


As reported by CBS News on May 6, 2017

Labrador made the comments the day after the U.S. House passed a GOP-led health care bill repealing and replacing chunks of Obamacare. Labrador, a member of the conservative House Freedom Caucus, was responding to an audience member who expressed concern about how the bill would affect Medicaid recipients.

'You are mandating people on Medicaid accept dying. You are making a mandate that will kill people,' the audience member said, before being drowned out by Labrador's response.

'No one wants anybody to die,' Labrador said. 'You know, that line is so indefensible. Nobody dies because they don't have access to health care.'

It is not completely clear whether Rep Labrador meant access to health care, or access to health care insurance. A person with appendicitis, acute bacterial pneumonia, a myocardial infarction, etc, etc who fails to seek acute care because of lack of a means to pay for it could well die. As an absolute, this statement is obviously untrue.  

Mick Mulvaney, Director of the Office of Management and Budget: "The Person Who Sits at Home, Eats Poorly and Gets Diabetes" Does Not Deserve Health Insurance

As reported by the Huffington Post on  May 12, 2017

he drew a distinction between people like Kimmel’s son, born with a congenital heart disease, and people who end up with conditions like diabetes. 'That doesn’t mean we should take care of the person who sits at home, eats poorly and gets diabetes,' Mulvaney said, according to a Washington Examiner account consistent with real-time social media reports. 'Is that the same thing as Jimmy Kimmel’s kid? I don’t think that it is.'

This is not exactly the clearest statement but it seems to imply that only people who make unhealthy life-style choices get diabetes, which certainly as an absolute is not true; and furthermore that people who develop diseases due to poor life-style choices do not deserve care.  The juxtaposition suggests that driving this is an ideological or religious judgment about who is deserving.

Video diversion: would Mr Mulvaney think this person deserves "health care?"





 Summary

In 2003 I published an article entitled "A Cautionary Tale: the Dysfunction of American Health Care," which summarized the views of health care professionals about the causes of health care dysfunction.  One of the major findings was the importance of " attacks on the scientific basis of medicine."  In turn, I hypothesized that some of these attacks stemmed from the rise of post-modernism, then a fashionable intellectual affectation on university campuses, mainly of the avant garde left-wing.  I wrote then:

Postmodernism is 'an attempt to question the fundamental philosophical and political premises of the West.   It argues that many of the concepts we take for granted—including truth, morality, and objectivity—are culturally ‘constructed’'  To postmodernists, truth is just what the powerful say is true.

Now it seems that post-modernist "thought" has escaped the confines of left-wing humanities departments, and infiltrated political discourse, and for some unfathomable reason, seems to particularly affect some of those who profess to be conservative. After all, in January, KellyAnne Conway, a senior White House adviser, defended the administration's arguments as "alternative facts." (Look here.)

Facts, however, are stubborn things.  Evidence is evidence, no matter what politician it might offend.  Basing legislation on the sorts of alternative thinking displayed in the cases above could lead to real life, or life and death consequences for the sick, injured and vulnerable.  True health care reform requires clear thinking and the input of people who actually know something about health care. 

Health Insurance For Me But Not for Thee? - How Legislators Tried to Rig the Repeal of the ACA to Keep Their Own Health Insurance Affordable

The turmoil swirling around the new Trump administration has flushed into the open some things that the public heretofore was probably not meant to see....

We have been writing a lot lately about how the insiders who run large health care organizations, and benefit mightily therefrom, try very hard to control the health care policy discourse, and keep us distracted from their wizardry behind the curtain.  Again, these days the curtain is likely to get blown away.

Sarah Kliff just reported in Vox about a provision newly inserted into the proposed American Health Care Act

Wednesday night, text leaked of a new Republican amendment to the party’s health care bill, the American Health Care Act, which was part of an ongoing effort to revive the bill in the House.

The amendment would allow states to opt out of some politically popular Obamacare provisions, like the requirement to charge sick people the same prices as healthy people, or to cover a core set of benefits.

Health law expert Tim Jost called me when he noticed something surprising on the sixth page of the amendment: an exemption for the health insurance of legislators and their staff. This means that members of Congress and their aides would be guaranteed access to Obamacare provisions that constituents could lose.

I wrote about it. It caused a stir. Twelve hours later, Republican legislators appear to be split — but not over the exemption policy itself. Instead, they have disputed whether it even exists.

This morning alone, legislators have claimed that the exemption never existed, that it does exist and was inserted by senators, and that it used to exist but has been removed. 

So, to recap, the amendment would have let individual states allow insurance companies to bill patients with pre-existing conditions at higher rates than healthy people.  That would negate the essential function of health care - to pool costs among large populations so that care is affordable for the sick.  Thus many people with pre-existing conditions would have to forego health insurance because of the cost.  However, legislators and their staffs would have had special privileges allowing them to get insurance at the low rate for healthy people even if they were to have pre-existing conditions.  For the legislators and their staffs, health care for me but not for thee.

This is conceptually like other special health care deals that insiders and the wealthy can get now, like "VIP care" at hospitals (look here, here, and here), or executive health plans for top corporate managers (look here).  Such privileges allow the American version of the nomenklatura to get better health care than the little people get (just like Soviet apparatchiks could get much better care than the proletariat, and now like Putin and his cronies will have access to a special health clinic, according to Reuters, via Business Insider.) 

It is likely that the persistence of health care dysfunction in the US has been driven in part by the ability of the rich and insiders to bypass the current system.  And this ability may have been in turn driven by how insiders have been able to manipulate the public discussion of health care policy to conceal such unpleasant truths (as noted here and here).

To ever achieve true health care reform, we need an honest discussion of what is wrong with health care, and especially of how the system has been rigged to protect the insiders who currently benefit the most from the status quo. 

ADDENDUM (4 May, 2017) - According to Sarah Kliff at Vox News (look here and here) that barely passed the US House of Representatives still allows federal legislators and their staffs to keep their own protection from discrimination due to preexisting illness.  As she noted,

Republican legislators liked this policy well enough to offer it in a new amendment. They do not, however, seem to like it enough to have it apply to themselves and their staff.

Again, this suggests that some legislators cynically believe what is good enough for their constituents is not good enough for their august legislative personages.

Pontifications About Health Care Reform Written by Insiders Who Benefit from the Status Quo - Worse Than We Think

Perceptions that the US health care system is dysfunctional and needs major reform go way back.  A timeline from the Tampa Bay Times noted President Theodore Roosevelt's proposal for a national health service in 1912.  Nonetheless, as we have discussed endlessly, most attempts at reform failed, and health care dysfunction seems to be getting worse.

One big problem may be that we don't understand how much discussion of health care reform is driven by those who benefit from the status quo. 

A Personal Anecdote

When I began my academic career in 1983, I was often in the audience for talks about how to fix health care by people billed as experts.  Often these talks seemed oddly disconnected from the realities on the ground for a junior assistant professor with a lot of clinical and teaching responsbilities.  Worse, many of the solutions they offered seemed to entail greater burdens for health care professionals, with no obvious compensation other than the warm feeling that we would be benefiting society.  Who else these solutions might benefit was not discussed. 

One talk given a bit later stands out in my memory. On November 29, 2001, one Dr John W Rowe gave the prestigious Levinger Lecture at Brown University entitled "Good Health: Can we Afford It?" (referenced here, see items for 11/14 and 11/16)  As I recall, Dr Rowe spent considerable time scolding us hard working physicians for overuse of medical interventions leading to endless increases in health care costs, and promising more burdensome bureaucratic interventions to rein in our follies.  While promising more burdens on physicians, Dr Rowe did not dwell on how the resulting cost savings might benefit him in his role as CEO and Chairman of Aetna Inc.  Aetna had purchased the notoriously physician-unfriendly US Healthcare, and thus had become a big for-profit health care insurer already known for imposing bureaucratic burdens on physicians in hopes of decreasing their utilization, while increasing the company's revenues (look here).  Were Dr Rowe's pontifications really about improving health care for all Americans, or about justifying his previous management behavior, and perhaps supporting the price of his shares in Aetna? Why was Aetna's public relations given the patina of an academic lecture?

These days, health care professionals continue to be exhorted about health care reform.  Many such pontifications may be not so much about true health care reform as about preserving the fundamental status quo which has benefited and enriched so many insiders. The interests of the pontificators are often less obvious than those of Dr Rowe.  Maybe that is so why there has been so little real reform, and what little reform there has been seems to be under continuous attack.

Two Examples of How Hard It Is to Discover the Interests of Health Care Policy Pontificators

In the last few weeks I posted about two recent ostensibly authoritative pontifications.  One was about ways to address the worsening problem of physician burn-out (see this post). It was written by the CEOs of large, non-profit hospital systems, joined by the CEO of the American Medical Association.  The other was about a health care reform proposal from the prestigious National Academy of Medicine (see this post).  A rather uncritical article in the Washington Post hailed it as a "radical idea" because it was written by "doctors." In both cases, I was skeptical, mainly because many of the proponents had conflicts of interest, mostly undisclosed, that suggested they were already benefiting mightily from the current system.

However, it gets worse.  While I thought my posts were based on reasonable efforts to find undisclosed conflicts of interest affecting the authors of these exhortations, within a few weeks I realized I had missed one important item affecting each.  The lesson is that the web of conflicts of interest that ensnares the insiders who run most of US health care is even more complex and adherent than any of us realizes.

Dr John Noseworthy, Author of the Health Affairs Post on Reducing Physician Burnout: CEO of the Mayo Clinic, But Also Now Nominated to be a Director of Merck

Dr Noseworthy, CEO of the Mayo Clinic, was the lead author of a post in HealthAffairs about reducing physician burnout.  (Oddly enough, none of the proposed action items seemed to involve increasing physician autonomy by reducing the power of managers over health care professionals.)

Two weeks after Noseworthy and colleagues' post appeared, an article on the Minnesota Public Radio website reported that Dr Noseworthy has just been nominated to a seat on the Merck board of directors.  Presumably the possibility of this nomination had been known at the time the post was published.

I had previously written that two of the authors of the Health Affairs post were on corporate boards.  One, Dr Paul Rothman, was already on the board of Merck.  As corporate directors, they have fiduciary responsibilties to promote the revenues of their corporations.  Now it turns out there were at least three such board members among the health system CEOs who had pontificated to physicians about how to reduce their burn-out.

Yet the power of such health care systems, whose management is often mission-hostile, and who often put revenue ahead of physicians' professional values (per the shareholder value theory), is arguably a major cause of physician burnout.  Furthermore, Merck, in particular, has had its share of management misbehavior as demonstrated by a recent $830 million settlement for deceiving shareholders, a mere $5.9 million 2015 settlement for deceptive marketing, and multiple setttlements, cumulatively totaling more than $1 billion, plus one guilty plea for the historic deceptive marketing of Vioxx (see this post).

So to what extent are the authors of this pontification about reducing physician burnout (without really giving physicians much new autonomy) insiders benefiting from the status quo in health care?  It may be more than what we think, even now.

Mr Leonard Schaeffer, Author of National Academy of Medicine Article on Health Care Reform: Member of the Boards of Wahlgreen Boots, Quintiles, scPharmaceuticals, but Also Long-Term Director of Amgen

Mr Schaeffer was an author of the National Academy of Medicine article, now published online in JAMA, about health care reform.  (Oddly enough, none of the "vital directions issue areas" mentioned in the article involved real challenges to the power of large health care organizations, particularly for-profit corporations, or increased autonomy for health care professionals.)

The version of the article published online by the NAM did not include any explicit disclosures of conflicts of interest.  It did note that two authors were full-time employees of health care corporations, one was a consultant to health care corporations, one was a lobbyist for health care corporations, and one was on the boards of health care corporations.  The online JAMA version added more disclosures, but these were incomplete.  In my post, I noted that fully 13 of the 19 authors had major ties to large health care corporations, as employees, lobbyists, consultants or  board members.

In particular, Mr Leonard D Schaeffer was listed in the NAM version as simply affiliated with the University of Southern California, but I found was actually on the boards of Wahlgreens Boots Alliance, Quintiles Transnational, and scPharmaceuticals Inc.  That was still an incomplete picture of his conflicts of interest.

A ProPublica article from February, 2017 recounted how big pharmaceutical companies engaged Precision Health Economics to wage public relations campaigns to try to justify high pharmaceutical prices.  The article noted the following about Mr Schaeffer.  

Amgen has ties to all three founders of Precision Health Economics. Working for other firms, Philipson has twice testified as an expert witness for Amgen, defending the company’s rights to drug patents, according to his curriculum vitae. The other two founders, Goldman and Lakdawalla, are principals at the Leonard D. Schaeffer Center for Health Policy and Economics at USC, which received $500,000 in late 2016 from Amgen for an 'innovation initiative,' according to public disclosures. Goldman said the funds were unrestricted and could be used at the center’s discretion. Robert Bradway, the CEO and chair of Amgen, is on the advisory board of the university center, and Leonard Schaeffer, a professor at USC and the namesake of the center, sat on Amgen’s board of directors for nearly a decade.

With funding from Amgen, the Schaeffer Center hosted a forum in Washington, D.C., in October 2015 on the affordability of specialty drugs. Before a panel focused on the new cholesterol treatment, Goldman cautioned against lowering drug prices.

So Mr Schaeffer, in addition to his current board positions, turns out to have had a long relationship with Amgen.  Given that according to the 2013 Amgen proxy statement, Mr Schaeffer retired from the board with at least 28,277 shares of Amgen stock and options for 15,000 more, he may have current financial ties to the company. 

So once again, to what extent were the authors of the 2017 NAM report on health care reform (which did not challenge the influence of large health care corporations over the health of US citizens) insiders benefiting from the status quo in health care?  It may be more than what we think, even now.

Summary

Health care professionals, policy makers, and the public are constantly harangued by apparently unbaised experts about health care reform.  Yet many of these authorities are insiders who benefit from the status quo.  Many of their financial connections to the corporations that make the most money from the US commercialized health care system are not disclosed.  It may take considerable investigation to determine their involvement in a web of conflicts of interest that drapes over the US health care system.

Meanwhile, audiences should demand that those who lecture us about health care reform disclose all their financial conflicts of interest.  Any whiff of deception about their personal interests should suggest intense skepticism. 

True health care reform requires honest discussion of the issues.  Honesty in this case entails complete and detailed disclosure of the discussants' conflicts of interest. Until such honesty is the rule, be very, very careful about taking sanctimonious spiels at face value. 

"A Radical Idea for Health-Care Reform: Listen to the Doctors" - Oops, I Mean Listen to the Corporate Executives, Directors, and Lobbyists

It has been the season for health care reform in the US since at least the Nixon administration.  We have endlessly discussed the unholy triad of health care dysfunction: rising costs, declining access, and stagnant quality.

These days, with all the furor over whether Obamacare should be repealed and replaced, let alone, or improved, it is still the season for health care reform.  Last week an article by David Ignatius in the Washington Post entitled "A Radical Idea for Health Care Reform: Listen to the Doctors," appeared.   Since on Health Care Renewal we are all about trying to uphold physicians' professional values, I thought this deserved a closer look, with the hope that it would provide some down-to-earth wisdom from physicians in the real clinical world.

Background - Doctors Views on the Causes of Health Care Dysfunction


As we recently discussed, we began the project that led to the establishment of Health Care Renewal because of our general perception that physician angst was worsening (in the first few years of the 21st century), and that no one was seriously addressing its causes.  Our first crude qualitative research(1) suggested  that physicians' angst was due to perceived threats to their core values, and in turn that these threats arose from the issues this blog discusses: concentration and abuse of power, health care leadership that is ill-informed, uncaring about or hostile to the values of health care professionals, incompetent, deceptive or dishonest, self-interested, conflicted, or outright corrupt, and health care governance that lacks accountability, and transparency, . We have found hundreds of cases and anecdotes supporting these proposed causes of health care dysfunction. 

Other research provided some corroboration.  Written comments from a 2001 survey of Massachusetts physicians made similar points about the causes of dissatisfaction, for example: "too much emphasis on the bottom line.  Taken over by large corporations.  Quality of care and interaction now subsumed by productivity and profit," and "the once most noble profession has become a factory job with a facade of ethics"(2)  Pololi and colleagues' qualitative interviews of young medical faculty included anecdotes of angst due to academic leaders who put revenues ahead of patient care, teaching, and research; and who allegedly used deception for personal gain.(3)  (Also, see our comments on this paper.)(4)  Pololi and colleagues' large survey of US medical faculty showed that over half thought that managers were only interested in them because of the money they brought in.(5)   We were able to show in a preliminary analysis of data from a physician survey that an instrument meant to measure physicians' perception of the integrity of the leadership of their organizations, which incorporated questions about whether leaders supported core values, put patient care ahead of revenue, supported transparency about quality issues, put patient care ahead of self-interest, and displayed honesty strongly correlated (negatively) with stress, intention to leave the practice, and burnout.(6)

The Latest Attempt to Listen to the Doctors about Health Care Reform


Ignatius' WaPo article was based on the pre-publication version of a new report by the National Academy of Medicine, (formerly the Institute of Medicine) made available on its website, entitled, Vital Directions for Health and Health Care.  According to Ignatius' interpretation, the basic problem health care reformers need to address is that America "squanders money on the wrong things - expensive procedures and tests rather than preventive care and social programs."  His summary of the supposed doctor recommended cures for this problem were: 

First, providers should be paid for value — for patient outcomes, not for the volume of procedures. Second, incentives should empower people to take better care of themselves through wellness programs or lifestyle changes. Third, better connectivity is needed among doctors, patients and others to encourage data-driven advances. Finally, the Academy argues for community strategies that target the highest-need patients, who are also most costly to treat.

It sounded good at first, but I quickly thought of questions: Does it make sense to pay for patients' outcomes, when those outcomes may occur regardless of what doctors do? What sort of incentives would be needed to make patients who are not taking good care of themselves change their ways?  Why would connectivity help when health care dyfunction has gotten worse as the world has become more connected?  How to you find patients with highest need, and how would you target such patients?  And above all, how would these cures, assuming one could figure out what they mean, prevent squandering money on the wrong things?

I left the Ignatius piece confused.  Perhaps the NAM publication on which Ignatrius' WaPo article was based would provide enlightenment.

What the National Academy of Medicine Wrought


So my next step was to quickly read the underlying report.  But that did not lessen the confusion.

The report did begin with sort of a definition of health care dysfunction

Health care today is marked by structural inefficiencies, unprecedented costs, and fragmented care delivery.

However it did not go on to providing an organized list of possible causes of these problems, with justifications for these diagnoses.  At best, it sort of alluded to the following as possible causes:

- the "rapidly aging population;"
- "persisting care fragmentation and discontinuity;"
- "costs associated with unnecessary services, inefficiently delivered services, excess administrative costs, prices that are too high, missed prevention opportunities, and fraud;" and
- "constrained innovation" due to "outdated regulatory, education and training models," particularly "uncertaintly and unpredictability around approval" of drugs and devices; and payment models that might place "excessive burden on manufacturers to demonstrate the value of their products."

"Rapidly again population" often appears as a postulated caused of health care dysfunction.  On Health Care Renewal we frequently discuss the problem of outright criminality and corruption in health care, including fraud; and the take over of health care by managers, which can result in "excess administrative costs."  However many of the other items were either too vaguely described to assess, or did not appear with clear justification. 


Furthermore, this list also raised some obvious questions.  For example, why are US costs so much higher than those of European countries whose populations are also aging?  Who sets criteria for how "high" prices should be?  What causes prices to be excessively high? Whose uncertainty and what unpredictability affect drug and device approvals?  How is the burden on manufacturers excessive?

Here was more confusion.  More was to follow. 

The bulk of the report is about "Vital Directions Issue Areas," again sort of a list of cures for health care dysfunction     

Vital Directions Issue Areas
Better health and well-being
Systems strategies for better health throughout the life course
Addressing social determinants of health and health disparities
Preparing for better health and health care for an aging population
Chronic disease prevention: tobacco, physical activity, and nutrition for a healthy start
Improving access to effective care for people who have mental health and substance use disorders
Advancing the health of communities and populations
 High-value health care
Benefit design to promote effective, efficient, and affordable care
Payment reform for better value and medical innovation
Competencies and tools to shift payments from volume to value
Tailoring complex care management, coordination, and integration for high-need, high-cost patients
Realizing the full potential of precision medicine in health and health care
Fostering transparency in outcomes, quality, safety, and costs
The democratization of health care
Workforce for 21st century health and health care
 Strong science and technology
Information technology interoperability and use for better care and evidence
Data acquisition, curation, and use for a continuously learning health system
Innovation in development, regulatory review, and use of clinical advances
Targeted research: brain disorders as an example
Training the workforce for 21st century science

However these apparent action items were not clearly associated with the causes of health care dysfunction they were supposed to address.  The discussions of these items raised yet more questions.  For example, the report discussed how to "drive health care payment innovation providing incentives for outcomes and value," presumably related to "payment reform" in the above list.  New payment and delivery models would have the "aim to reduce waste, increase value, and improve outcomes."  What was the evidence that they would be able to do so?  The next item was to "help clinicians develop the core competencies required for new payment models."  Would physicians be willing to accept a new payment system that would not work without subjecting the same busy clinicians to extensive new training? Etc, etc, etc

So in summary, the ful report did not give a clear definiton of the health care dysfunction, did not discuss the causes of the problem, and did not provide solutions keyed to either.  Furthermore, the report does did not provide clear justification for the action items it suggested.

Instead of a clear common-sense set of reforms, the new report just muddied the waters. Listening to the doctors was not helping at all. 


Listening to Not So Much Doctors as Health Care Corporate Executives, Directors and Lobbyists

The reason may be that the National Academy of Medicine report was written more by health care corporate executives, members of health care corporations' boards of directors, and lobbyists for health care corporations than by doctos.  The report's author list appeared thus on the NAM website:

Victor J. Dzau, National Academy of Medicine; Mark McClellan, Duke University; Sheila Burke, Harvard Kennedy School; Molly J. Coye, AVIA; The Honorable Thomas A. Daschle, The Daschle Group; Angela Diaz, Icahn School of Medicine at Mount Sinai; The Honorable William H. Frist, Vanderbilt University; Martha E. Gaines, University of Wisconsin Law School; Margaret A. Hamburg, National Academy of Medicine; Jane E. Henney, National Academy of Medicine; Shiriki Kumanyika, University of Pennsylvania Perelman School of Medicine; The Honorable Michael O. Leavitt, Leavitt Partners; J. Michael McGinnis, National Academy of Medicine; Ruth Parker, Emory University School of Medicine; Lewis G. Sandy, UnitedHealth Group; Leonard D. Schaeffer, University of Southern California; Glenn D. Steele, xG Health Solutions; Pamela Thompson, American Organization of Nurse Executives; Elias Zerhouni, Sanofi

Thus two physician authors were obviously employees of large health care corporations. Both in fact were high ranking executives. Dr Lewis G Sandy, is Senior Vice President, Advancement, for UnitedHealth Group; and Dr Elias Zerhouni, is President, Global Research and Development, for Sanofi.  Also, The Honorable Michael O Leavitt was the founder of Leavitt Partners, a business consulting group, whose clients include companies in the "pharmaceuticals and biopharmaceuticals, medtech and medical devices, health IT, diagnostics" and "commercial [health care insurance] plans," according to its website.

The author information provided at the end of this version of the article also stated that "the Honorable Thomas A Daschle is Founder and CEO of The Daschle Group, a Public Policy Advisory of Baker Donelson.'  Note that Baker Donelson is a Washington, DC lobbying firm.  Furthermore the author information included the fact that The Honorable Willaim Frist is "chairman of the Executive Board of the health service private equity firm Cressey & Company." Finally, Leonard D Schaeffer was identified as "the founding Chairman & CEO of Wellpoint."

While most of the other authors were listed as affiliated with academic organizations, some searching reveals that most of them had major financial relationships with for-profit health care corporations, including some of the largest.  Many, in fact, had come to the attention of Health Care Renewal in the past because of their important conflicts of interest. 

When Dr Victor Dzau was proclaimed the new president of the then Institute of Medicine, there was little initial discussion of his major conflicts of interest.  At the time of the announcement, he was on the boards of directors of Alnylam Pharmaceuticals, device maker Medtronic, and sugary drink maker Pepsico (see our 2014 blog post).  At the time of the announcement, he owned millions of dollars of shares or share equivalents of the three companies.  In 2010, Duke University students had protested his multi-million dollar salary as Chancellor for Health Affairs (see our blog post).

We discussed in a 2013 blog post how Dr Mark McClellan transited the revolving door from his position as head of the Center for Medicare and Medicaid Services (CMS) in the Bush administration to positions as special advisor to private equity firm General Atlantic LLC, strategic advisory committee member for private equity firm Capital Royalty LP, on the advisory board for Castlight Health, and on the boards of directors of AvivReit and Johnson and Johnson.  In 2016 we discussed how Dr McClellan pretended to be an independent scholar for the Brooking Institution while he was still on the board of Johnson and Johnson.

Sheila Burke is a strategic advisor to Baker Donelson, the Washington, DC lobbying firm for which Mr Daschle also works. 

Dr Molly J Coye is currently on the boards of directors of health insurance company Aetna, and chairwoman of the board of Prosetta Biosciences Inc.

Former US Senator Thomas A Daschle's firm is actually a lobbying firm, and was officially registered as a lobbyist for Aetna in 2016 (per Politico).  His firm is now part of Baker Donelson, a larger Washington, DC lobbying firm (as noted above).

Former US Senate Majority Leader Dr William H Frist was a founder of the Hospital Corporation of America (HCA) and likely holds millions of shares of related stock (per Wikipedia), and currently serves on the boards of directors of Teledoc, and "publicly held companies Select Medical and AECOM. In addition, he serves as a board member for several of Cressey & Company’s privately-held portfolio companies." He had been on the board of the controversial diagnostic testing company Theranos (per this news release).

After Dr Margaret Hamburg was confirmed commissioner of the US Food and Drug Administration (FDA) in 2009 in the Obama administration, we discussed how she had to divest herself of shares of medical supply company Henry Schein Inc, on whose board of directors she formerly sat, and how she and her husband, a top hedge fund manager, had to divest themselves of various other holdings that entailed conflicts of interest.

We first discussed Dr Jane E Henney's multiple conflicts of interest in 2006.  Currently, she is on the board of directors of global pharmaceutical distributor AmeriSourceBergen and giant health insurance company Cigna. Recently, she had been on the boards of pharmaceutical companies AstraZeneca (through 2011), and Cubist (through 2014).

In 2011, we discussed how Michael D Leavitt, former US Secretary of Health and Human Services  under the Bush administration, transited the revolving door to a position on the board of directors of Medtronic.

Leonard D Schaeffer serves on the boards of Walgreens Boots Alliance, Quintiles Transnational Holdings, Inc. and scPharmaceuticals Inc

Dr Glenn D. Steele is on the boards of directors for medical app developer Ingenious Med; Director, PTC Therapeutics; Director, Stratus Video; biotechnology company Synaptive Medical; and again large for-profit health insurance company Wellcare Health Plans Inc (look here).

By the way, in 2010, we discussed how Dr Elias Zerhouni, former Director of the National Institutes of Health (NIH) in the Bush administration, transited the revolving door to positions on the board of directors of biotechnology company Actelion and of Danaher, which makes, among other things, medical devices, and then to a full-time position with global pharmaceutical company Sanofi.  In 2005 we discussed how Dr Zerhouni, as NIH director, lead a not very vigorous response to a series of scandals involving conflicts of interest at that august institution, after relevant government rules had been relaxed in the Clinton administration (see also this post and links backward).

Just to add to the confusion, while none of these relationships were noted in the version of the report on the NAM website, a few were listed in an online published version in JAMA.(7)  The JAMA version omitted those of Dr Dzau; all of the relationships of Dr McClellan, save an admission that he "received personal fees from Johnson & Johnson"; Ms Burke's position with Baker Donelson; Dr Coye's position on the board of Aetna; Mr Daschle's position as lobbyist for Aetna; Dr Frist's positions on the boards of Select Medical and AECOM, and former position on the board of Theranos, although the JAMA version added a position on the board of Aspire Health; Mr Leavitt's board membership; Mr Schaeffer's membership on the boards of Quintiles and scPharmaceuticals; and all of Dr Steele's board memberships.

By my count, a majority, 13 of 19 authors had major financial ties to large for-profit health care corporations.  The authors included three who worked for Washington, DC lobbying and consulting firms with major health care industry clients, including one who explicitly lobbied for for Aetna.  The authors included  top executives of UnitedHealth and Sanofi.  The authors included current or recent members of the boards of directors of Alnylam Pharmaceuticals, Medtronic(2), Castlight Health, AvivReit, Johnson and Johnson, Aetna, Prosetta Biosciences, Teledoc, Select Medical, AECOM, Theranos, Aspire Health,  AmeriSourceBergen, Cigna, AstraZeneca, Cubist, Walgreens Boots Alliance, Quintiles Transnational Holdings, scPharmaceuticals Inc, Ingenious Med, PTC Therapeutics, Synaptive Medical, and Wellcare.

The Washington Post article would better have been sub-titled, "Listen to Health Care Corporate Eexecutives, Directors, and Lobbyists." 

Summary

A recent report by the prestigious National Academy of Medicine, now published electronically in JAMA,  and an accompanying newspaper article promised common sense ideas for health care reform suggested by physicians.  On its website, the Academy did not disclose most of the multitudinous and serious conflicts of interest of its authors.  A version electronically published by JAMA disclosed a few more, but was still very incomplete.  Relationships that were not disclosed included positions on the boards of directors of for-profit health care corporations, from start-ups to some of the biggest such corporations in the US.  In my humble opinion, such incomplete and inconsistent disclosures was dishonest and deceptive.

The prevalence of health care corporate board members as authors of this report is particularly concerning.  In 2006, we first blogged about a "new species of conflict of interest" which involved health care organizational leaders who were simultaneously members of the boards of directors of for-profit health care corporations or other corporations which could strongly influence health care.  We posited these conflicts would be particularly important because being on the board of directors entails not just a financial incentive, but also requires board members to "demonstrate unyielding loyalty to the company's shareholders" [Per Monks RAG, Minow N. Corporate Governance, 3rd edition. Malden, MA: Blackwell Publishing, 2004. P.200.]  So it should be no surprise that the NAM report did not really suggest any radical ideas for health care reform, despite Mr Ignatius' title.  Most of its authors were in a position to benefit from the status quo in health care.

Furthermore, it is no wonder the NAM report was confusing and muddled.  As Joe Collier  observed, "people who have conflicts of interest often find giving clear advice (or opinions) particularly difficult."(8)

In my humble opinion, the NAM report represents the sort of obfuscation that has been befogging discussion of health care policy for a long time.  Wendell Potter described how years of debate on health care policy that started during the Clinton administration was defined by concepts developed by for-profit insurance company public relations departments to steer debate away from ideas would threaten their profits.  In his book Deadly Spin, (p 64) he described a the AHIP (America's Health Insurance Plans, an insurance industry lobbying group) Strategic Communications Committee discourse on

the approach the industry would be taking when the reform debate heated up.  The goal would be to divert the public's and the media's attention from the uninsured and toward problems the insurers coudl insist were beyond their control.  The industry's spin, in other words, was going to be something like this: Health care costs are out of control because new treatments and technologies are more expensive than ever, the population's getting older and sicker, too many people are seeking care they don't really need, and health care professionals and providers are all too willing to provide the care that people don't need.

These putative causes of health care dysfunction, derived from an insurance industry organized public relations effort, have become the accepted wisdom.  Note that there were vestiges of them ("rapidly aging population") among the somewhat disorganized presentation of causes of health care dysfunction in the NAM report.  That there were not more of them may reflect the fact that the NAM report was not written just by people tied to the insurance industry.  It also included many people tied to biotechnology, drug, device, etc companies.  


Now during an era in which "fake news," propaganda and disinformation are in the headlines, we still see the terms of debate seemingly engineered by powerful health care organizations.

Physicians, other health care professionals, journalists, policy makers and the public at large should be extremely skeptical of apparently authoritative pronouncements on health care reform, especially when it is not clear what financial interests the authors of the pronouncements have, or when it is clear that the authors have important financial ties to large health care organizations, particularly large for-profit health care corporations.

At a minimum, media and certainly scholarly articles on health care reform and related policy issues should have at least as rigorous disclosure of conflicts of interests as clinical research articles.  

Real health care reform would start with honest debate in which the contestants at least make clear their underlying financial interests. 


References

1. Poses MD. A cautionary tale: the dysfunction of American health care. Eur J Int Med 2003; 14: 123-130. Link here.
2. Massachusetts Medical Society. Physician satisfaction survey (2001). Link here.
3.Pololi L, Kern DE, Carr P, et al. The culture of academic medicine: faculty perceptions of the lack of alignment between individual and institutional values. J Gen Intern Med 2009; 24: 1289-95. Link here.
4. Poses RM, Smith WR. Faculty values. J Gen Intern Med 2010; 25: 646. Link here.
5. Pololi L, Ash A, Krupat E. Faculty values in the culture of academic medicine: findings of a national faculty survey. Link here.
6. Poses RM, Baier-Manwell L, Mundt M, Linzer M. Perceived leadership integrity and physicians’ stress, burnout, and intention to leave practice. J Gen Intern Med 2005; 20: S182. Link here.
7. Dzau DJ et al.  Vital directions for health and health care: priorities from a National Academy of Medicine initiative.  JAMA 2017; doi:10.1001/jama.2017.1964.  Link here.
8.  Collier J. The price of independence. Br Med J 2006; 332: 1447-9.  Link here